Simple cases

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Case 48

89-year-old bed-ridden woman with deep tissue defect over her sacrum

(History from patient's nurse)This patient has been here for years. She had a stroke about 6 months ago and since then has been in bed. Now she has developed this big sore.

A open question is a good way to start. This lesion is typical for old, frail, under-nourished, bed-ridden patients who are immobile. In younger individuals, it is only seen in those who are in a coma or otherwise immobilized.

(History from patient's nurse)She can't tell us, but I think it hurts her. Sometimes when we move her, she is really restless.

The pain can be modest or intolerable. The elderly are often less pain-sensitive and that plays a role in the development of such lesions.

(History from patient's nurse)We try to turn her frequently and have covered it with a dressing.

Important question, as both the prophylaxis and the therapy are often not carried out properly.

(History from patient's nurse)Yes, she has diabetes mellitus, heart disease and chronic renal insufficiency.

Important question to assess other risk factors.

(History from patient's nurse)Every 2-3 hours.

The most common risk factor is failing the turn the patient every 2 hours.

(History from patient's nurse)No, not yet.

Physical therapy is often a helpful addition to the prophylactic regimen.

Choose the right efflorescences:

Correct, this is big ulcer, extending to the deep fascia and muscles.

Poikiloderma features atrophy, telangiectases and pigmentary changes. This is not seen here.

A rhagade is a fissure or tear—a long thin defect.

An erosion is a superficial defect.

Choose the right diagnosis:

False. TEN is a drug-induced reaction in which large sheets of skin are lost. It does not feature deep ulcers.

This is a classic decubitus ulcer, caused by prolonged ischemic pressure in patients unable to move themselves.

False. The patient did not deliberately induce these lesions.

False. Dermatomyositis is an autoimmune disease affecting skin and muscles. It does not match this case at all.

Choose the right therapy(ies):

The golden rule is every 2 hours! Two hours of ischemic pressure is enough to induce an ulcer. The patient should be turned and then propped in bed to relieve pressure over the sacrum and trochanters.

Special mattresses, usually with regulating cycles of inflation and deflation, are helpful.

Of course. Moist wound care is essential, but it must be combined with turning and a special mattress.

More advanced (Stage III and IV—see Cyberlecture) decubitus ulcers often extend further than inspection suggests appear. So debridement is essential. In Stage IV, surgery is desirable.

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