__ :..:~ J B-year-ojd ma!~ pahem pr=nted w,il, hisl<>ly ol pain idt low..,.

_hmb ,n lhc

-~Tf/2f~IJ~l;}~~;§ls~~fsI;}~~!;
reg1ooofcalfdurfogwalkingfor!beJas1 l ycar.A1thcoruet.poltentu,;oo10

1he bed. He had a history of trauma in hi1 left fool about 2 moµ1hs back . Following
this_1rauma,hedcvelopcdawoor.dwhichhasn<>1he1iledt!llnow. Hchasatso
not,ced gradual black discoloration ·of his left second and third toes for lS days.
He h"-5 no history of pain in the othcr limb. No his1ory ofchcs1 pain and
breathlcssncss.No.hil;tory_oubdommaJ ~ sl:'!!~opal anacl<s.
Bladderandbowcr habitsarenormal
Nohistoryofsimi!arpaininthcpastinanyoflheothcrlimbs.
Hcisnotakll0\'11hypcnensiwor.diabc1ic.
Hc isasm okerforiast20yearsanduscdtosmoke20-2Sbidispcrday.Forlasl

~~~n~~~ f~;~::,:~~di~3¥- .... ·=-···--- ~---- -··-

Physica l En111ioatiou:

theoo! "Jichleftfoothanging

- web space with sloug), over the floor '111d mild SWTOunding edema. The skin over

- -:d:~G:::ra~~'~:~
dorsum of foot is thin and shiny, nailsarebritt leandthcrearetransvcrseridges
1
~:~~~~o~i~:~~~~~~
increased. . _____ ----
Pcriphera!pulses:Absence-dOrsiiispedisandpostcriortibia!pulsesontheiefi
side. Poplitealand fcmora!pu!ses -arepi-escnt. Rightside lowerlimbandboth
upperlimbpu!sesarenormal. Theadjaccntjointmovementsintheleft!owcr
 l:liJtory:
·:-
~. -------..1.:
Cii.e_S.•n~rlo No.~ . @ ?

PhysicalEumination:

qeneral Examination - Patient is C011'5cious and oriented. He is obese and vital

tt:bf.6iJfJlt~Js~~1?~r.fi>.~~gr,a~,;lf.l~.E~l,.~ ~~.:!.~
~ - The<¢ is an ulcer of2 x I cm over the ~istal as~ct ofri~t
great toe with exposed bone and prese~ of slough. Very minimal gnmulatmn
tissue is prese_m. l:!lail,i ~ brit1l; .and _thCr:e js_lo~S ofhairoyerthc"dorsal aspect
offoo1. Tendeinessisprescnt0ntheadjllcentpartoffoot.<;:apillaryftl!ingtime
--=-t ~~:=-~~aj:~_M$.~~~sI?~~-E.4~--~w[~h~-~ ~~-_
Arterial Pulse ,RigM_LQl'\::er Limb Left Lo1;Ver Limb
Femoral ++
- Popliteal
Posterior Tibial
__Qorsali~Pedis .. .,.. ___ i!!,,.,,,_~
~ - ·=
Upperlimbpuls"esaiidWOtidpu!seiarenorrna!.
-~-~-¥-••--
.
The joipt movements in . the right lower .limb are no~ ,and there IS no
neurologicaldeficicinthelowerlif1:bS. - I i
Systemic-examination-- Clinically-Normal..- --
 -:~i:-ry,--·--,·--"~c..S.m,~
A32-year-oldma!e ·
':.'·~ .=-~ --_:_;; - -
1
~ifi{~fi~li1i~f~[~1'.¥i;}~l~l
~z fs":1s~:tiry 'i}0riM~f;~:::~i~:
Family hist:; i~:i;i~::/~;\:~~~l~.:t:i~;:~.a\cohol.
Physical Examination:

Genera_! Examination - Patient is average built wilh average nutritional status. No

~~:~•~~~:~~:~a]·~e;;~ral::f~~~:~:~~ofsize 8 x pcm overt¥ medial

_ side of left Ingumal region on standingposition_and_reach;es up ts:, b_ase of the
scrotum. The s~ over the s)Vell~~ is no~a!, surface is smooth and no visib\e
pulsations. There is an expaiisiliimpulse-ori coughing and ~ometimes ~ ristaltic
waves are seen over the s"".'~Ui~S- Consistep.cy is soft and 1doughy. Sw~Uing is
completely reducible with a ·gurgling s·ound. It reappears 01.1 making the patient
cough. Same side testis is felt separately just below the swelling and normal size
On ring occlusion test, the swelling re-appears on making the patient cough.
On i ieurnn's three finger test, impulse is felt on the index finger.
Right testis is normal. No swellin·g ih left inguinal region.
~)'.Ste_n1i~ ~~amina~ion .. Normal.

,...,... ... . .___.. 11 . · y, ~ •,_,~ - ;-w ,;•,'," •

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