Management of Venous Leg Ulcer in an Elderly Patient with Rheumatoid Arthritis and Diabetes Mellitus

Introduction/Background Condition
Mrs A was a 72 year old woman with Rheumatoid arthritis and steroid induced type 2 diabetes mellitus.
She was married and non-smoker and does not drink alcohol. Mrs A presented to Kogarah Railway Medical centre
with ulcer that had been present for 3 years. Mrs A has a long standing ulcer on the left lower near the lateral
malleolus which became worse in the hot weather recently.
She previously has large rheumatoid nodules the size of an orange resected from the radial nerve on the
Humerus. At another point she has a left hip replacement where the protrusion was acetabuli that required
disimpaction. During the procedure there was inadvertent compression of the left common perineal nerve and
she counties to have some neuropathic pain in the region. This is why she takes the Tramal.
Mrs A has had conventional disease modifying anti-rheumatic drugs long ago in the past and at one point
took part in an experimental treatment of autologous bone marrow transplantation that gave her some
temporary remission. She tried a number of TNK antagonist but these each causing various kind of allergic rashes
and eventually she was put on the drug Rituximb, Mabthera , which has been her treatment for many years . She
has this done as an infusion approximately once every 6 months.
History of presenting complaint
Mrs A is an elderly person who has been presented with a 6 month history deterioration of a left leg ulcer
at the lower gaiter area. She had limited mobility and has to depend on the family. Mrs A med with an accident
where a piece of rusted iron pierced her leg. With due time the condition of her ulcer deteriorated. The ulcer was
shallow and irregular shape. The ulcer was presented with yellow-white exudates, which is secondary type of
wound with delayed healing. The ulcer appear to be ruddy. On examining the history, she and had been suffering
from type 2 diabetes and deep venous thrombosis. Mrs A has poor diet which has greatly impacted her health.
She is unable to manage her diabetes which has increase dependence on insulin. Her lifestyle has been greatly
affected as she is not able to do her daily living activity. She also complaint of having peripheral vascular disease
which has deteriorated her leg ulcer. She has been taking non-steroidal corticosteroid drug and
immunosuppressant drug.
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Past Medical/Psychosocial/Surgical History
Left ventricular dysfunction Medication induced
Left perineal nerve neuropraxia
Diverticular disease
Left Hip replacement
Rheumatoid nodules
2009 Bilateral TKR
11/06/2011 Rheumatoid arthritis
2014 Stenosis, Aortic Valve-Mild
2014 Coronary artery disease nonobstructive
2014 Type 2 Diabetes Mellitus Cortisone induced
2015 Right Cataract removal
21/02/2018 Hypercholesterolaemia
28/02/2018 Chronic Venous ulcer L ankle
Allergies/Medications/Impact on Wound Healing
MEDICINE DOSES RATIONALE IMPACT ON WOUND
Cartia 100mg Tablet 1 daily Prevent blood
clotting
No
Crestor 10mg Tablet 1 In the evening Prevent
cardiovascular
disease
No
Folic Acid 0.5mg Tablet 1 daily Treat folic acid
deficiency
Heal wound
Karvea 75mg Tablet 1 nocte Treat
hypertension
Faster healing
Mabthera 100mg/10mL Injection 6 monthly 2
infusions
Used to treat
rheumatoid
arthritis
No
Metoprolol Tartrate 50mg Tablet 1/2 tab Daily Treat
hypertension
Faster healing
Movicol 13.125g per sachet Sachet 1-2 sachet daily prn Treat
constipation
No
Novomix 30 Flexpen 3ml Injection 12 u mane 10 nocte Maintain insulin
level in blood
Faster healing
Pariet 20mg Tablet 1 Twice a day Treat heartburn No
Prednisone 5mg Tablet 1 daily Treat arthritis No
Tramal 50mg Capsule 1 Twice a day Relieve pain Reduce wound pain
Tramal SR 100 100mg Slow
Release Tablets
1 Twice a day Relieve pain Reduce wound pain
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Allergies
Augmentin Vomiting
Celecoxib Dyspnoea
Enbrel
Humira
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