Medical Challenge Question 14, yes I'm skipping 13; Warning Graphic Medical Picture

A 69-year old Asian man is evaluated because of complaints of pain in the buttocks area, lumbrosacral region. He was previously given the diagnosis of non-Hodgkin large B-cell lymphoma 6 months ago by histology reporting. The lymphoma responded well to chemotherapy and he has no evidence of active disease, but he has been hospitalization three times for various chemotherapy-associated complications.

He is bedbound at home currently. The patient says the pain is severe while he sits and he experiences great difficulty finding a comfortable position while lying down in bed. The pain improves with standing, but he cannot stand for very long. He has had no fever. His past medical history is positive for hypertension, hyperlipidemia, type 2 diabetes mellitus, and end stage renal disease being treated with hemodialysis. Medications include felodipine, insulin, calcium carbonate, calcitriol, and erythropoietin.

On examination, the patient is afebrile, blood pressure is 108/62 mm Hg, and pulse rate is 67 beats per minute. BMI is 20. Weight is 68 kg, decreased from 82 kg 4 months ago. He appears cachectic and in mild distress due to pain. Examination of his back shows no vertebral tenderness to palpation and wasting of the gluteal muscles. Examination of the sacrum reveals a shallow ulcer, 6 cm in diameter with a hard black eschar covering the base. The ulcer is without drainage and has no surrounding erythema.

Which of the following is the most appropriate management of this patient's lesion?

A. Reccommend biopsy of the lesion

B. Start intravenous antibiotics

C. Leave the wound open to air to dry

D. Surgical debridement

E. Recommend palliative care

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Reference:

Schiffman J, Golinko MS, Yan A, Flattau A, Tomic-Canic M, Brem H. Operative debridement of pressure ulcers. World J Surg. 2009 Jul;33(7):1396-402. PMID: 19424752