Ischemic Ulcer in a Diabetic Patient - Case Study Example

RUNNING HEAD: Ischemic Ulcer Case Discussion on Ischemic Ulcer in a Diabetic Patient of the Under the guidance of Case scenario 65 year old John presented to the hospital with history of ulcer over the lateral malleolus of the left leg since four weeks. The wound is associated with pain which was severe in the nights. History revealed that John is a known hypertensive since 10 years and was diagnosed to have diabetes mellitus- type 2 6 years ago. He has been taking nifedipine twice a day for hypertension and glipizide and metformin for diabetes mellitus. Johns lipid profile revealed hypercholesterolemia and hypertriglyceridemia four years ago since when he has been on atovostatin 10 mg once a day. Other important findings in the history include presence of intermittent claudication of the left lower limb since one year. John is a chronic smoker. He decreased smoking since one year after onset of claudication symptoms, following advice from a physician. However, he has not been able to completely quit smoking. During the current visit to the hospital, there is no history of fever or any other symptoms. The patient complains that the onset of ulcer started after he began to wear new slip-on shoes with narrow toe box. The patient reported being allergic to penicillin. There is no history suggestive of occupational injury, trauma, varicose veins, previous history of lower limb wounds/ulcers/gangrene, history of amputations and history of any other surgeries. There is no family history of similar ulcers either. The patient is not suffering from any collagen diseases. He is not on any anti-inflammatory drugs or steroids. Physical examination of the patient and assessment of the ulcer The condition of the patient is stable. He is afebrile. He looks well nourished. Vitals signs are stable. Systemic examination is within normal limits. The ulcer is located over the lateral malleolus of the left leg. The size of the ulcer is 3cm in length, 2 cm in width and about 0.5 cm in depth. The borders are regular and the wound appears punched out and clean. The color of the ulcer is yellowish. There is minimal granulation tissue. The exudate from the ulcer is mainly serous and minimal. The surrounding skin appears pale, non-edematous, shiny and has decreased hair. Dorsalis pedis pulsation appears normal. Discussion Lower extremity ulcers are very common in patients with diabetes and infact, these are the most common causes for limb amputation in diabetic population (Armstrong and Lavery, 1998). Factors which contribute to the development of ulcers in the diabetic population are diabetic neuropathy, peripheral arterial disease and structural deformity (Armstrong and Lavery, 1998). From a podiatrician perspective, it is very important to evaluate, assess and manage foot ulcers in diabetic patients properly, because amputation risk is atleast 15- 46 times higher than in non-diabetic population (Armstrong and Lavery, 1998). Ulcers in diabetic population can be either ischemic, venous type or neurotropic. Identification of the type of ulcer makes it possible to provide correct treatment and advice. The first step in the evaluation of a patient with lower extremity ulcer is taking appropriate medical history. History should include age and sex of the patient and presenting complaints. The chronology of events, whether the onset of the wound was traumatic or spontaneous, the treatments taken for the wounds and the outcomes of the treatments must be enquired. The history should also include whether the ulcer is associated with pain and if present, whether the pain is sudden in onset, and whether it is nocturnal or present when the leg has been in the dependent position for a long time. Other details to be included in the history are history of any chronic disease like diabetes and hypertension, occupational history, history of varicose veins, previous history of lower limb wounds/ulcers/gangrene, history of amputations and history of any other surgeries. Family history of similar ulcers also must be enquired into (Kunimoto, 2001). Influence of biological and social factors also must be assessed. The next step in assessment is to determine the etiology and risk factors of the wound. Age, malnutrition, collagen disease and drugs like steroids inhibit wound healing (Kunimoto, 2001). After medical history, physical examination of the wound must be undertaken. Physical examination gives valuable information especially in the elderly who cannot recall history details. One of the aims of physical examination is to differentiate between venous leg ulcers and non-venous leg ulcers. Venous leg ulcers occur in the distal medial third of the lower extremity and they are shallow without punched margins. The amount of granulation tissue and its color must also be assessed. Decreased granulation tissue or bluish hue color of this tissue are indicators of bacterial infection. The drainage from the wound must be examined as to whether it is serous, purulent or serosanguinous. Purulent discharge is an indicator of bacterial infection. The length, depth and width of the ulcer must also be assessed. Surrounding skin examination gives a valuable clue to differentiate between venous and non-venous ulcers. Peripheral arterial circulation assessment is a must in ulcer evaluation. Palpation of the dorsalis pedis artery is useful for this purpose. However, it is absent in about 10% of people. Color and perfusion are other markers for arterial sufficiency (Kunimoto, 2001). Diagnosis There are basically 3 types of ulcers which can present in the lower limb. They are venous stasis ulcers, arterial or ischemic ulcers and neuropathic or diabetic ulcers. Venous stasis ulcers are mainly located below the knee and in the inner aspects of the leg just above the ankle, like the medial malleolus. The base of the ulcer is usually red, the borders are irregular and the ulcer may be covered with yellowish tissue. Fluid drainage is a characteristic feature of venous ulcer. The surrounding skin will be discolored and swollen and may feel warm. Ischemic or arterial ulcers are usually located in the feet, especially in regions where there is friction between toes or parts of feet with shoes, or when there is a deformity. The ulcer base is yellowish, grey or black and does not bleed (Gabriel and Camp, 2008). The borders are punched out and regular. Ischemic ulcers are painful, especially in the nights. Neuropathic ulcers usually occur in diabetic patients and they are located at pressure points on the bottom of the feet. They can also occur related trauma any where else on the foot. They are usually seen in diabetic patients who have both neuropathy and also peripheral arterial disease. Neuropathy causes loss of foot sensation and also changes in sweat-producing glands increasing the risk of being unaware of foot trauma, injuries and callosities. Neuropathic ulcers are preceded by symptoms of neuropathy like numbness, tingling sensation and burning sensation. The ulcers appear punched out with the surrounding skin callosed. The ulcer may appear pink or brown (Gabriel and Camp, 2008).The wound in John is ischemic ulcer and appears uninfected. Laboratory investigations John will require certain laboratory tests which include routine complete blood picture, serum albumin levels, doppler examination to assess the ankle-brachial index, culture of the wounds and wound biopsy are essential to arrive at the cause of ulcer (Kunimoto, 2001). Since John also suffers from diabetes mellitus, fasting blood sugar, postprandial blood sugar and glycosylated hemoglobin levels also must be checked. Factors affecting foot health in the patient The wound in John is ischemic ulcer. The systemic factors which have contributed to the ulcer are diabetes mellitus and peripheral arterial disease. Factors which affect wound healing in John are old-age, diabetes, peripheral arterial disease and smoking (OBrien, grace and Perry, 2000). In diabetes, there is deranged glucose metabolism which contributed to delayed wound healing. Aging causes damage to the various genetic materials in the cells like DNA, proteins, and others, leading to diminished deposition of collagen and re-epithelization that contribute to delayed wound healing (Pittman, 2007). Aging also causes fragility of cells, tissues and various organ systems, making the organs and tissues more vulnerable to damage and injury (NIMHANS, 2003). As age advances, the process of recovery is slow. Lifestyle, patterns of living and social life attitudes are different in the elderly which contribute to delayed wound healing. The change in the pattern of living, associated with increased difficulties in recognition of risk and ability to cope increases the risk of injuries in the elderly (NIMHANS, 2003). Delayed recovery and inability to take proper care of themselves results in poor quality of life which futher incapacitates the day-to-day activities (NIMHANS, 2003). Smoking worsens peripheral arterial disease and can contribute to delayed wound healing. Peripheral arterial disease causes decreased blood supply to the tissue of the wound and thus delays wound healing. All these aspects also can contribute to delayed ulcer healing in John. Management of the ulcer Since, John is a diabetic patient; ulcer management involves management of both systemic and local factors. Proper control of blood sugars and quitting of smoking is crucial for healing of the ulcer. The first step would be to cause off load of the wound by wearing foot appropriate therapeutic foot wear. Daily saline dressings must be done to create a moist environment. If there is suspicion of wound infection, wound swabs must be sent for culture and appropriate antibiotic started based on the culture report. The ulcer must be covered by either cultured human cells or heterogenic grafts or dressings. Application of hyperbaric oxygen, recombinant growth factors or negative pressure therapy (vacuum assisted closure) may also be considered. Hydrotherapy with saline pulse lavage also may be given if the wound is infected and intractable (Stillman, 2008). Debridement of non-viable tissue and debris must be done before application of any wound therapy product to prevent hampering of wound healing. Another important aspect in the management of wound is detection and treatment of osteomyelitis of the underlying bone, namely fibular malleolus. If the architecture of the bone is causing pressure and is preventing wound healing, revisional surgery of the bone may need to be attempted at. Any identified vascular lesion may also be corrected (Stillman, 2008). Another important aspect of ulcer management in John is pain management. Pain relief can be achieved by acetaminophen and opiates. Non-steroidal ant-inflammatory drugs are not prescribed in ulcer patients because they cause delay in wound healing. Nutritional supplement and proper patient education also are important to manage ulcer in John. As discussed above, the wound in John needs to be covered with a proper dressing or wound product. The pharmaceutical market is flooded with many wound products. Some of them are alginate, hydrofiber, debriding agents like hypertonic saline, papain urea and collagenase, polyurethane, hydrocolloid and hydrogel dressings (Stillman, 2008). In John, hydrocolloid is useful because the wound appears clean and dry with minimal exudate. Many grafts are also available for coverage of the soft tissue. Since Johns ulcer is a partial thickness wound, autologous skin graft is suitable. Tissue culture grafts like dermagraft and apligraft are also available (Stillman, 2008). Acellular collagen matrix graft, also known as Xeno-graft is useful for induction of wound healing. After the ulcer is well-vascularised and clean, surgical closure of the ulcer wound with skin flaps creation and myocutaneous flaps creation can be done (Stillman, 2008). Currently there are recommendations to add low-frequency ultrasound therapy to standard wound care for improved wound healing of ischemic ulcers, which may be advised for John (Kavros, Miller and Hanna, 2004). Counseling of the patient Since John has diabetes and peripheral arterial disease, he must be counseled and educated to take proper care as advised and to come for regular follow up. Management of wounds in elderly patients with diabetes demands regular follow up, strict adherence to advice about diet, nutrition, rest, antibiotics, anti-analgesics and wound dressings. Otherwise, necrosis and gangrene can occur leading to amputation of the limb. John must also be advised about hygiene and cleanliness. References Armstrong, D.G., and Lavery, L.A. (1998). Diabetic Foot Ulcers: Prevention, Diagnosis and Classification. American Family Physician. Retrieved on Aug 5th 2009 from http://www.aafp.org/afp/980315ap/armstron.html Gabriel, A., and Camp, C.C. (2008). Vascular Ulcers. Emedicine from WebMD. Retrieved on Aug 5th 2009 from http://emedicine.medscape.com/article/1298345-overview Kavros, S.J., Miller, J.L., Hanna, S.W. (2004). Treatment of ischemic wounds with noncontact, low-frequency ultrasound: the Mayo clinic experience Adv Skin Wound Care, 20(4), 221-6 Kunimoto, B.T. (2001). Discussion of a Literature-Guided Approach. Ostomy/Wound Management, 47(5), 38–53. NIMHANS BISP Fact Sheet. (2003). Injuries among elderly. Retrieved on Aug 5th 2009 from http://www.nimhans.kar.nic.in/epidemiology/bisp/fs3.pdf OBrien, J.F., Grace, P.A., Perry, I.J., et al. (2000). Prevalence and aetiology of leg ulcers in Ireland. Ir J Med Sci., 169(2), 110-2. Pittman, J. (2007). Effect of Aging on Wound Healing Current Concepts. Journal of Wound, Ostomy and Continence Nursing, 34 (4), 412-417. Stillman, R.M. (2008). Diabetic Ulcers: Treatment and medication. Emedicine from WebMD. Retrieved on Aug 5th 2009 from http://emedicine.medscape.com/article/460282-overview Read More