2. CHIEF COMPLAIN
• A CASE OF 70 YRS OLD MUSLIM MARRIED MALE PATIENT NAMED HARUNBHAI
LADUJI RESIDING AT JAMALPUR, AHMEDABAD BELONGING TO MIDDLE SOCIO
ECONOMIC CLASS FORMERLY A DYING MILL WORKER PRESENTED TO SVP OPD ON
9/01/2021 WITH
• C/O RIGHT LEG PAIN SINCE 3 MONTHS
• C/O RAW AREA OVER RIGHT FOOT SINCE 1 MONTH
AW PAIN SINCE 1 MONTH
3. ORIGIN DURATION PROGRESS
• PATIENT WAS RELATIVELY ASYMPTOMATIC BEFORE 3 MONTHS.
• THEN HE DEVELOPED COMPLAIN OF PAIN OVER RIGHT LEG WHICH IS CRAMP LIKE IN
NATURE, MILD INTENSITY,INTERMITTENT,NON-RADIATING
• PAIN INCREASES ON WALKING DISTANCE OF ABOUT 1 KM AND IS RELEIVED ON WALKING
FURTHER DISTANCE. NO SUCH PAIN IS EXPERIENCED OVER OTHER LIMB.
• PATIENT DEVELOPED RAW AREA OVER DORSUM OF RIGHT FOOT NEAR 4TH INTERDIGITAL
CLEFT 1 MONTH AGO . PATIENT HAD BEEN OPERATED FOR RIGHT 4TH TOE AMPUTAION 1
YR AGO. PATIENT CONTINUED REGULAR CLEANING & DRESSING SOMETIMES AT HOME
AND SOMETIMES AT PRIVATE CLINIC.
4. • LATER, 1 MONTH AGO PT DEVELOPED RAW AREA OVER STUMP SITE OVER DORSUM OF RIGHT
FOOT NEAR 4TH INTERDIGITAL CLEFT WHICH WAS SPONTANEOUS IN ORIGIN. RAW AREA WAS
INITIALLY SMALL IN SIZE AND NOT ASSOCIATED WITH ANY DISCHARGE.
• THEN GRADUALLY THE RAW AREA INCREASED IN SIZE UPTO PRESENT SIZE, ASSOCIATED WITH
GREENISH DISCHARGE. RAW AREA WAS ASSOCIATED WITH DULL ACHING PAIN WHICH WAS
INITIALLY MILD IN INTENSITY AND REMAINED THE SAME THROUGHOUT THE COURSE. PAIN
INCREASED ON WALKING AND RELEIVED ON TAKING MEDICATIONS. PAIN DOESNT RADIATE NOR
DOES IT REFER TO ANY OTHER SITE.
5. • NO H/O FEVER,TRAUMA
• NO H/O LOSS OF LEG MOVEMENT
• NO H/O LOSS OF SENSATIONS OVER LEG
• NO H/O SKIN BLACKENING
• NO H/O REST PAIN
• NO H/O CARDIAC PROBLEM
• NO H/O BLACKOUTS,BLURRED VISION
• NO H/O ABDOMINAL PAIN
• NO H/O IMPOTENCE
6. PAST HISTORY
• K/C/O DM SINCE 25YRS ON INJ. HUMALOG 8 UNITS 12HRLY.
TAB. GLYNASE MF (5/500 MG) 1-1-1
TAB. VILDAGLIPTIN (50MG) 1-0-1
• NO H/O HYPERTENSION,IHD
• H/O CVA 1 YEAR AGO CAUSING PARALYSIS OF LEFT SIDE OF FACE
PT IS ON TAB. ECOSPRIN (75MG) 0-1-0
• H/O RIGHT 4TH TOE AMPUTATION 1 YEAR AGO DUE TO BLACKENING OF 4TH TOE FOLLOWING TRAUMA
7. PERSONAL HISTORY
• PATIENT TAKES MIXED DIET HAVING NORMAL APPETITE, HAS NORMAL BOWEL & BLADDER MOVEMENTS,
TAKES ADEQUATE SLEEP AND NO KNOWN ALLERGIES OR HABITS KNOWN
8. FAMILY HISTORY
• PATIENT FATHER AND BROTHER IS K/C/O DM AND TAKING MEDICATIONS.
• NO H/O HTN, TB AMONG FIRST DEGREE RELATIVES
9. GENERAL EXAMINATION
• PATIENT IS CONSCIOUS, ORIENTED TO TIME/PLACE/PERSON
• PATIENT IS AVERAGELY NOURISHED, AVERAGELY BUILT
• NO SIGNS OF PALOR, OEDEMA, CYANOSIS, CLUBBING, ICTERUS, LYMPHADENOPATHY
PRESENT
• T - N
• P - 72/MIN REGULAR AT RIGHT RADIAL ARTERY WITH NORMAL RHYTHM,FORCE,VOLUME
AND TENSION
• BP - 130/80 MMHG AT RIGHT BRACHIAL ARTERY AND 128/82 MMHG IN LEFT BRACHIAL
ARTERY IN SUPINE POSITION
10.
11.
12. LOCAL EXAMINATION
-Inspection
• BROWNISH SKIN HYPERPIGMENTATION PRESENT OVER B/L FOOT EXTENDING FROM ANKLE
JOINT UPTO TIP OF TOES MORE EVIDENT ON RIGHT FOOT THAN LEFT FOOT
• SKIN THINNING, LOSS OF SUBCUTANEOUS FAT, DIMINISHED HAIR GROWTH, SHININESS OF SKIN
EVIDENT OVER ANTERIOR ASPECT OF LEG MORE EVIDENT OVER RIGHT LEG THAN LEFT LEG
• AN APPROX 6*4CM SINGLE IRREGULAR SHAPE ULCER PRESENT OVER DORSALASPECT OF RIGHT
FOOT WITH PROXIMAL BORDER APPROX. 6CM DISTAL TO RIGHT ANKLE JOINT EXTENDING INTO
THE INTERDIGITAL CLEFT BETWEEN 3RD AND 5TH TOE. ULCER HAS PUNCHED OUT EDGES,
IRREGULAR MARGINS, FLOOR FORMED BY UNDERLYING TENDONS AND SLOUGH ASSOCIATED
WITH GREENISH PUS DISCHARGE.
• CAPILLARY REFILLNG TIME DELAYED OVER RIGHT FOOT, NORMAL OVER LEFT FOOT
• VENOUS REFILLING NORMAL OVER BOTH LIMBS
• ON BUERGER’S POSTURAL TEST, PALLOR IS NOT APPRECIATED OVER B/L LOWER LIMBS.
• MOVEMENT OVER ANKLE JOINT,MP AND IP JOINT IS NORMAL OF LEFT FOOT.
• PATIENT IS UNABLE TO MOVE 3RD AND 5TH TOES OF RIGHT LOWER LIMB.
13. Palpation
ALL INSPECTORY FINDINGS CONFIRMED BY PALPATION
• LOCAL TEMPERATURE IS NORMAL AND MILD TENDERNESS ELICITED ON
PALPATING THE BASE OF ULCER AND SURROUNDING SKIN
• CAPILLARY REFILLNG TIME DELAYED OVER RIGHT FOOT, NORMAL OVER LEFT
FOOT
• VENOUS REFILLING NORMAL OVER BOTH LIMBS
• A 6*4CM SINGLE IRREGULAR SHAPE ULCER PRESENT OVER DORSAL ASPECT OF
RIGHT FOOT WITH PROXIMAL BORDER 5CM DISTAL TO RIGHT ANKLE JOINT
EXTENDING INTO THE INTERDIGITAL CLEFT BETWEEN 3RD AND 5TH TOE. ULCER
HAS IRREGULAR MARGINS, PUNCHED OUT EDGES, FLOOR FORMED BY TENDONS
AND SLOUGH, BASE FORMED BY UNDERLYING BONE ASSOCIATED WITH GREENISH
PUS DISCHARGE.
• NO PALPABLE INGUINAL LYMPH NODES.
14. • ARTERIAL PULSATIONS OF LOWER LIMB
RIGHT SIDE LEFT SIDE
• COMMON CAROTID + +
• SUBCLAVIAN A. + +
• AXILLARY A. + +
• BRACHIAL A. + +
• RADIAL A. + +
• ULNAR A. + +
• FEMORAL A. + +
• POPLITEALA. + +
• ANTERIOR TIBIAL A. - +
• POSTERIOR TIBIALA. - +
• DORSALIS PEDIS A. - +
16. Diagnosis
• PERIPHERAL ARTERIAL OCCLUSIVE DISEASE OVER RIGHT LOWER LIMB WITH RIGHT
DIABETIC FOOT ULCER WAGNER(GRADE 3) PROBABLY DUE TO ATHEROSCLEROSIS.
