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Case Presentation Ulcer: Sparsha Vijay Roll Number 77 8 Term

This document presents a case study of a 48-year-old male construction worker with a non-healing ulcer on his right foot that has been present for 3 weeks. He has a history of diabetes for 11 years. Examination found a 7x5cm irregular ulcer on his lateral plantar foot with slough and purulent discharge. Provisional diagnosis was a chronic non-healing ulcer associated with diabetes. Investigations like blood tests and biopsy were planned along with management including better blood sugar control, wound cleaning and dressing, and potential skin grafting.

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960 views

Case Presentation Ulcer: Sparsha Vijay Roll Number 77 8 Term

This document presents a case study of a 48-year-old male construction worker with a non-healing ulcer on his right foot that has been present for 3 weeks. He has a history of diabetes for 11 years. Examination found a 7x5cm irregular ulcer on his lateral plantar foot with slough and purulent discharge. Provisional diagnosis was a chronic non-healing ulcer associated with diabetes. Investigations like blood tests and biopsy were planned along with management including better blood sugar control, wound cleaning and dressing, and potential skin grafting.

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CASE PRESENTATION

ULCER

Sparsha Vijay
Roll number 77
8th term
• Name : Mr X
• Age : 48yrs
• Sex: Male
• Address : Bangalore
• Occupation : Construction worker
• Education : 7th std
• Chief complaints: Wound over the right foot × 3 weeks
• Discharge from the wound × 3 weeks
HISTORY OF PRESENTING ILLNESS

Patient was apparently normal 1month back when he noticed a swelling


over the right heel which gradually progressed to form a Wound
Wound was about 3x4cm and has now progressed to about 6x5
cm.
It is also associated with yellowish(purulent),foul smelling
discharge, non blood tinged.
The patient does not give any h/o
Trauma
Pain
Fever
Cough
Weight loss
PAST HISTORY

• He is a known case of Diabetes mellitus since 11 years and is on oral


medication.
• No history of similar complaints in the past
• No history of TB /Hypertension/Varicose Viens
FAMILY HISTORY

• No h/o
• Diabetes mellitus
• Hypertension
• Tuberculosis
PERSONAL HISTORY

• Diet : Mixed diet


• Appetite : Normal
• Sleep : Adequate
• Bowel : Regular
• Bladder : Normal
• Habits : None
GENERAL EXAMINATION

• • A middle aged patient moderately built and moderately nourished


• conscious, cooperative and well oriented to time, place and person.
• VITALS
• • BP- 126/82 mm Hg
• • Pulse- 74 beats per minute
• • Respiratory rate- 13 cycles/min
• • Temperature – afebrile
• Pallor, icterus, clubbing, lymphadenopathy and edema are absent
LOC AL EXAMINATION

INSPECTION

A solitary ulcer present on the lateral


plantar aspect of the right foot
approximately 7x5cm, irregular in shape,
with punched out edge . The floor is
covered with slough ,pale granulation tissue
and purulent discharge which is foul
smelling.
The surrounding area appears normal.
Rest of the limb appears normal.
PALPATION

• Not local rise in temperature, No tenderness


• The ulcer does not bleed on touch, Not mobile, no induration
• Size of the ulcer:6.8x5x3cm
• The margin is well defined.The edge is punched out.
• The base is made of tendons.
• Surrounding area is normal.
• EXAMINATION OF LYMPH NODES: No palpable lymph nodes
•
• EXAMINATION OF VASCULAR INSUFFICIENCY: No varicose veins.
Peripheral pulses felt.
•
SYSTEMIC EXAMINATION

• RS- B/L NVBS, no added sounds


• CVS- S1S2 heard, no murmurs
• PA- abdomen soft, non tender, no organomegaly
• CNS- Loss of sensation in the right Sole
PROVISIONAL DIAGNOSIS

Chronic Non healing ulcer over the lateral plantar aspect of the right
foot associated with diabetes mellitus.
INVESTIGATION

• CBC,
• Hb%,
• ESR
• Blood sugar estimation
• Biopsy
• Culture and sensitivity of the discharge.
MANAGEMENT

• Advise patient about blood sugar control with regular intake of tablets
and proper monitoring.
• Advise the patient to use a proper footwear like microcellular rubber
footwear.
• Rest, immobilization, avoid trauma
• Antibiotics
• Ulcer debridement, cleaning, dressing.
• Split skin grafting.
THANK YOU

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