November 18, 2024

Morbidly obese 75-year old with diabetes mellitus

By Med-Challenger · 2 minute read

A 75-year-old woman who has diabetes mellitus and is morbidly obese presents to you with an ulceration on her right lower extremity (see Figure).

image (22)

Figure.

She tells you that it has been present for 4 months, and that the ulceration started as a small opening in the skin after she bumped her leg on a piece of cardboard. Since then, the lesion has become progressively larger in size.

The patient tells you that she has been using topical antifungal creams, antimicrobials, and hydrogen peroxide to treat the wound. She also has been using rolled gauze to keep the area covered, but the lesion has increased progressively in size. What bothers her the most is a large amount of serous drainage that requires changing the dressing 3 or 4 times a day.

On physical examination, she has a large ulceration. There is overall red granular tissue visible. There are changes suggestive of stasis dermatitis both above and below the leg ulcer. There is prominent edema.

What is the most important therapy in this case?

collagenase
superabsorbent dressing
compression therapy
antibiotic treatment

The correct answer is:

Compression therapy

Educational Objective:

Discuss the appropriate treatment for venous ulcers.

Key Point:

The most important therapy of venous ulcers is control of edema with compression therapy.

Explanation:

The patient has a large venous ulcer. The erythema seen above and below the ulcer represents stasis dermatitis and not cellulitis. Compression therapy is a key component of the therapy required to treat venous insufficiency and venous ulcers. This can be achieved with the use of compression stockings or multilayer compression wraps. Edema control is the most important element to allow for healing of the ulcerations.

Debridement of the ulceration is indicated in the presence of sloughing or devitalized tissue. Collagenase is an option for some patients; however, this patient has predominantly granular tissue on the surface of the wound, a sufficient base for healing without the need for collagenase.

Superabsorbent dressing will help the patient control her symptoms and will provide her comfort. Dressings are an important element for the treatment of venous ulcers; however, the drainage will continue unabated unless compression therapy is applied at the same time.

All wounds are colonized with bacteria. A diagnosis of infection is based on clinical findings. This wound does not appear to be infected and does not require antibiotic treatment.

References:

O’Donnell TF, Passman MA, et al. SVS/AVF Joint Clinical Practice Guidelines Committee-Venous Leg Ulcer. Journal of Vascular Surgery.2014; 60: 3S-59S

Bonilla-Martinez ZL, Kirsner RS. Venous Ulcers. Diseases of the Skin. Conn’s Current Therapy. 2014; 14: 889-990

This question appears in Med-Challenger Internal Medicine Exam Review with CME

Try for free and save. Ace your exams and meet your CME/MOC requirements for just $35 a month!

No matter your program, no matter the size, Med-Challenger for Groups and Institutions can better prepare your program or group, fulfill industry requirements, and increase test scores.