Leg Ulcer

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CASE PRESENTATION:

CASE PRESENTATION Neeraj Kumar Jain Pg Surgery

Case presentation:

Case presentation Kailash son of Bherulalji ,30 year , hindu , married male, resident of Pipliya Kheda , Prajapati Nagar, Kaanipura Ujjain admitted in surgery ward on 22 December 2012 at 3.15pm : With alleged History of Road traffic accident by cartwheel on 7 dec 2012 after which he had complaints of Pain in left lower leg for 15 days. Swelling in left lower leg for 14 days. Pus Discharge from swelling for 10 days Ulcer over left lower leg for 10 days.

H/o presenting illness :

H/o presenting illness As per patient he was alright 15 days back then he had accident with cartwheel after which he developed pain in left lower leg which was initially dull aching , progressive in nature gradually it has increased in intensity. Swelling in left lower leg for 14days which was limited to lower leg gradually increased in size .For which he was admitted in Some hospital and dressing was done after 4 days swelling burst opened and pus came out then swelling decreased in size. Then he developed black discoloration of skin so debridement was done. Since then he is having Ulcer over left lower leg associated with Pus discharge.

Past history :

Past history No History of any previous Surgery. No history of any long illness in past .

Family history: :

Family history: He is married having 4 Children . No history of any long illness in family.

Personal history:

Personal history He is Non vegetarian. History of smoking bidi for 8 years half bundle daily, Tobacco chewing for 10 years, Alcohol drinking for 7 years. Bowel and bladder habits normal DRUG HISTORY History of taking some medication for pain. No history of drug allergy.

GENERAL EXAMINATION :

GENERAL EXAMINATION Temp not raised Pulse -84 per min Blood pressure -110/80mm Hg Bulbar Conjunctiva –White Palpable conjunctiva- pink Oral Hygiene-Poor Nails-no Koilonychia,No clubbing Neck veins/neck glands- not Palpable. Odema , lymphadenopathy absent

Local examination:

Local examination Single large ulcer present on dorsum of left lower foot extending from 5cm away from great toe to lateral malleolus . Irregular shaped ,nearly 15cm * 7cm in size. Margin- inflamed and oedematous . Edge-Sloping and punched out Floor- Slough present Base-underlying Muscles and bones. Skin around Ulcer is hyper pigmented.

Palpation:

Palpation Temperature not raised Tenderness present Single large ulcer present on dorsum of left lower foot extending from 5cm away from great toe to lateral malleolus . Irregular shaped ,nearly 15cm * 7cm in size. Margin- inflamed and oedematous . Edge-Sloping and punched out Floor- Slough present , Bleeding present on touch at some sites. Base-underlying Muscles and bones. Skin around Ulcer is hyper pigmented.

PROBABLE DIAGNOSIS:

PROBABLE DIAGNOSIS Necrotizing fasciitis of left lower leg Traumatic Infected Non healing Ulcer on left lower leg

Hematological investigations:

Hematological investigations Hb- 12.4 g/dl TLC- 8500/ cumm DLC- N-62 L-30 E-06 M-02

Other investigations :

Other investigations Urine examination-NAD. RBS-90mg/dl CREATININE-0.6mg/dl UREA-24.8mg/dl HIV & HBSAg -NR

PowerPoint Presentation:

He was operated on 24 Dec and Debridement was done.

PowerPoint Presentation:

THANKING YOU

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