LONG CASE PRESENTATION-SAMPLE

Sir,

My patient Jagarnath, a Hindu male aged about 50 years, masson by profession /occupation hails
from Nayagarh district of Odisha, got admitted to KIMS 5 days back with history of..

C/C -Two huge non healing wounds in right lower leg and ankle region since four months

HOPI-My patient was apparently alright till four months back when he sustained injury in the right
leg when he tripped while walking on the road. He had a wound in the right ankle region .since then
the foot and leg started swelling gradually .The pain started next day which was increasing in
severity. Subsequently the wound near ankle was increasing in size associated with pain and foul
smelling purulent discharge. The pain was continuous and dull aching in nature, non-radiating and
confined to the wound area.

He was not able to walk because of pain and weakness. He lost about 5.6kg of weight in the last
three months.

He has consulted a local doctor and advised regular dressing. He was also advised to take Tab
Amoxicillin-clavulanate 625 mg twice daily for two weeks. No history of claudication , pain, fever or
similar symptoms in the other leg. No history of altered sensations in the foot. He was passing urine
and stool normally.

The patient is not a known case of hypertension/tuberculosis/drug allergy. But he is a known case
of type-2 Diabetes mellitus and is on irregular oral hypoglycemic agents for last three years .Other-
wise on no long term medications.

PAST MEDICAL HISTORY-nothing contributory

FAMILY HISTORY-His father was a known diabetic for 10 years and died at the age of 65 years due
to cerebro vascular accident. None of the other family members are suffering from Diabetes mellitus.

PERSONAL HISTORY -Married having two children. A known case of smoking since last 10 years
smoking 2 packs of beedis per day .He takes alcohol occasionally. He has a mixed diet habit .His
bowel and bladder habits are normal. Socio-economic status is average.

ON GENERAL EXAMINATION

A male patient aged about 50 years, moderately built and poorly nourished, conscious, co-operative
and comfortable in supine position with sunken looks and sparse hairs. His higher intellectual
functions are normal. There is pallor, no icterus, no cyanosis, no clubbing, no koilonychia, no
lymphadenopathy, pedal edema present on right foot, Jugular Venous Pressure not raised.

Pulse is 90 beats/min, bilaterally symmetrical , regular, normal volume, no water hammer pulse.

Blood pressure is 130/70 mm of hg

Respiratory rate is 20 cycles/min with thoraco-abdominal breathing.

Temperature is afebrile

LOCAL EXAMINATION

A large ulcer irregular in shape extending from lower leg to the dorsum of the right foot measuring
about 12 cm above the ankle joint and about 8 cm on dorsum of the foot with width ranging from 2
cm to 5 cm with sloping edges in most of the areas and few undermining edges.

Another ulcer was also seen medial to the medial malleolus measuring about 5 x4 cm which also
has sloping edges in most of the areas with few undermining edges

The surrounding skin of these ulcers are edematous ,hyper-pigmented and endurated. floor of both
ulcers are made of healthy as well as unhealthy granulation tissues with foul smelling discharge
from the wound .The base of lateral ulcer is formed by the underlying fibula .The base of the medial
ulcer is directly over the calcaneum extending on to the medial metatarsals.

On examination of peripheral vessels Dorsalis pedis, Posterior tibial, Anterior tibial pulses were
palpable.

On examination of sensation loss of fine touch on right leg upto mid leg.

No varicose veins seen.

Joint movements were normal.

SYSTEMIC EXAMINATION

CVS-both S1 and S2 normal, no added sounds.

RESPIRATORY SYSTEM-normal vesicular breath sounds heard.

PER ABDOMEN-no abdominal distension, no ascitis, no venous engorgement, no

hepatosplenomegaly

CNS- higher intellectual functions intact.

PROVISIONAL DIAGNOSIS

Non healing Wagners grade-2 Diabetic foot ulcer with neuropathy.

INVESTIGATIONS

-CBC

-FBS,PPBS

-HbA1C
- urea,creatinine,INR

-PUS (C&S)

-DOPPLER STUDY

-X-RAY OF FOOT-LATERAL,AP

MANAGEMENT

Wound care,debridement/amputation