Name of the Condition

• Non-pressure chronic ulcer of right ankle with unspecified severity
• Generally referred to as a "chronic leg ulcer" or "venous ulcer"

Summary

Non-pressure chronic ulcers, particularly on the ankle, are open sores that occur due to poor blood flow and prolonged pressure on the skin. This condition typically results when the ulcer fails to heal properly over time, leading to persistent skin breakdown on the right ankle.

Causes

• Poor blood circulation (e.g., venous insufficiency)
• Diabetes or other conditions leading to impaired wound healing
• Trauma or injury to the area
• Chronic inflammation

Risk Factors

• Age, particularly older adults
• History of blood circulation problems
• Obesity, which increases pressure on extremities
• A sedentary lifestyle
• Smoking, which affects blood flow and healing
• Having a history of ulcers or wounds

Symptoms

• Open sores on the right ankle
• Pain or tenderness around the ulcer
• Redness or swelling
• Discharge or oozing from the wound
• Possible foul smell

Diagnosis

• Physical examination of the ulcer
• Ankle-brachial index test to check blood flow
• Doppler ultrasound to assess circulation
• Tissue biopsy (in some cases) to rule out other conditions

Treatment Options

• Wound care, including cleaning and dressing the ulcer
• Compression therapy to improve circulation
• Medications such as antibiotics to prevent or treat infection
• Surgery may be considered to improve blood flow in severe cases
• Pain management strategies

Prognosis and Follow-Up

• With appropriate care, many ulcers can heal over time, but they may recur.
• Regular follow-up visits are essential to monitor healing and prevent complications.
• Early intervention often leads to better outcomes.

Complications

• Infection can occur if the ulcer is not properly managed.
• Tissue death or necrosis
• The potential for cellulitis or more serious systemic infections

Lifestyle & Prevention

• Engage in regular physical activity to promote circulation.
• Maintain a healthy weight and diet to reduce pressure and promote healing.
• Quit smoking to enhance circulation and recovery.
• Elevate legs as prescribed to reduce swelling.

When to Seek Professional Help

• Significant increase in pain or swelling
• Signs of infection, such as increased redness, warmth, or discharge
• Fever or feeling unwell
• Rapidly worsening of the ulcer

Additional Resources

• Wound, Ostomy, and Continence Nurses Society (WOCN)
• American Diabetes Association
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Tips for Medical Coders

• Ensure the correct laterality is noted (i.e., right ankle).
• Verify the ulcer is non-pressure related to distinguish from pressure ulcers.
• Consider the context and potential underlying causes documented in patient records to avoid misclassification.