CABRERA, AGATA CRISTINE E.

ORAL REVALIDA CASE: THROMBOANGITIS OBLITERANS

Initial Evaluation

Pt’s Name: B.D.

Age: 38
Sex: M
Address: Q.C.
Civil Status: Married
Handedness: Right
Occupation: Fruit and Vegetable vendor
Referring Unit: Primary Care
Referring MD: T.S.
Rehab MD: C.H.
Date of Referral: August 10, 2018
Date of Consultation: August 10, 2018
Date of IE: August 14, 2018
MDDx: Buerger’s Disease / Thromboangitis Obliterans

HPI:
Pt’s condition started 2 mos. ago, when pt. noticed intermittent tingling on R ankle and big toe which caused mild
discomfort. Pt. dismissed sx & attributed it to “ingrown” that might just go away. ~2 weeks later, pain was persistent,
arch of the foot became numb and pt. began to notice skin changes like blanching and cyanosis on digits of both LE &
UE, especially during cold nights. As the condition of the right foot worsens, pt. bore the pain because of financial
restraints. By the time that pt. decided to have a consultation at UERM Medical Center, pt. already had cyanotic 1st, 3rd
& 4th digits of the R foot, edematous and cold to touch. Pt. complained of constant prickling and throbbing pain graded
8/10 on R ankle, big toe, and 3rd & 4th digits. Pt. underwent special tests, lab tests and ancillary procedures (see
Ancillary procedures, Lab tests, & special tests) to conclude pt’s dx of Thromboangitis Obliterans. Pt. was given meds
(see Medications) & was advised to discontinue smoking and referred to PT to do gentle exercises.

PMHx:
(+) Htn (diagnosed since 2012, controlled)
(-) Hx of recent trauma
(-) Previous Hospitalization
(-) DM
(-) CA
(-) Pulmonary Conditions
(-) Cardiac Complications

FMHx:
Maternal Paternal
DM - +
Htn - +
CA - -
COPD - -
Cardiac Diseases + -
CABRERA, AGATA CRISTINE E. ORAL REVALIDA CASE: THROMBOANGITIS OBLITERANS

PSHx:
 Pt. is a fruit and vegetable vendor for 25 years, working for 10hrs/day, usually sits for ~7hrs per work day,
remaining hrs are for breaks, pt. walks to the market ~400m away from home.
 Pt has been smoking a pack/day since he was 16 yrs old (22 pack years) & recently tried the smokeless
tobacco, Tres B, which could easily be bought at the “palengke” and started chewing it every so often.
 Pt drinks alcoholic beverage occasionally. (1-2 bottles of beer per month)
 Pt is sedentary & does not have any form of exercise other than walking to the market
 Pt’s only hobby is bonding c his family at home.

Environmental Assessment:
Home:
Pt lives on a 2 storey house c ~15 step staircase; bedrooms are located at 2nd floor
In reference to the main door:
 Kitchen: ~2m
 Dining Room: ~1m
 Living Room: ~1m
 Comfort Room: ~4m
 Pt’s Bedroom: ~7m
Work:
Pt works at the fruit and vegetables corner of the market; passes the wet, slippery floors of the meat & seafood area
before getting there.
In reference to Pt’s working area:
 Comfort Room: ~12m

Home Situation:
Pt is currently living c his wife, & 2 sons (17 & 15 yrs old, both single, high school students); pt is an only child, moved
away from parents who are in the province. Pt’s wife and children help in fruit and vegetable selling to cover the
expenses with the help of pt’s sister-in-law.

Ancillary Procedures:
Tests Date Findings
Contrast Angiography (CTA) August 10, 2018 (+) Blockage on medial & lateral
plantar aa. & ulnar aa leading to
ischemia; presence of corkscrew
collaterals
Ankle-Brachial Index August 10, 2018 0.9

Lab Tests:
Screening for homoocysteine August 11, 2018 (+) Hyperhomocysteinemia
C-Reactive Protein (CRP) August 11, 2018 (-) Negative
CABRERA, AGATA CRISTINE E. ORAL REVALIDA CASE: THROMBOANGITIS OBLITERANS

Medications Taken:
Medication Dosage Route Frequency Indication

Metoprolol 25 mg Oral BID Maintenance for

(beta-blocker) Htn control
ASA 325 mg Oral TID Reduction of
pain and
inflammation

S>
C/C
Pt c/o not being able to tolerate walking to work d/t constant prickling & throbbing pain graded 8/10 on R
ankle, big toe, and 3rd & 4th digits; slightly relieved by rest and only optimally relieved by medications.

Pt goals:
“Nais kong makapaglakad papunta sa palengke at makapag trabaho nang hindi sumasakit ang aking paa at
kamay upang matigil na ang pagiging pabigat ko sa aking pamilya.”

O>
VS
BP = 110/80 mm Hg Findings: Vital signs are WNL
HR = 76 bpm Significance: For baseline purposes
RR = 20 cpm
Temp = 37.1

OI
amb s AD
Pt is Alert, Coherent, Cooperative
Mesomorph
 (+) Pallor on B hands, plantar surface & 1st, 3rd and 4th digits of R foot
 (+) Cyanosis of nail beds
 (+) Clubbing (see Special Tests)
 (+) Reynaud’s Phenomenon on B hands & R foot** (see Special Tests)
 (-) Gross deformities on B UE & LE
 (-) Wounds on B UE & LE
 (-) Swelling on B UE & LE

Palpation
Hypothermic on B hands & anterior 1/3 of plantar aspect of R foot
Normotonic on L LE
 (+) Edema on B UE & R LE
 (+) Grade II Tenderness on anterior 1/3 of plantar aspect of R foot, and R palmar arch
CABRERA, AGATA CRISTINE E. ORAL REVALIDA CASE: THROMBOANGITIS OBLITERANS

ROM
All major joints of B UE & LE were assessed actively and passively, and were all found WNL c N, & pain-
free end feels except:

Motion Normal Active Passive Difference End-feel

R PIP flexion of 0-100 0-90 0-100 10/0 Firm
2nd-5th fingers
L PIP flexion of 0-100 0-90 0-100 10/0 Firm
2nd-5th fingers
R DIP flexion of 0-90 0-80 0-90 10/0 Firm
2nd-5th fingers
L DIP flexion of 0-90 0-80 0-90 10/0 Firm
2nd-5th fingers
R ankle plantar 0-50 0-30 0-45 20/5 Empty
flexion
R ankle 0-20 0-10 0-20 10/0 Empty
dorsiflexion
R 1st MTP 70 0-40 0-55 30/15 Empty
extension
R 1 MTP flexion
st 45 0-20 0-40 25/5 Empty
R 3rd MTP flexion 40 0-20 0-40 20/0 Empty
R 4th MTP flexion 40 0-20 0-40 20/0 Empty

Findings: There is significant active LOM in 2nd-5th finger flexion, R ankle plantar & dorsiflexion, R big toe’s MTP
flexion and extension, and R 3rd and 4th toes’ MTP flexion.
Significance: LOM may be d/t decreased oxygen delivery 2 to arterial occlusions w/c may cause pt to have difficulties
in amb.

MMT
All major muscle groups of B UE, LE, Head & Trunk have been grossly assessed using Daniels and
Worthingham’s muscle testing, and graded Normal except:
Muscle Grade
R ankle plantar flexor Fair +
R ankle dorsiflexor Fair +
R 1st MTP extensor Fair +
R 1 MTP flexor
st Fair +
R 3 MTP flexor
rd Fair +
R 4 MTP flexor
th Fair +

Findings: Pt. was able to hold test position against slight resistance and graded Fair +
Significance: Inadequate strength of R foot musculature may retard pt’s ability to amb. normally

Postural Assessement:
All Bony Landmarks were assessed in all views in standing, and were found to be within N alignment.
CABRERA, AGATA CRISTINE E. ORAL REVALIDA CASE: THROMBOANGITIS OBLITERANS

Findings: Pt does not have any postural deviations

Cardiac Assessment:
N Heart Sounds on all Auscultatory Landmarks
Rhythm: Regular
Rate: WNL; 76 bpm (normal 60 – 100 bpm)
All palpable pulse sites were assessed and were found to be WNL except:
Pulse A:
Pulse Site Pulse Grade
Dorsal Pedal 1+
Posterior Tibial 1+
Findings: There is diminished/weakness of pulse on Dorsal Pedal & Posterior Tibial pulse sites
Significance: This is because of poor circulation on these sites d/t occlusion of the arteries which may be a factor for
the occurrence of pt’s claudication.

Superficial Sensory Assessment:

Area Modality Used Deficit
Horse hair 70% intact
Palmar aspect of Hands Pointed part of neurohammer 70% intact
Test tube c warm water 70% intact
Test tube c cold water 70% intact
Horse hair 70% intact
Plantar aspect of Feet Pointed Part of neurohammer 70% intact
Test tube c warm water 70% intact
Test tube c cold water 70% intact
Findings: Pt has a slight decrease of sensation on the affected areas.
Significance: Decreased sensation may be d/t insufficient blood supply which may potentially affect the pt negatively
if left unchecked.

Special Tests:
Test Positive Sign Result
Schamroth’s Test Absence of schamroth’s window (+) positive
(diamond-shaped)
Buerger’s Test Persistent Pallor (+) positive
Cold Stimulation Test (+) if finger temperature takes (+) positive
longer than 20mins to return to
normal.

Functional Assessment:
Pt was assessed c 6 Minute Walk Test (6MWT) and was asked to at least cover 600m within 6 minutes.
CABRERA, AGATA CRISTINE E. ORAL REVALIDA CASE: THROMBOANGITIS OBLITERANS

Time Rest Duration Distance covered Distance Covered Feedback of

before resting therapist
1 minute No rest 150m n/a N
2 minutes No rest 275m n/a N
3 minutes No rest 325m n/a N
4 minutes 30 secs 400m 400m Pt rested because
of recurrence of
claudication on
plantar aspect of his
R foot
5 minutes No rest 510m n/a N
6 minutes No rest 620m n/a N
Findings: The 6MWD is reduced, a thorough search for the cause of the impairment is still warranted.
Significance: Pt. may require resting periods during amb exercises to avoid claudication

ADL Assessment:
Pt is independent, and has no problems in most of his ADls, Self-care, Bed Mobility, & Transfers, and only
has problems c prolonged amb, especially whenever going to work d/t onset of claudication.

A>

PT Dx:
MD Dx of Thromboangitis Obliterans 2° impaired arterial blood flow further defined by difficulty performing prolonged
amb d/t claudication.

PT Prognosis:
Fair prognosis as to return to amb because there is no cure for pt’s disease. However, disease is only at its acute
phase, as seen with the absence of major complications e.g. gangrene. Pt. also has the motivation to return to work
and to intake nutritious food since fruits and vegetables are easily accessible in his line of work. Most importantly, pt.
has complied with instruction to quit smoking which is the key factor in controlling the progression of the disease. The
lifestyle changes along with gentle exercise provided by PT Mx will positively affect prognosis.

Rehab potential:
Fair rehab potential because although pt. is willing enough to participate in PT program & comply to smoking
cessation and dietary instructions; financial support from family may be inadequate in the future and financial
restraints may again limit pt’s access to intervention as seen from pt’s history.

Problem list:
1. Debilitating pain in R LE after certain activities, such as walking or climbing stairs (claudication)
2. Weakness of R plantar and dorsiflexors
3. LOM of B UE & R LE

LTG
Pt. will be able to perform indep amb s claudication p 1 mos of PT session.
CABRERA, AGATA CRISTINE E. ORAL REVALIDA CASE: THROMBOANGITIS OBLITERANS

STG
1. Pt. will have improved ROM of B UE & LE to normal ranges p 1 wk. of PT sessions.
2. Pt. will have improved strength in B UE & LE p 3 wks. PT sessions.
3. Pt. will demonstrate improved exercise tolerance for ADL & decreased incidence of intermittent claudication
during prolonged walking, given c rest periods of 20 mins. p 4 wks. of PT sessions.

P>

Initial Treatment
1. HMP on R thigh x 20 mins c 8 layers of towels & pt. in sitting adjunct to therapy for increased circulation of
the LE.
2. IPC to R leg at 80 sec inflation x 35 sec deflation, & maximum inflation pressure of 50 mm Hg x 2 hr. to
increase blood flow towards the R foot.
3. Gentle stretching of gastrocnemius and soleus ms. 30 SH x 4 sets to increase ROM and lengthening of
muscle for warm-up and cool-down periods of LE musculature.
4. AROM of all shoulder, elbow, wrist, & hand motions x 10 reps x 3 sets per day for 1 week to increase blood
flow to the UE.
5. Active ankle pumps x 10 reps x 3 sets 3 days/week for warm up/
6. Endurance Training (Aerobics) to prevent muscle cramping d/t fatigue.

Progression:
 Buerger’s exercises for 1 hr./day for 1 week.
 AROM of all hip, knee, ankle, & foot motions x10 reps x3 sets for 3 days/week to increase blood flow to the
LE.
 Treadmill walking for 30 mins c warm up & cool down 3 days/week to reach predetermined maximum HR s
causing intermittent claudication .
 Regular, graded aerobic exercise or walking as tol.

HEP
 Apply warm compress to affected extremities 3-5x/day.
 AROME of the B UE in wrist rotations, finger flexion and extensions for 10 reps x 3 sets each motion in B
hands to increase circulation.
 AROME of the B LE in ankle flexion, extension, and rotations in

Pt. Education:
 Advice the pt. to completely stop using tobacco of any kind because sx are often relieved by cessation of
tobacco use.
 Encourage pt. to attend smoking-cessation programs. Daily conseling sessions and other activities helps pt.
deal with the cravings.
 Advice pt. to avoid drugs that can cause vasoconstriction, such as ergotamines.
 Encourage pt to exercise, control weight and follow a low cholesterol and low fat diet to promote healing and
prevent tissue breakdown.
 Advice the pt. to elevate the head of the bed to or assuming a seating position with the feet resting on the
floor to improve peripheral circulation.
CABRERA, AGATA CRISTINE E. ORAL REVALIDA CASE: THROMBOANGITIS OBLITERANS

 Educate pt. that the use of neutral soaps and lotion prevents drying and cracking of skin.
 Encourage pt. to protect the extremities from trauma and infection by: (1) taking care of fingers and toes/nail
care; (2) wearing comfortable footwear; and (3) checking the skin on arms and legs daily for cuts and
scrapes.
 Advice pt. to clean any cuts with water and cover with a clean bandage, in case of any cuts or scrapes.
 Advice pt. to see the doctor promptly if cuts get worse or heal slowly.
 Advice pt. to avoid cold temperatures and other conditions that reduce blood flow in the hands and feet by
wearing gloves when handling frozen foods and wearing socks during cold weather.