Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Surgery Final Year Case Presentation Ulcer Clinical Examination Discussion and Treatment
Kanappan coming from Triplican who
is a mechanic by occupation belongs
to socio economic class middle lower
came to the OPD with C/O WOUND
in the Right foot for past 6 month
HISTORY OF PRESENTING ILLNESS
The patient was apparently normal 6 month back
after which he developed a wound during his work
by a chisel
Insidious in onset
6 month duration
Progressive to attain the current size
Assosiated with serous discharge
No foul smelling
Not assosiated with pain
No h/o fever
No h/o swelling
No h/o loss of sensation
No h/o restriction of movements
No h/o loss of weight and apetite
No h/o cough with expectoration
No h/o evening raise of temperature
No h/o urethral discharge or itching
Ho h/o wound elswhere in the body
PAST HISTORY
H/O DM for 10 years on regular treatment
H/O HT for 2 year on regular treatment
No h/o similar complaints in the past
No h/o previous hospitalization or surgeries
No h/o asthma ,epilepsy , jaundice, TB,STD
PERSONAL HISTORY
Consumes mixed diet
Normal bowel and bladder habit
h/o alcohol intake for 20 years ,180 ml/day
No h/o smoking
No h/o bleeding dissorders
No h/o blood transfusion
General examination
Examination of patient after explaining procedure and
getting consernt from the patient
PATIENT IS
Conscious
Oriented
Moderately built and nourished
No pallor /cynosis/icterus/clubbing/pedaledema
No generalised lymphadenopathy
vitals
PR 68/min regular in rhythm ,normal in volume
and character
All peripheral pulses felt
RR 16/min abdomino thorasic
BP 130/90 mmHg
Temperature afebrile
LOCAL EXAMINATION
EXAMINATION OF RIGHT FOOT
INSPECTI ON
single irregular ulcer of size 8*4cm on the lateral side of right
foot
Extend
Anterior border 3 cm from little toe
Posterior border 3 cm from latteral malleolus
Inferior border along the lateral margin of sole
Superior border 4cm from lateral margin of sole
MARGINES well defined
FLOOR slough and granulation tissue present
EDGE sloping
Serous discharge from ulcer
Not blood stained or foul smelling
Surrounding area hyperpigmented
No pedal edema
No loss of hair
No dilated veins,scars or sinuses
No fullness in inguinal region
PALPATION
No warmth or tenderness
All inspectory finding site,size, shape,floor confirmed
by palpation
No induration on edge and margin
Base rest on bone
immobile
Depth 3cm
Depth 3cm
Not bleed no touch
No restriction of ankle movement
Surrrounding skin normal
External genitaliya normal
No palpable lymph node in inguinal region
NEUROVASCULAR EXAMINATION
DPA and posterior tibial artery pulsation felt
Femoral and popliteal pulsation felt equaly on both
legs
No sensory loss
Other system examination
RS Normal vesicular breath sound heard ,no added
sound
CVS S1 S2 Heard ,no added sound or murmur
CNS no focal neurological deficit
ABDOMEN soft , non tender ,no organo megaly
DIAGNOSIS
HEALING ULCER OF GRADE 2 ON RIGHT FOOT
PROBABLY DUE TO DIABETES MELLITUS WITH
OUT COMPLICATION
INVESTIGATION
BASE LINE
Blood sugar,urea,creatinine
Urine sugar,albumin
Complete blood count,DC,Hb%,platelet, ESR
Chest x ray,ECG
RFT
SPECIFIC
Culture and sensitivity,AFB study,cytology
Edge wedge biopsy
Glycated hemoglobin
Urine ketone bodies
X ray foot
Mantoux test
Arterial dopler of lower limb
VDRL
TREATMENT
Control of Diabetes Mellitus by insulin
Regular cleaning ,debridment of necrotic tissue and calus,
dressing
Antibiotic based on culture sensitivity
Rest
Elevation of limb
Good nutriton
Correct the deficiencies like anemia, protein and vitamin
deficiency
Once granulation tissues appear covered with skin graft
Protective footware [microcellular rubber chappel]
Patient education ,Prophylactic skin and nail care
This post was last modified on 08 August 2021