This document provides background information on a male patient aged 41 presenting with a chronic skin ulcer on his right foot. It details his medical history, examination findings, investigations and treatment to date. The ulcer has been present for 3 years and is associated with blackish discoloration, pain, burning and discharge. Doppler studies show incompetent perforators in the lower right leg. The patient has been treated with medications, dressings and stockings with some improvement but the ulcer has not fully healed. He is now being referred to a new hospital for further management.

1. Dr. Sahana
2nd Year PG Scholar,
Dept of PG Studies in Kayachikitsa,
SKAMCH&RC,
Bangalore.

2. Name : G. Ranganathan
Age :41yrs
Sex :Male
Religion :Hindu
Socio-Economic status :Middle class
Marital status :Married life of 6 years.
Education :SSLC
Occupation :Works in his own Book stall

3. Date of Admission :09/05/2015
Ward :MGW
Source of History :Patient
Case taken on :13/05/2015
Consultant Doctor :Dr. Byresh
IP No :1827/15
OP No :C 11675
Address :#8, 4th Main Road,
LD Block, Ganganagar,
Bangalore-32.
Contact No :9880301989

4.  C/O skin discolouration with wound in medial aspect
of right foot since 3 years.

5. C/O
 Pricking type of pain
 Burning sensation at the site of lesion since
 Itching 3 years.
 Watery discharge
 Peeling skin

6. A male patient aged 41 years, N/K/C/O
HTN/DM/Dyslipidemia was apparently normal 3 years
back, when he gradually developed blackish
discolouration in the medial and lateral aspect of his right
ankle joint. He ignored this discolouration .Once due to
fall from a two wheeler, he had an wound in the lateral
malleolus of his right foot. On consulting a physician,
Dr.Vidyadhar he was prescribed with an ointment for

7. local application and the wound got healed in 1-2 weeks.
After 2-3 months there was peeling off of skin in lateral
malleolus i.e at the site where he had wound priorly.
Simultaneously he developed an wound in the medial
malleolus, which was less than 1cm.The wound was
associated with pricking type of pain, burning sensation
and occasionally itching. Pain would be noticed on
changing posture from supine to sitting with legs down
and vice-versa. There was watery discharge from the

8. wound at night time and little in quantity. The skin around
the wound had blackish discolouration. During this
period he also noticed altered sensation in his right foot,
he couldn’t feel the footwear slipping off from his foot
and he wouldn’t feel the sensation of his foot being
placed on pedal on riding. Symptoms of intermittent
claudication, rest pain, postural colour change, excessive
or diminished sweating were not present.

9. For this he again consulted the same physician, who
suggested venous doppler study. Doppler study revealed
incompetent perforator in lower leg. He was referred to
Bhagavan Mahaveer Jain hospital for further treatment
by the physician. The treating doctor in Mahaveer Jain
hospital prescribed an oral medication and some
ointments and advised to use stockings for both lower
limbs. He continued medication for a period of 6-7
months. In this duration the wound in the medial aspect
of the right foot was healed. The altered sensation in the

10. right foot was reduced. Pain, burning sensation, itching,
discharge and blackish discolouration was still persisting.
He developed peeling off of skin at the site of the healed
wound which gradually led to discontinuation of skin at
the site. Since then the wound has not completely healed
and the above mentioned features have been persisting.
He consulted an ayurvedic physician for these
complaints, who prescribed him with an oil for
application followed by ushna jala prakshalana and an
ointment and tablets. Patient had not taken the medicines

11. regularly and was not able to appreciate any changes in the
condition.On the follow up visit he was referred to
SKAMCH & RC by that ayurvedic Doctor. Patient’s
bowel and bladder habits are not affected after the onset
of the disease.

12. Treatment in Mahaveer Jain Hospital:
1)T.Daflon500mg 1-0-0
2)Kojiglo ointment
3)Kojivit plus ointment
4)Flutibact ointment
5)T-bact ointment
6)Fusidin H cream
Treatment prescribed by the Ayurvedic physician:-
1)Wright Oil-L/A
2)J.T Ointment
3)C.Manjista 2-0-2

13. 4)T.Gandhaka Rasayana 1-0-1
Treatment in SKAMCH &RC:-
1)Raktamokshana by jalokavacharana at right medial
malleolus-1 sitting

14.  No H/O TB/leprosy/PVD.
 No H/O any injury or surgery.

15.  Patient has 2 brothers.
 Both pateint’s father and mother were hypertensive
and diabetic.
 Patient’s father expired before three years,1 month
after being affected by CVA.
 Patient is married and has a child.
 No one in the family is said to have similar
complaints.

16.  Diet -Mixed, Non-Veg;chicken and mutton
2- 3 times a week,fish-once in 6 months.
 Appetite -Good(Untimely food habits)
 Sleep -Usually Sound, sometimes disturbed
when pain is severe
 Micturition -4-5 times/day
 Bowel -Once/day, regular,sometimes difficult
to pass and has to strain.
 Habits -Alcohol-once in a month occasionally,
Tobacco-10 times/day,started since 3 yrs
Coffee- 1 cup/day

17.  Working since past 35 years in his book stall.
 Daily work hours of 12hours with 1-2hrs of
break in between.
 H/O long standing present.

18.  Built - well built
 Nourishment - well nourished
 Pallour - Absent
 Icterus - Absent
 Cyanosis - Absent
 Clubbing - Absent
 Lymhadenopathy - Absent
 Edema - Present in right foot
 Tongue - Not coated

19.  Pulse - 78/m
 B.P - 130/80 mm of Hg
 Temp - 98° F
 Respiratory - 18/min
 Height - 167 cms
 Weight - 79 kg
 BMI -28.33

20.  PA
Inspection:
No distension
Umbilical centrally placed
No visible peristalsis,scars
Palpation:
Soft, No tenderness, No organomegaly

21. Percussion:
Tympanic sound heard
Dullness in right hypochondrium
Auscultation:
Bowel sounds heard
 CVS
On auscultation; S1 S2 heard, No murmurs.

22.  RS
Inspection
 Shape of chest - bilaterally symmetrical
 Respiratory rate - 18/min
Palpation
 Trachea - centrally placed
Auscultation
 No added sounds

23. Inspection:
Varicose veins- slight dilataion of veins seen in posterio
medial aspect of both legs below the knee.
Swelling: Localized
Present in right foot

24. Skin:
Colour-No generalized colour changes
Blackish discolouration in medial and
lateral aspect of right foot.
Texture- shiny in dorsum of right foot.
Ulceration- in the right medial malleolus
Toes-plantar flexion of right metatarsals seen.

25. Palpation:
 Trendelenburg test-negative
 Perthe’s test- negative
 Schwartz test- negative
 Morris cough impulse-negative
 Lymph nodes-no enlargemnt
 Homan’s sign-negative
 Mose’s sign-negative

26. Ulcer Examination
Inspection:
 Shape -irregular
 Number-1
 Position-medial malleolus
 Edge-sloping
 Floor-red granulomatous
 Discharge-watery, little in quantity
 Surrounding area-blackish pigmentation

27. Palpation:
 Tendernss -present
 Edge- sloping
 Bleeding on touch-absent
 Fixity –not fixed
 Surrounding skin-incresed temperature, tenderness,
fixity, loss of sensation absent
 Pulse- dorsalis pedis pulsation presnt

28. Prakruti - vaata kapha
Vikruti :-
Hetu - dadhi,masha sevana, standing for long time,
achankramanasheela
Dosha - vata
Dushya –rasa,rakta, asthi,sandhi
Prakruti - chirakari
Desha - saadharana desha
Kaala - 3 years,
Bala - daruna
Lakshana- vrana with toda,daha,kandu,srava and twak bheda in
dakshina pada.

29.  xÉÉU-qÉkrÉqÉ
 xÉÇWûlÉlÉ-qÉkrÉqÉ
 mÉëqÉÉhÉ- Ht- 167cms,
-Wt- 79 kg
 xÉÉiqrÉ–urÉÉÍqÉ´É(qÉkÉÑU,AqsÉ,sÉuÉhÉ,MüOÒû,MüwÉÉrÉ)
bÉëiÉ,¤ÉÏUAxÉÉiqrÉ,iÉæsÉ,qÉÉÇxÉUxÉxÉÉiqrÉ
 xÉiuÉ -qÉkrÉqÉ
 AÉWûÉUzÉÌ£ü-AprÉuÉWûUhÉzÉÌ£ü- qÉkrÉqÉ
-eÉUhÉzÉÌ£ü–qÉkrÉqÉ
 urÉÉrÉÉqÉzÉÌ£ü–qÉkrÉqÉ
 uÉrÉ–qÉkrÉqÉ
 ÌuÉMüÉU-mÉëuÉU

30.  Nidana-Aharaja- dadhi sevana in greeshma,masha(pitta-
rakta prakopaka)
- Katu pradhana ahara nitya sevana(vata-pitta prakopaka)
Viharaja-standing for long duration(vata prakopa)
 Purvarupa-Karshnya, sparshajnatva
 Rupa- vrana with toda,daha,kandu, srava and twak
bheda,anguli vakrata in dakshina pada.

31.  Rakta prakopa due to rakta prakopaka nidana sevana
 Vata prakopa due to vata prakopaka hetu
 Vriddha vata patha avarana by Rakta
 Dushita vata and rakta having moola in pada
 Gamana in sarva shareera due to sukshmata,sarva sarta of
vata and dravata,saratva of rakta
 Stana samsharaya in the parva of legs
 Manifesting lakshanas of vatarakta in Dakshina pada
 Presenting with upadravas

32. xÉÇmÉëÉÎmiÉ bÉOûMü
 SÉåwÉ -uÉÉiÉ
 SÕwrÉ -UxÉ,U£ü,AÎxjÉ,xÉÎlkÉ
 AÎalÉ -eÉÉPûUÉÎalÉ,kÉÉiuÉÉÎalÉ
 xÉëÉåiÉxÉç -U£üuÉWû
 xÉëÉåiÉÉåSÒ̹mÉëMüÉU -xÉ…¡û,ÌuÉqÉÉaÉïaÉqÉlÉ
 E°uÉxjÉÉlÉ -mÉYuÉÉzÉrÉ
 xÉÇcÉÉUxjÉÉlÉ -xÉuÉïzÉUÏU
 urÉ£üxjÉÉlÉ -SͤÉhÉmÉÉS

33.  AÍkɹÉlÉ -iuÉMçü,U£ü,AÎxjÉ,xÉÎlkÉ
 qÉÉaÉï - oÉɽ,qÉkrÉqÉ
 xÉÉkrÉÉxÉÉkrÉiÉÉ–rÉÉmrÉ

34. vyadhi Inclusion criteria Exclusion criteria
Raktavruta Vata Daha,shwayatu
present
Raga,Mandala absent,
srava,kandu, toda,
shyava varnata present
Dhamani
pratichaya
Kandu,
kleda,chirakarita
present
Sheeta,shaitya,gourava
, arochaka,supti absent;
vrana with toda, srava,
Siragata Vata Manda ruk,shopha Shushyati spanadate,
supti
Dushta Vrana Deerghakalanubandhi
, Daha, Kandu,
Shopha
Puti,puya,mamsa,sira,s
nayu purna,shonita
sraava,

35. Vyadhi Inclusion criteria Exclusion criteria
Shataru Shyava, daha, Bahuvranata absent
Sthularushka Sandhishu, arumshi Daha, shotha,
kandu,srava, anguli
vakrata present
Pama Sasraava,kandu,paridaha,
Anu pidaka
Daha, shotha,
shyava varna,shotha,
anguli vakrata
present
Siraja granthi Sirapratanata seen,unnata
granthi appearance in the
sira.
Other lakshanas are
also noted in patient.
Vatarakta with
upadrava
Shyava varnata, sirayama,
daha, kandu,shotha,toda
anguli vakrata
----------

36. Vatarakta with upadrava

37. Disease Inclusion
criteria
Exclusion criteria
Atherosclerotic
ulcer
Pain present Intermittent claudication,rest
pain,numbness absent,
pulsation intact
Buerger’s
disease
Distal lower
extremity
involved,
ulceration,history
of tobacco
chewing
Triad of claudication of
affected extremity,Raynaud’s
phenomenon nd migratory
superficial vein
thrombophlebitis absent
Vasculitic ulcer Presenting with
pain
Intermittent claudication,rest
pain,numbness absent,
pulsation intact

38. Disease Inclusion criteria Exclusion criteria
Deep Vein
thrombosis
Oedema present in
leg, ulceration in leg
No symptoms of
paralysis/paresis,
characteristic low grade
fever absent, negative
homan’s sign
Diabetic
Ulcer
H/O altered sensation Non diabetic
Tropic
Ulcer
H/O altered sensation Punched out edge
absent,no pus
discharge, no
induration, no slough
seen,callosity absent

39. Disease Inclusion criteria Exclusion criteria
Non healing
Ulcer
Chronicity,scanty
discharge
Red granulation tissue
observed
Varicose
ulcer
Medial malleolus
site, associated with
varicose veins in
upper part of
limb,pigmentation
around ulcer,
discharge present
ankle edema
----------

40. Varicose ulcer

41. RIGHT LOWER LIMB VENOUS DOPPLER STUDY
dated 5/11/2012:-
 Incompetent perforator in the lower leg causing
incompetence of the great saphenous vein in the
lower leg.
 No evidence of Deep Vein Thrombosis.

42. BILATERAL LOWER LIMB VENOUS DOPPLER
dated 11/10/2013:-
 Incompetent right leg perforators.
 No evidence of Acute or Chronic Deep Vein
Thrombosis bilaterally.

43. COLOUR DUPLEX STUDY OF BOTH LOWER
LIMB VEINS dated 17/2/2014:-
 Bilateral chronic venous insufficiency due to
femooropopliteal reflux and multiple perforators
No evidence of Acute Deep vein thrombosis at
present.

44. Date Treatment Observations
9/5/15 1)C.Manjista 2-0-2
2)T.Gandhaka Rasayana 1-0-1
3)T.Kaishora Guggulu 2-0-2
4)Sarv Abhyanga with
Balaguduchyadi taila+Ushna jala
snana
5)Kala Basti-Anuvasana –
Yastimadhu taila-50ml+Gugulu
tiktaka Ghrita-50ml
Vrana in dakshina
pada with toda,
daha, srava, kandu,
twak bheda,shyava
varnata.
10/5/15 Cont 1) to 4),
5)Niruha-Madhu-100ml+ Yasti
taila-100ml+GTG-100ml+ Guduci
Ksheerapaka-200ml
All lakshanas
persisting.

45. Date Treatment Observations
11/5/15 Cont 1) to 4)
5)Anuvasana Basti-3/16
Reduced srava,other
lakshanas present.
12/5/15 1) And 2) stopped,
3) And 4) continued
5)Niruha-4/16
5)Mahamanjistadi kashaya+
6)T.Kanchanara Guggulu-2
tab powdered+3tsp Kashaya+
9tsp water-BD-B/F
7)T.Chandraprabha Vati+
Punarnavasa-2 tab powdered+
3tsp Asava+ 3tsp water-A/F
Srava persists with
other lakshanas

46. Date Treatment Observation
13/5/15 Cont 3) to 7) Toda and kandu reduced
14/5/15 Cont 3) to 7)
8)Balaguduchyadi
taila for L/A to
wound
Toda and kandu reduced
15/5/15 Cont 3) to 8) No changes noted
16/5/15 Cont 3) to 8) Superficial dry skin peeling off.

47. Date Treatment Observation
17/5/15 Cont 3) to 8) Toda,kandu increased in
intensity by 50%
18/5/15 Cont 3) to 8) Toda,kandu increased in
intensity by 50%
19/5/15 Cont 3) to 8) Decrease in the quantity of
srava

48. 1)Jaloukavacharana
2)Virechana -Snehapana- Guggulu tiktaka ghrita
Vishramakala-bahya sneha-sarv Abhyanga with
Balaguduchyadi taila-Parisheka with Manjista+Guduchi churna
sadhita kwatha
Virechana -Nimbamrutadi eranda taila-60ml
3)Basti- anuvasana with Yastimadhu Taila
Niruha with sneha-yastimadhu taila, kalka-guduchi
churna, kwatha-manjista kwatha

49.  Tab.Kaishora Guggulu 2-0-2
 Mahamanjistadi kashaya 4tsp-0-4tsp
 Guduchi ksheerapaka 100ml BD
 Amritaprashavaleha 1tsp BD
 Guggulu tikataka ghrita1tsp BD(after shodhana)