Download MBBS Final Year Surgery Case Presentation Ulcer Clinical Examination Discussion and Treatment

40 year old male patient Mr. Kanappan coming from Triplicane 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 months.

HISTORY OF PRESENTING ILLNESS

• The patient was apparently normal 6 months back after which he developed a wound during his work by a chisel.
• Insidious in onset

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• 6 month duration
• Progressive to attain the current size
• Associated with serous discharge
• No foul smelling
• Not associated with pain

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• 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 appetite

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• No h/o cough with expectoration
• No h/o evening raise of temperature
• No h/o urethral discharge or itching
• Ho h/o wound elsewhere in the body

PAST HISTORY

• H/O DM for 10 years on regular treatment

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• H/O HT for 2 years 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

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• Normal bowel and bladder habit
• h/o alcohol intake for 20 years, 180 ml/day
• No h/o smoking
• No h/o bleeding disorders
• No h/o blood transfusion

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General examination

• Examination of patient after explaining procedure and getting consent from the patient
• PATIENT IS
• Conscious
• Oriented
• Moderately built and nourished

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• No pallor /cyanosis/icterus/clubbing/pedal edema
• No generalized lymphadenopathy

Vitals

• PR 68/min regular in rhythm, normal in volume and character
• All peripheral pulses felt
• RR 16/min abdomino-thoracic

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• BP 130/90 mmHg
• Temperature afebrile

LOCAL EXAMINATION

• EXAMINATION OF RIGHT FOOT
• INSPECTION
• Single irregular ulcer of size 8*4cm on the lateral side of right foot

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• Extend
• Anterior border 3 cm from little toe
• Posterior border 3 cm from lateral malleolus
• Inferior border along the lateral margin of sole
• Superior border 4cm from lateral margin of sole

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• MARGINS well defined
• FLOOR slough and granulation tissue present
• EDGE sloping

• Serous discharge from ulcer
• Not blood stained or foul smelling

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• Surrounding area hyperpigmented
• No pedal edema
• No loss of hair
• No dilated veins, scars or sinuses
• No fullness in inguinal region

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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

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• Depth 3cm

• Depth 3cm
• Not bleed no touch
• No restriction of ankle movement
• Surrounding skin normal

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• External genitalia normal
• No palpable lymph node in inguinal region

NEUROVASCULAR EXAMINATION

• DPA and posterior tibial artery pulsation felt
• Femoral and popliteal pulsation felt equally on both legs
• No sensory loss

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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 organomegaly

DIAGNOSIS

• HEALING ULCER OF GRADE 2 ON RIGHT FOOT PROBABLY DUE TO DIABETES MELLITUS WITHOUT COMPLICATION

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INVESTIGATION

• BASE LINE
• Blood sugar, urea, creatinine
• Urine sugar, albumin
• Complete blood count, DC, Hb%, platelet, ESR
• Chest x ray, ECG

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• RFT

SPECIFIC

• Culture and sensitivity, AFB study, cytology
• Edge wedge biopsy
• Glycated hemoglobin
• Urine ketone bodies

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• X ray foot
• Mantoux test
• Arterial doppler of lower limb
• VDRL

TREATMENT

• Control of Diabetes Mellitus by insulin

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• Regular cleaning, debridement of necrotic tissue and callus, dressing
• Antibiotic based on culture sensitivity
• Rest
• Elevation of limb
• Good nutrition

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• Correct the deficiencies like anemia, protein and vitamin deficiency
• Once granulation tissues appear covered with skin graft
• Protective footwear [microcellular rubber chappel]
• Patient education, Prophylactic skin and nail care

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