A 54-year-old man presented with a 1-month history of pain and swelling on the outer left foot and blackening of the left little toe for 15 days. He has type 2 diabetes for 5 years and underwent amputation of the left little toe. On examination, he has an 8.5x7 cm ulcer on the left foot dorsum and plantar aspect with features of peripheral neuropathy and restricted ankle range of motion. He was diagnosed with a left diabetic foot ulcer post little toe amputation that has improved from Wagner grade 4 to grade 2, along with bilateral mixed peripheral neuropathy.
UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
Case study on Varicose Veins & Venous UlcersAbhineet Dey
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Moderator:
Dr M. K. Mazumdar
Asst. Professor,
Dept. of Obstetrics and Gynaecology,
Gauhati Medical College & Hospital
Presented by:
29: Abhineet Dey
30: Devasree Kalita
31: Parishmita Sharma
32: Samadrita Borkakoty
33: Ankur Jain
34: Dhurjyoti Nath
35: Mousumi Mehtaz
Students of 8th Semester,
Gauhati Medical College & Hospital, Guwahati, Assam
UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
Case study on Varicose Veins & Venous UlcersAbhineet Dey
A clinically based study of a case of Varicose Veins & Venous Ulcers.
Moderator:
Dr M. K. Mazumdar
Asst. Professor,
Dept. of Obstetrics and Gynaecology,
Gauhati Medical College & Hospital
Presented by:
29: Abhineet Dey
30: Devasree Kalita
31: Parishmita Sharma
32: Samadrita Borkakoty
33: Ankur Jain
34: Dhurjyoti Nath
35: Mousumi Mehtaz
Students of 8th Semester,
Gauhati Medical College & Hospital, Guwahati, Assam
Examination of Swelling in a patient is always a task for MBBS students. This PPT provides the students, how to elicit a history & also the easy way to examine a swelling.
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Long case examination done during MBBS and MD examination. Neurology case is mostly the long case. History, general examination , systemic examination, provisional diagnosis, investigation and final diagnosis are the sequential steps. Neurology examinations includes higher mental function, cranial nerve examination, motor and sensory system examination, cerebellar signs, gait, peripheral nerves, spine and skull and peripheral nerve examination.
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Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
2. 1. Patient Particulars
• Name – Mr A
• Age – 54 years
• Occupation – Driver
• Resident from – Orang
• SES – Lower middle class
• Date of Admission- 02/02/2020
• Date of Examination - 12/03/2020
3. 2. Presenting Complaint
• Pain & swelling over the outer aspect of left foot -1 month.
• Blackish discoloration of left little toe -15 days.
4. 3. History of Presenting Complaint
• Complained of pain & swelling over the outer aspect of the left
foot towards the little toe following a trivial trauma while walking
one month back.
• Pain was throbbing and localized to the same region, continuous
which aggravates on movements relived by medications. It was
associated with swelling and later mild fever and small quantity
purulent discharge from the lower aspect of foot.
• Following treatment after consultation with a local practitioner,
there was symptomatic improvement in form of reduction of pain
,swelling and discharge ,later there was spontaneous blackening
of tip of left small toe gradually progressed to involve the entire
toe , with reappearance of foot pain since 15 days
5. • He was admitted and underwent amputation of the little
toe , serial debridements and the affected limb presently
has an ulcer over the outer aspect of left foot .
• Tingling, numbness and reduced sensation over both the
foot was present since 2 years.
• No complaints of swelling over the groin, or previous
history of ulcer over the genitals.
• No features of claudication pain.n
• No h/o alteration in bowel and bladder habits ,loss of
weight or appetite, features s/o TIA /LOC, dyspnea, chest
pain or palpitations.
6. 4. Past History
• Known case of type 2 diabetes mellitus on
irregular medication for the past 5 years .
• No other known comorbidities.(Hypertension ,
chronic kidney disease, CAD,TB, Hansen’s
disease, hypo or hyper thyroidism,
rheumatological disorders, varicose veins )
• No previous hospitalization or surgeries in the
past.
5. Family History
• No known TB, hematological, cardiac or
vasculitis related illnesses.
7. 6. Personal & Social History
• Tobacco in the form of smoking – 5 pack
years.
• Occasional alcohol consumption for 12 years.
• Married and living with wife and 2 children.
8. 7. Physical Exam & General Survey
• Examined the patient with informed consent,
in a well lit room, after adequate exposure.
• Patient is lying comfortably with both limbs
stretched on the examination couch.
• Average built – 165 cm
• BMI - 20.8 Kg/m2
• KFS –80
• Gait : limping /antalgic (pain)
9. • Skin – Trophic changes of lower extremity. No hypopigmented patches
noted.
Eyes – no icterus, pink palpebral conjunctiva
Oral cavity – normal
• Neck – normal
• Fingers & Nails – no joint swelling or deformity , Onychodystrophy of
bilateral toe nails ,no clubbing, koilonychia
• No significant generalized inguinal lymphadenopathy
Vital Signs –
• Afebrile
• PR – 72 beats/min in R radial artery; regular in rhythm with normal vessel
wall & character and without radioradial or radio-femoral delay.
• BP – 130/80 mmHg in right arm supine position.
• RR – 14 cycles/min and regular.
10.
11. 8. Examination of Lower Limbs
Right Left (affected)
Attitude Neutral 10◦ of dorsiflexion at ankle
Deformities nil 5th toe amputated
Skin hair and nails Dry and scaly skin,
sparse hair,
onychodystrophy
Ulcer present ,Dry and scaly skin with
hyperpigmentation over the dorsal aspect ore
around the ulcer , sparse hair, onychodystrophy
• Single ulcer located over the left foot dorsum extending to the plantar aspect
occupying the distal outer aspect .
• Irregularly curved margin , with sloping edge all around with red ,blue and white
zones.
• Floor is formed by healthy granulation tissue ,with minimal slough interspersed
and with extensor tendon of 4th toe exposed ,minimal serous discharge present
• No gangrenous changes over the limb , No dilated veins , ankle joint grossly
normal.
• Areas of pressure points – normal.
12. PALPATION
• Temperature normal over the ulcer and surrounding area.
• Ulcer and the surrounding area is mildly tender
• Measurements of the ulcer : 8.5 * 7 cm
• Other inspector findings are confirmed.
• Base : formed by the muscles over dorsum and plantar, mildly indurated
,granulation tissue bleeds on touch,distal portion of the fifth metatarsal is palpable
beneath the granulation tissue.
• Web spaces normal. Long bones normal.
• Capillary filling and refill time - normal (b/l)
• No inguinal lymphadenopathy (b/l)
• No peripheral nerve thickening
13.
14. Right Left (affected)
Peripheral pulse DPA (+); ATA (+); PTA (+); Pop. A (+);
Femoral A(++); RA (++); UA (++); Br A
(++); Ax A (++); Subcl A (++); Carotid A
(++); STA (++).
DPA (+); ATA (+); PTA (+); Pop. A (+);
Femoral A(++); RA (++); UA (++); Br A
(++); Ax A (++); Subcl A (++); Carotid A
(++); STA (++).
Neurological
sensation-Vibration
proprioception,pain
monofilament test,
Ankle reflex
knee reflex
Power
Diminished
0
+
N
Diminished
0
+
N
Measurements
Length 85 cm 85 cm
Muscle bulk 33 (ak), 31(calf) 33 (ak), 31(calf)
Range’movements
Flexion
Extension
Pronation
Supination
Knee
20◦
50◦
30◦
50◦
N
<10◦
40◦
10◦
20◦
N
15. 9. Systemic Examination
• Respiratory System
Bilateral vesicular breath sounds heard; no added sounds.
• Abdomen and perineum
Soft, non tender, no visceromegaly, normal bowel sounds
heard. Perineal examination normal.
• Cardiovascular System
S1 S2 heard. No abnormal sounds heard.
• Central Nervous System and spine.
Normal.
16. 10. Summary
• A 54 YO ,type 2 diabetic male patient come with
a complaint of pain ,swelling over the left little
toe ,followed by gangrene an purulent discharge
from the same site for 15 days. He underwent
rayamputation of the little toe and is currently
have a healing ulcer over the lateral ,dorsal and
plantar aspect of left foot .
• Clinical exam significant for 8.5*7cm ulcer with
features of peripheral neuropathy and restriction
of range of movements of ankle joint.
17. 11. Diagnosis
Diabetic foot ulcer left side ,post ray amputation
status left 5th toe (Wagner grade 4 improved to
grade 2 ) with bilateral mixed peripheral
neuropathy .
Diabetic foot ulcer – PEDIS system
P1 E(8x7.5) D2 I1 S2
Temperature normal over the ulcer and surrounding area.
Ulcer and the surrounding area is mildly tender
Measurements of the ulcer : 8.5 * 7 cm
Other inspector findings are confirmed.
Base : formed by the muscles over dorsum and plantar, mildly indurated ,granulation tissue bleeds on touch,distal portion of the fifth metatarsal is palpable beneath the granulation tissue.
Web spaces normal. Long bones normal.
Capillary filling and refill time - normal (b/l)
No inguinal lymphadenopathy (b/l)
No peripheral nerve thickening
Hba1c level , xray of the limb , tissue or pus c/s,Doppler study , ABPI,other anciliary investigations.
Adequate glycemic control, wound bed preparation - Debridement and dressing,appropriate antibiotics ,revascularization ,off loading(TCC,removable cast walkers /crutches/wheel chairs) ,patient education –signs and symptoms of foot probs,imp of glycemic contro,avoid smoking,daily inspection of feet, toes ,webs, dosum, avoid bear foot walking, use custom made MCR shoes