KURSK STATE MEDICAL UNIVERSITY

Department of Surgery

CASE HISTORY of
Patient name: D.V. V., 66yrs Clinical diagnosis: Varicose disease; decompensation stage with trophic changes Chronic venous insufficiency; leg edema with trophic changes (leg ulcer) and skin hyperpigmentation and induration.

Student: BROBBY I. Medical Faculty 5th year, 2nd semester Group 13

-Kursk 2009-

Personal data 1. 2. 3. 4. 5. 6. 7. 8. Name of patient : D. V. V. Age of patient : 66yrs Sex : female Occupation : canteen worker Address : Kursk. Marital status : Married Date of hospitalization : 09.02.09 Date of discharge : 25.02.09

Complaints At the time of quarry, patient had no complains. Anamnesis Morbi Patient developed engorgement of cutaneous veins in the lower extremities about the age of 35yrs old, however she did not seek any medical advice, since it was symptomless and in her opinion it wasnt a serious issue. Patient developed an ulcer on the lower 1/3rd of the right leg about 2cm in diameter and edema up to the knee during December, 2008, which lasted for about 2months. Patient once again ignored to seek medical assistance and decided to treat herself at home with aspirin and other home therapies. Another ulcer reappeared near the original site + edema up to the knee, which prompted the patient to seek medical advice this time. The ulcer was about 1.5cm in diameter. On admission, surgery was performed on the varicosities on the left leg on 13.02.09.

Anamnesis Vitae Patient lives in satisfactory conditions, and had normal development. Patient had no difficulty in intellectual development. No history of jaundice, tuberculosis, Patient does not use alcohol neither does she smoke. No operation had been done before and no blood transfusion done. Patient does not have any medical history of hypertension nor diabetes mellitus Patient has a son aged 40 years. According to patient, her mother, uncle and grandmother suffered from this same clinical case of varicosities and leg ulcer.

OBJECTIVE EXAMINATION: I- GENERAL INSPECTION:

1. 2. 3. 4. 5.

General condition: Satisfactory condition. Show: there is conformity of appearance and age. Consciousness and stages: Good consciousness. Posture: Active. Weight, Height, Nutritional state: Nutritional state is good, well nourished, and the state of development is normal: symmetrical development of muscles. 6. Skin: Normal color of the skin and of the mucous membrane, no rash and is moist apart from the skin of the lower extremities; the right leg present with ulcer about 1-1.5cm in diameter, scaly reddish-brown hyperpigmentation skin in its lower 1/3rd and mild tenderness of both lower legs, skin here is a bit edematous 7. Nails: normal nails in fingers of upper extremities, however the nails in the toes show thickening. 8. Hair: No change in hair growth, normal growth. 9. Subcutaneous fat: Low deposit of fat. Edema: Absence of peripheral edema but present slight edema on feets. Lymphatic system: no palpable lymph nodes, normal color of the Skin above the lymph nodes. 10. Musculature: Normal degree of development, symmetrical development, normal muscular tension, no tremor, good muscular strength. 11. Bones: No pathological changes, no deformation, no shortening of bones, no shifting, no pain. 12. Joints: Normal form, normal size, no changes of the skin above the joints, no temperature, pain, no crackles, active movement, no change in joint size or mobility. 13. Head: normal size and form of skull, no scars, no tremor. Nose: normal form, no septum deviation, Eyes: normal. Lips: usual color of mucous with no fissures and ulcerations.

14. Neck: No enlargement of thyroid, no pulsation. 15. Body temperature: normal.

II- RESPIRATORY SYSTEM:

1. General inspection: normosthenic, symmetrical, anterior, no

deformation, symmetrical equality of expansion. Normal intercostals region. Epigastric angle is about 90 degree. 2. Type of respiration: Abdominal respiration. Respiration per minute is 20/min. Normal rhythm. 3. Short breath: None. 4. Palpation of the chest: During surface palpation of the chest no pain, no deformities in ribs, in breast-bone, normal intercostals spaces, normal vocal fremitus. 5. Topographic percussion: -Anteriorly the apex of each lung rises about 3.5cm above from upper border of clavicle. Posteriorly, it is found at the level of the spinous process of the 7th cervical vertebrae. -Lower border of lungs according to the following topographic lines:i) parasternal 5th rib ii) Mid-clavicular 6th intercostal space iii) Anterior axillary 7th intercostal space th iv) Mid-axillary 8 intercostal space v) Posterior axillary 9th intercostal space th vi) Scapular 10 intercostal space vii) Para-vertebral T11 spinous process - Lung mobility i) Mid-axillary ii) mid-clavicular iii) Scapular 6cm 4cm 4cm

6. Auscultation: Lung auscultation reveals no pathology. Absence

of rales or crepitation. Normal vesicular breathing over the lung tissue. Bronchial breathing over the bronchi and trachea.

II- CARDIOVASCULAR SYSTEM:

1. Inspection: Region of the heart: No presence of cardiac humpback. No abnormal pulsations in aorta or in pulmonary trunk. Region of the neck: No aortic arch or carotid arteries pulsations, no engorgement of jugular veins, and no undulation of neck veins. Trachea: midline position without deviation. Peripheral arteries pulsations are absent, no worm sign. Epigastric pulsations are absent, no hepatic and no right ventricle and no abdominal aorta pulsations. Presence of varicose veins on lower extremities. 2. Palpation: Apex beat is palpated in the 5th ICS 1.5cm laterally from the left mid-clavicular line. The intensity is usual and not exaggerated. Peripheral arteries palpation has usual pulsation and intensity. Absence of Quinckes pulse. Absence of Pleshs sign, pulsation of right ventricle of the heart and abdominal aorta pulsation Radial artery pulsation is normal, rhythmic, no changing of pulse during exertion. Intensity of the posterior tibia artery is diminished in intensity. 3. Percussion: Upper border 3rd rib left border 1.5cm laterally to left midclavicular line Right border 1cm laterally to the right border of the sternum. Transverse diameter is 13.5cm Diameter of the vascular bundle is 5.5cm 4. Auscultation: Accentuation of S1 at apex site and accentuation of S2 with no murmurs

III- GASTROINTESTINAL SYSTEM. 1. Inspection: of the oral cavity is normal, no smell, and no odor. There are no artificial teeth. Color of the gums is normal no bleeding, no ulcerations. No cicatrices or ulcerations of mucous membrane of the oral cavity. Usual size of the tongue and normal color, humid,

and no deviation of the tongue. Usual color of the mucous membrane of throat. Normal size and color of the tonsils. 2. Abdomen: No stria, no pigmentation. In surface and deep abdominal palpation no presence of masses, no muscle tension, ascites present. 3. Palpation Liver: No pain in palpation of the liver with usual sizes. The spleen: No pain during palpation, no sign of splenomegaly. Surface abdominal palpation no tenderness or rigidity present. Painless Stomach painless during palpation. Lower border is at level of 3cm above umbilicus. Sigmoid colon smooth and cylinder in shape, painless in palpation Caecum - painless in palpation, about 1.5-2cm in size, firm in consistency Ascending colon painless in palpation, about 1.5-2cm in size, firm in consistency, smooth surface. Descending colon painless in palpation, about 1.5-2cm in size, firm in consistency, smooth Transverse colon painless palpation, normal shape

IV- EXAMINATION OF URINARY SYSTEM 1. 2. 3. 4. Skin redness, swelling or edema are absent in lumbar region. No painful points are observed in the right lumbar region. No displacement of kidneys. No kidney enlargement or pain present. Its surface is smooth and soft consistency. No tenderness present during palpation. 5. No noticeable variations are observed in examination of genital organs. V- EXAMINATION OF NERVOUS SYSTEM Organs of sense: Vision: Normal Audition: Normal Smell: Normal Taste: Normal

Touch: Normal

VI- LOCAL STATUS Vascular: pulses diminished in the feet, warmth is felt above site of ulcer and comparatively decreased temperature below site of ulcer; varicose veins (engorgement of cutaneous veins) on legs. Skin/Extremities: scaly reddish-brown hyperpigmentation and mild tenderness of both lower legs; trace of edema in both ankles; scabbed over 1.5-2cm shallow ulcer on lower third of right leg; fresh, clean 1.5cm ulcer near the old ulcer with irregular borders, dependent rubor that diminishes with elevation; no lesions on the toes or heels. Skin around ulcer shows excoriations, crusting dependent edema and the place shows indentation.

Neurologic: sensation intact in the feet.

Primary diagnosis Varicose diseases Deep vein thrombosis

PLAN OF INVESTIGATION Clinical minimum: i) General analysis of blood ii) Urine analysis iii) Biochemical analysis Instrumental investigation i) Colour flow Duplex ultrasound scanning ii) Hand held Doppler- ankle: brachial index (ABI) iii) X-ray exam iv) Phlebography

RESULTS Blood analysis i) RBC - 4.1x109/l ii) Hb 133g/l iii) CI 0.9 iv) WBC 5.3x1012/l v) Eosinophils 1 vi) Neutrophils: Segmented 66, band 2 viii) Monocyte 8 ix) ESR 2mm/Hr Urine analysis i) colour-yellow ii) Reaction -acidic iii) specific gravity-1.010 iv) Volume 150ml v) Protein -0

Biochemical analysis i) AST 19.5U/l ii) ALT 15.0U/l iii) creatinine-84.80m/mol v) General Protein 82.2mg/dl vi) Na - 138 vii) K 3.6 i) Colour flow Duplex ultrasound scanning Examination showed abnormal reverse flow (reflux) in the veins of the legs. The backflow is from the deep to superficial veins (horizontal reflux) ii) Hand held Doppler- ankle: brachial index (ABI) ABI is less than 0.9 but greater than 0.5 iii) X-ray exam

X-ray examination reveals incompetence in deep and communicating veins and tortuous n engorged superficial veins. iv) Phlebography Reveals incompetent communicating and deep veins passability. Valve incompetence in deep and communicating veins.

Clinical diagnosis Varicose disease; decompensation stage with trophic changes Chronic venous insufficiency; leg edema with trophic changes (leg ulcer) and skin hyperpigmentation and induration.

Differential Diagnosis Arterial insufficiency (ischemia): In this case the leg ulcers are much more painful and ABI measurement is < 0.5 Neuropathy (e.g., diabetes mellitus): This also presents with loss of sensation in the feet and toes, there may also be marked defects in the toe nails as well. Pressure: There is history of external or pressurizing object. Other (e.g., injury, malignancy, infection, vasculitis) Injury will be present with history of trauma, and positive culture with purulent secretions in infections, whereas malignancy will show abnormalities in the leg ulcers and nature of skin underlying ulcers and positive biopsy.

PLAN OF TREATMENT 1. conservative management 2. surgical treatment

Conservative management medical therapy: 1. Anticoagulant-to prevent increased coagulation and risk of thrombosis eg. Heparin, warfarin Treatment dose: 5000 IU 6x/day Prophylactic dose: 5000 IU 4x/day Final dose: 2500 4x/day, later decrease to 2500 2x/day 2. Rheolytics-to increase circulation eg. Curantil 3. Nutrition to promote ulcer healing and edema resolutionProtein/calorie supplementation Mechanical therapy (to improve and reduce edema) 4. Elevation of legs Rest supine, raise ankles above the heart level on a pillow 5. Compression stockings and elastic bandages- elastic stockings usually used post operatively help squeeze the tortuous veins and stop excess blood from flowing backward. In this way, compression stockings can often also help heal skin sores and prevent them from returning. 6. Zinc-paste impregnated bandages- to improve skin blood supply due to vent effect stimulation leading to increased arterial blood supply of the skin and relieves venous congestion in ulcer area 7. ambulation- patient needs to walk about frequently and not stay in bed all the time to help blood flow to and from the legs. Surgical treatment Vein stripping Bypass Valve repair Angioplasty and Stenting Ablation

DIARY 14.02.09 Patient has no complains. Slight edema on feet of left leg.

Appetite is normal. BP 130/80, PR 74 & regular, T 36.50 C 15.02.09 Patient has no complains. Edema slightly reduced on feet of left leg. Appetite is normal. Patient could walk however she limbs in trying to do so. BP 120/80, PR 72 & regular, T 360 C 16.02.09 Patient has no complains. Edema reduced on feet of left leg. Appetite is normal. Patient could walk however she limbs but better than previous day. BP 130/80, PR 72 & regular, body temperature normal EPICRISIS Patient was admitted to the hospital on 09.02.09 with an ulcer of about 1.5cm in the lower third of the right leg, and edema up to the knee. Both legs showed varicosities due to venous engorgement. Based on clinical picture and history of disease, the above investigations were performed, analysis and discussion of the results proved the diagnosis of Varicose disease; decompensation stage with trophic changes and Chronic venous insufficiency; leg edema with trophic changes (leg ulcer) and skin hyperpigmentation and induration. A surgery (phlebectomy) was performed on the varicose veins on the left leg and discharged on the 25.02.09 since treatment was effective. Patient is due to undergo another surgery on the right leg in a months time. PROGNOSIS Prognosis is favorable for both social activities and life.