Scribd
Upload
2K views15 pages

Diabetic Foot Ulcer Case Study

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.

Uploaded by

Fake Account
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
2K views15 pages

Diabetic Foot Ulcer Case Study

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.

Uploaded by

Fake Account
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 15

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

You might also like