HPI: The patient is a 77 y/o female who presents with a history of a chronic ulceration along the medial aspect of the right ankle. She relates that it has been there for approximately 2 years and that it is sometimes smaller, sometimes larger, but that it never fully resolves, but will occasionally scab over. She relates that she has previously tried a number of topical wound healing agents and has been seen by her primary care provider for this condition in the past.
PMH: DM, thyroid disease, CVA, Left Hand skin cancer, Measles, Psorasis
PSHx: Resection of an ovarian tumor, excision of left hand skin cancer
FAMHx: Breast CA
Meds: Insulin 20 units SQ in AM, Levothyroxine 125 mcg, Furosemide 80mg bid, pantoprazole 40mg, Coumadin 2mg, oxazepam 30 mg bid, Ketorolac solution Pen PRN.
Social: Denies Tobacco, ETOH, or drug use
VS: Pt is 5’6” wt: 190lbs, Temp 96.7, FBS 104, RR 18
Physical Exam: The patient is a pleasant elderly woman who presents with appropriate mood and effect. She is well nourished and demonstrates an enlarged body habitus with an elevated BMI. Upon exam of the bilateral lower extremities, she demonstrates pedal pulses that are palpable with a loss of protective sensation along the distal distribution of the L4, L5, S1 nerve roots. She demonstrates a loss of proprioception as well as vibratory sensation. Deep tendon reflexes are assessed bilaterally and are appropriate. Muscle strength is appropriate and with a weight bearing exam, the patient demonstrates an appropriate angle and base of gate, as well as a non-antalgic gait with ambulation. She demonstrates bilateral varicosities as well minor telangiectasias. Along the right ankle, the patient demonstrates a medially based ulceration measuring approximately 4.0 x 2.0 in greatest dimension located just proximal and slightly posterior to the medial malleolus (Figure 1). The base is fibrotic with areas of granulation tissue intermittently spaced along the wound. There is evidence of crusting along the wound margins, and it does appear to bleed freely.
Figure 1: 77 y/o Female with a Chronic Medial Right Ankle Wound |
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Imaging Studies: Radiographs of the right ankle were obtained which demonstrated vascular calcification consistent with vascular disease, but nothing notable radiographically in the area of the skin lesion.
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