History: This patient presents to the wound care clinic with a history of alcohol abuse, tobacco use, and congestive heart failure. Patient states that her legs are prone to swelling.
General: This patient is a 48-year-old female in NAD and all VSS.
Dermatological: Xerosis present to bilateral LE. Medial left leg wound measuring 0.8cm x 0.4cm x 0.2cm. Wound bed is 70% granular, 30% fibronecrotic.
Neurologial: Protective and epicritic sensation are grossly intact. DTR are WNL. Superficial reflexive testing is negative.
Vascular: Palpable pedal pulses +2 to DP and PT. Pedal hair growth is scant, but present. Bilateral pitting edema +2.
Orthopedic: Muscle strength testing is 5/5. Ankle and pedal joint ROM is WNL, without crepitation.
Studies: Arterial and venous ultrasounds are unremarkable.
(The physical strain the edema is placing on the integument is causing ulceration.)
Excerpted from Textbook of Chronic Wound Care: An Evidence-Based Approach to Diagnosis and Treatment, Chapter 3: Etiology of Wounds, page 65.
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