2. DEMOGRAPHIC DETAIIL:
Name: Mr. Perumal samy
Age/sex : 54 years, male
Occupation: shop keeper
Address: Madurai
CHIEF COMPLAINT:
• Ulcer in the right foot for 2 months duration
3. Summery of history:
A 54 years old Mr. Perumal samy presented
with ulcer in the planter aspect of right foot for
2 months duration. It starts as small blister and
rapidly turn into ulcer of present size. He was
known diabetic for 14 years duration on regular
medication and reformed alcoholic since 5
years, non smoker.
4. General examination:
• Patient was conscious, alert, afebrile and comfort at rest.
• No pallor, No icterus, No cyanosis, No clubbing, No
lymphadenopathy, No pedal edema.
Vitals:
• Pulse: 84 beats per minutes, regular rhythm, normal volume, no
specific character. All peripheral pulses are felt
• Blood pressure: 134/82 mmHg in right upper arm in sitting posture
• Temperature: 98.2 degree F
• Respiratory rate: 14 breaths per minute.
• Height: 164 cm Weight: 88 kg BMI: 32.7
Systemic examination: normal
5.
6. Local examination: of right foot
Inspection:
•Site: planter surface of head of first metatarsal
•Number: single
•Size: 5*4 cm in size
•Shape: oval
•Edge: punched out
•Margin: well defined
•Floor: filled with slough and sero purulent discharge
•Discharge: sero purulent discharge
•Surrounding area: pale and inflamed
•Whole limb: Normal
•No similar feature in left lower limb
7. Local examination: of right foot
Palpation:
•Tenderness: no tenderness on palpation
•Surrounding area: pitting on pressure
•Findings of inspection are confirmed
•Base: ulcer rest over the tendons and bone, no fixity
•Depth: 8mm
•Bleeding: no bleeds on touch
•Extends into the deeper structure
Examination of regional lymphnodes:
• No palpable lymphnodes
8. Local examination: of right foot
Examination of vascular insufficiency:
•No varicose vein
•Anterior tibial and posterior tibial artery pulsation
are palpable.
•Dorsalis pedis artery pulsation feeble
Examination of Nerve lesion:
•Sensory loss around weight bearing area
•Absent ankle reflex
10. Investigation:
• Study of discharge: culture & sensitivity, cytology
• X- ray of right foot
• Haemoglobin, ESR, total count and differential count
• Plasma glucose
• HbA1c
• Blood lipid profile
• Serum creatinine and blood urea
• Duplex ultrasound
11. Treatment:
• Debridement of dead tissue
• Off loading of pressure
• Broad spectrum antibiotics
• Drain collections of pus
• Daily ulcer cleaning and dressing
• Blood sugar control
• Wide fitting footwear
• Regular foot inspection
