Malnutrition Presenting as a Necrotic Ulcer

84 year old man with a history of lymphoma but is purportedly disease free. Severe peripheral edema began 2 years ago. He says he developed this very large ulcer after minor trauma. His skin perfusion pressure is normal (68 mmHg), he has a biphasic PVR and strong DP and PT pulses. A biopsy was negative for malignancy. He’s lost 20 lbs over the past year since his chemotherapy.

A year ago he began complaining to his PCP that he felt generally weak. Exam reveals muscle wasting. A dietary history confirms that he eats almost no protein and his self-care has been poor since his wife died. He was started on vitamins, zinc, L-Arginine, and protein supplements. He underwent debridement, moist wound care and compression bandaging. This is the change in the ulcer over 8 weeks.

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