Candidate Instructions
Who are you:
You are an FY2 in GP surgeryWho the patient is:
Elliot Green, aged 60, has presented with some concerns.What you must do:
Talk to the patient and address his concerns.
Patient Information
- He has a ulcer on the right leg (medial malleoli).
- On his last GP visit he was referred to a tissue viability nurse but he did not go because he got busy.
- He wants to be referred to the specialists
Approach
GRIPS
History of Venous ulcer:
- Where is the uler acatea?
- When did the ulcer appear?
- Is this the first time he has had an ulcer?
- How many ulcers are there?
Symptoms of ulcer
- Any bleeding?
- Any pain?
- Any itchiness?
- Any discharge?
Previous medical treatment
- What was he told was the cause of the ulcer on his previous visit?
- Was any treatment offered?
- Did he go to the tissue viability assessment sepcialist?
- What stopped him from going?
History of Risk factors for Venous Ulcer
- Do you have any difficulty in moving around? Do you have any condition that restricts your movement?
- Have you had previous Deep vein thrombosis?
- Have you been diagnosed with having Varicose veins before ?
- Previous injury to leg such as broken or fractured bone which may have affected your walking?
- Have you had hip or knee replacement which has prevented you moving about?
- Have you been diagnosed with osteoarthritis?
ICE
Ideas:
- Have you thought of anything that could have caused the ulcer?
- Did the doctor that saw you last time mention anything to you?
Concerns
- Is there anything you are worried about?
Expectation:
- You have had this for sometime, what made you seek help now?
- Is there anything specific you would like me to do for you?
- Would you like to see the tissue viability nurse this time?
Differential Diagnosis
Venous Ulcer:
- Any swollen or enlarged veins on your legs (varicose veins in)?
- Any discolored or darkened skin?
- Any hardness of skin?
- Swelling of ankles?
- Feeling of heaviness in your legs?
- Aching or swelling of legs?
- Is it in one leg or both?
- Any ulcers anywhere else?
- Any itchiness?
Arterial Ulcers:
- Are the ulcers painful?
- Any pain in legs on walking
Cellulitis:
- Any redness of the skin?
- is the skin warm to touch?
- Fever?
Deep Venous thrombosis:
- Any Swelling?
- Any redness?
- History of immobility?
Neuropathic ulcers:
- Painless and deep ulcers
- Usually on the heel
- History of Diabetes Mellitus
Superficial Thrombophlebitis:
- Tenderness and redness along the veins with swelling
Assess for signs of Infection
- Worsening Pain?
- Unpleasant discharge or greenish discharge coming from the ulcer?
- Warmth?
- Redness?
- Swelling?
- Fever?
- An unpleasant smell coming from ulcer?
OTHER HISTORIES
PMAFTOSA
Effects
Examination:
• Picture showing varicose veins and ulcers on medial malleoli
Diagnosis
- Venous Ulcers secondary chronic venous insufficiency.
- This is suggested by varicose veins.
Management
Investigation
- ABPI using a doppler ultrasound to exclude peripheral arterial disease as the cause of ulcers
- Routine Investigations: FBC, U&E, LFT, Glucose, CRP, ESR and HbA1c.
Treatment
- Reassure that with appropriate treatment, venous ulcers heal within 6 months
- Refer to the tissue viability specialist nurse for:
– Cleaning and dressing of the dicer:
– Graduated Compression bandage: applying bandage to the legs maximizing pressure at the ankle; when compression bandages are first applied it may cause some pain so you can take paracetamol.
– Prescribe the medication pentoxifylline to help with healing.
– Refer to vascular specialist for assessment for possible venous surgery assesment.
Prevention
- Be compliant with the compression bandage/stockings.
- Elevate the legs. Use pillows under feet and leg to keep it raised when you are sleeping.
- Use emollient frequently for itchiness.
- Regular exercise will help reduce leg swelling.
- Examine the leg regularly for broken skin, blisters, swelling or redness.
- Adapt a healthy lifestyle.
- Quit smoking (if he smokes).
- Offer leaflet about venous ulcers.
- Refer to support groups.
Safety Netting
- Come back if there are any signs of infection: fever, discharge and increased pain
- Follow up: In one week
АВРІ
- < 0.5 suggests severe arterial disease, compression is contraindicated
- 0.5 - 0.8 suggests arterial disease
- 0.8 - 1.3 suggests no evidence of arterial disease
- less than 1.3 suggest the presence of arterial calcification