CASE PRESENTATION

Neeraj Kumar Jain Surgery

Case presentationKailash son of Bherulalji ,30 year , hindu,

married male, resident of Pipliya Kheda, Prajapati Nagar, Kaanipura Ujjain admitted in surgery ward on 22 December 2012 at 3.15pm :

With alleged History of Road traffic accident by cartwheel on 7 dec 2012 after which he had complaints of

Pain in left lower leg for 15 days.Swelling in left lower leg for 14 days.Pus Discharge from swelling for 10 daysUlcer over left lower leg for 10 days.

H/o presenting illnessAs per patient he was alright 15 days back then he had accident with cartwheel after which he developed pain in left lower leg which was initially dull aching , progressive in nature gradually it has increased in intensity.

Swelling in left lower leg for 14days which was limited to lower leg gradually increased in size .For which he was admitted in Some hospital and dressing was done after 4 days swelling burst opened and pus came out then swelling decreased in size.

Then he developed black discoloration of skin so debridement was done.

Since then he is having Ulcer over left lower leg associated with Pus discharge.

Past history

No History of any previous Surgery.No history of any long illness in past .

Family history:

He is married having 4 Children .No history of any long illness in family.

Personal historyHe is Non vegetarian. History of smoking bidi for 8 years half

bundle daily, Tobacco chewing for 10 years, Alcohol drinking for 7 years.

Bowel and bladder habits normalDRUG HISTORYHistory of taking some medication for pain.No history of drug allergy.

GENERAL EXAMINATIONTemp not raised Pulse -84 per minBlood pressure -110/80mm HgBulbar Conjunctiva –WhitePalpable conjunctiva- pinkOral Hygiene-PoorNails-no Koilonychia,No clubbingNeck veins/neck glands- not Palpable.Odema ,lymphadenopathy absent

Local examinationSingle large ulcer present on dorsum of left

lower foot extending from 5cm away from great toe to lateral malleolus.

Irregular shaped ,nearly 15cm * 7cm in size.Margin- inflamed and oedematous.Edge-Sloping and punched outFloor- Slough present Base-underlying Muscles and bones.Skin around Ulcer is hyper pigmented.

Palpation

Temperature not raised Tenderness presentSingle large ulcer present on dorsum of left

lower foot extending from 5cm away from great toe to lateral malleolus.

Irregular shaped ,nearly 15cm * 7cm in size.Margin- inflamed and oedematous.Edge-Sloping and punched outFloor- Slough present , Bleeding present on

touch at some sites.Base-underlying Muscles and bones.Skin around Ulcer is hyper pigmented.

PROBABLE DIAGNOSISNecrotizing fasciitis of left lower leg

Traumatic Infected Non healing Ulcer on left lower leg

Hematological investigationsHb- 12.4 g/dlTLC- 8500/cummDLC- N-62 L-30 E-06 M-02

Other investigations

Urine examination-NAD.RBS-90mg/dlCREATININE-0.6mg/dlUREA-24.8mg/dlHIV & HBSAg-NR

He was operated on 24 Dec and Debridement was done.

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