HOW TO EVALUATE A CASE OF PRESSURE SORE

I would like to present the case under following headings:

1. Introduction
2. Chief complaints
3. History of present illness
4. Treatment history
5. Past history
6. Family history
7. Personal history
8. Socio-economic history
9. Vitals recording
10. Head to toe general examination
11. Systemic Examination
12. Local examination
13. Clinical Diagnosis
14. Investigation
15. Plan of management

Name:
Age:
Sex:
Occupation:
Resident of:
Comes with complaints of a wound over lower back / buttock / heel / ankle / back of head / elbow of
duration, weakness of lower limbs of duration & loss of sensation over the limbs of
duration.
On enquiry patient gives a history of fall / road traffic accident after which he was unable to stand or
walk (or history of progressive wenkness: multiple sclerosis, fever followed by weakness: acute
transverse myelitis, symptoms suggestive of tuberculosis with weakness: acute tubercular meningitis,
history suggestive of syphilis with weakness: tabes dorsalis)
History of wound: when appeared, progression, initial and present site & size. Pain in the wound.
History of urinary incontinence. Dribbling or overflow, sensation of urine in bladder present / absent.
How is the patient managing the problem? Foley / condom catheter or clean intermittent
catheterization. Any history suggestive of UTI / calculi.
History of constipation / faecal incontinence. How is the patient managing the problem? Use of
laxatives / finger evacuation / reflex stimulation.
History of progression or regression of weakness from time of initial event to present.
Any history of use of splints / physiotherapy.
History of progression / regression of areas of anaesthesia from time of initial event to the present.
History of appearance of tightness in the movement of any joints (spasticity) - duration, progression &
treatment history of the same.
History of the development of any deformity of the joints (contractures)
History of any surgeries for the previous mentioned problems.
History of diabetes / hypertension / smoking / alcoholism
General examination:
Patient is a young/ elderly male/ female. Well/moderately / poorly built, well/moderately / poorly
nourished, alert, concious and co-operative and well oriented to time, place and person.
Attitude of patient: Patient is lying comfortably on the bed with knee in mild flexion and ankle in
slight plantar flexion
Pallor, Icterus, Cyanosis, Oedema, Nutrition.
[Nutritional assessment by measurement of MAC indicates protein loss (males 23cm and females 22
cm) Triceps skin fold thickness indicates lipids loss (males 12mm and females 23mm) and evaluation
of any vitamin deficiencies]
Vital signs: Pulse- / min. Blood pressure taken in right arm in supine position is
Systemic examination:
RS: Respiratory rate is 16/min, air entry bilateral equal, no foreign sounds heard.
CVS: S1, S2 present, no murmurs heard.
P/A: Abdomen is soft, no organomegaly present.
CNS examination is not contributory to present condition / is not significant.
mm of Hg
Local examination:
Inspection: (of decubitus ulcer)
Number, situation, size, position, extent, shape, margin, edge, floor, discharge, surrounding skin

Palpation:
1. Warmth / tenderness
2. Size of full extent of the undermined ulcer examined with a gloved finger and marked (This is the
usual extent of debridement required)
3. Base of the ulcer
4. Fixity of the ulcer to the underlying tissues
5. Distal vascularity
6. Any limb length discrepancies
7. Enlarged lymph nodes
Musculoskeletal examination:
1. Atrophy of muscles: circumference measured from fixed bony points
2. Tone of muscles
3. Power - Hip, knee, ankle
4. Sensory examination of the dermatomes starting from T10 level
5. Reflexes - Knee jerk, Ankle jerk, Superficial abdominal reflexes, Plantar response
6. Spasms (which joints)
7. Contractures (which joints, active & passive ROMs, structures contracted clinically)
8. Trophic changes (Thin dry skin, sparse hairs, brittle nails)

DIAGNOSIS
UMN or LMN type of paraplegia / paraparesis which is recovering / non-recovering type with
decubitus ulcer of
grade
with / without complications
secondary to trauma / myelopathy.

APPROACH
• All preventive measures put in place like weight redistribution for at least 5 mins every 2 hours,
keeping part away from moisture, physiotherapy, nutritional improvement (correct Anemia / Hypo-
proteinemia).
• Measures to rehabilitate urinary / fecal incontinence.
• Measures to rehabilitate sexually / socially.
• Treat spasm.
• Correct contractures.
• Evaluation of wound: Wound C/S, X-ray / CT scan.
• Investigations to assess fitness for GA: Routine blood tests / ECG / CXR.
• When patient is fit, debridement of wound (necrotic & scarred soft tissue / bursa / ostectomy)
followed by flapcover.
Intrinsic and extrinsic factors influencing the development of pressure ulcers
Intrinsic risk factors for development of pressure ulcers
Diabetes
Smoking
Malnutrition
Immunosuppression
Vascular disease
Spinal cord injury
Contractures
Prolonged immobility
Extrinsic risk factors for development of pressure ulcers
Lying on hard surfaces
Nursing homes
Poorly fitting prostheses
Poor skin hygiene
Patient restraints