leg ulcer- surgery case presentation.pptx

A case presentation of leg ulcers

1. Leg Ulcer A Clinical Case Presentation Rakesh A 4 th Year MBBS Shridevi Institute of Medical Sciences & Research Hospital Tumakuru

2. Patient Particulars Name – Mr ABC Age – 53 years Sex – Male Education – 7 th Class Occupation – Carpenter Address – BG palya, Tumakuru Socioeconomic status – Class 4 according modified BG Prasad classification DOE – 1 st October 2021 DOE - 1st October 2021

3. Chief Complaints Wound over left foot since three months

4. History of presenting illness Patient is a known case of diabetes Mellitus from past 20 years and has a history of smoking from last 30years.Patient was apparently normal three months back, later he met with an accident which led to a wound over dorsal aspect of left foot near 4 th and 5 th toe. Initially wound size was approximately 1cm and gradually progressed to involve the whole of the 4 th and 5 th toe. Patient also complaints of discharge from the wound since 2 ½ months initially scanty watery discharge. Later, it was foul smelling purulent discharge from last 3 weeks. Wound was not associated with pain. No history of claudication in the lower limbs. No history of altered sensations in the lower limbs.

5. Past medical history Known case of diabetes from 20 years. Patient was on oral hypoglycaemic drugs for first 14 years. Blood sugars levels were uncontrolled since last 6years so he is on insulin therapy Not a known case of Hypertension/TB/Asthma/epilepsy.

6. Past surgical history Patient had a similar complaint 5 years back for which he underwent amputation of big toe of left foot at CMC Vellore. 3 years back, he underwent amputation of 2 nd and 3 rd toe of left foot for similar complaint at CMC Vellore.

7. Family history History of diabetes mellitus in the family.

8. Personal history Diet – Mixed Appetite – Normal Sleep – adequate Bowel and bladder – Normal Abusive habits – Smoking and alcohol consumption from last 30 years

9. Summary A 53 year old patient who is a known case of diabetes since 20 years on regular medication presents with the wound over the dorsal aspect of lateral side of left foot after sustaining an injury 3 months back which was initially associated with scanty serous discharge which gradually progressed to foul smelling discharge not associated with pain.

10. General physical examination A 53 year old patient who is moderately built, moderately nourished, conscious, cooperative and well oriented to time, place and person. Height – 175 cm Weight – 68 kg BMI – 22.2 kg/ No pallor, icterus, clubbing, cyanosis, generalised lymphadenopathy and edema  

11. Vitals Pulse – 70 bpm, regular rhythm, normal volume, all peripheral pulses were felt. Blood pressure – 112/78 mmhg, measured in right upper limb on sitting position Respiratory rate – 18/min Temperature – 98.7 °F

12. Local examination Inspection A single ulcer irregular in shape present on the lateral side of dorsal aspect of left foot which measures approximately 3 6 cm, sloping edges with inflammation and edema. Floor is covered with pale tissue with slough and granulation tissue in the centre of ulcer. There is serous discharge, foul smelling. Surrounding area is hypopigmented .  

13. There was a another ulcer on the sole of the left hindfoot which was round in shape measuring 2 2cm, punched out edges. Floor is covered with granulation tissue, surrounding area is hypopigmented. Rest of the left limb is normal Joint movements are normal  

14. Palpation No local rise of temperature and tenderness A ulcer present on the left foot over dorsal aspect, measuring 3.5 7cm, irregular in shape. There is sloping edge with well defined margin. No induration, depth ranging from 0.5 to 1cm. Ulcer is immobile and do not bleed on touch, base is muscle and tendons. Associated with loss of sensation over ulcer and surrounding 3-4cm area.  

15. Ulcer is present over the sole of left foot, measuring 2 2cms, round in shape. There is punched out edges with slight induration and distinct margin, depth measuring up to 1cm. Ulcer is immobile, do not bleed with touch, base is muscle. Associated with loss of sensation over ulcer and surrounding 2-3cm area. Not associated with loss of sensation over other parts of left lower limb  

16. EXAMINATION OF LYMPH NODES no enlarged lymph nodes in the inguinal region. EXAMINATION OF VASCULAR DISEASE no signs suggestive of vascular disease EXAMINATION OF NERVE DISEASE no signs suggestive of nerve disease

17. SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM S1 and S2 heard, No murmurs RESPIRATORY SYSTEM Normal Vesicular Sounds are heard, No added sounds PER ABDOMEN Soft, non tender and no organomegaly CENTRAL NERVOUS SYSTEM No focal neurological deficit present

18. Provisional diagnosis A 53 year old patient who is a known case of diabetes with chronic non healing ulcer on the dorsal aspect of lateral side of left foot and tropic ulcer on the sole of left hindfoot.

19. Thank you..