Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in General Practice. Your next patient is called Lig Ma, who is a 56-year-old man coming in with left leg pain. Please take a history and perform an appropriate examination.
Patient History:
Lig Ma, a 56-year-old male, retired.
Since last week, you have been getting worsening lower left leg pain around the on-going ulcer located at the front of your left lower leg. This ulcer has been there for many years, and the area around it is getting redder and warmer to touch. The skin feels really tense and thickened and looks swollen compared to the other leg.
You are unsure if you have a fever as you don’t own a thermometer at home, but you sometimes shiver with occasional night sweats.
Your appetite has reduced. You do not feel well. You feel tired.
No fluid-filled blisters. No bleeding or discharge. No recent trauma or injury. No insect bites. No recent surgeries or immobility. No nausea or vomiting. No itchiness. The joints are normal. No abnormal sensation. No weakness.
Ideas, Concerns, Expectations:
You have no idea what this might be, but you heard from your friend that this might be something called “?DVT”, which your friend had following a hip replacement in the hospital. You are concerned about this, so you would like to find out what is happening!
Past Medical History:
Diabetes, obesity, venous insufficiency, venous ulcer left lower leg, IBD
Drug History:
Metformin, atorvastatin, azathioprine NKDA
Family History:
Diabetes, HTN
Social History:
Drink 2-4 cans of beer a night.
No recreational drug use.
Non-smoker.
Live alone in a Bungalow – you will often have district nurses around for wound care of your ulcer for the past few years.
Retired.
Examination Findings:
Venous ulcer at anterior left lower leg with surrounding warm and tender erythematous skin. Poorly demarcated redness. No skin crepitus. No blisters or vesicles. Varicose veins can be seen in both lower legs.
No necrotic / gangrenous tissues. No pitting oedema. No toe-web abnormalities. – e.g. fissures, scaling, maceration. No injury/trauma site. Neurovascular intact. CRT < 2seconds.
Differentials:
Cellulitis
Erysipelas
Rule out DVT
Rule out pyoderma granulosum/ necrotising fasciitis
Superficial thrombophlebitis
Varicose eczema
Investigations:
Cellulitis can be diagnosed clinically.
Consider wound, skin swab/blood culture/aspiration/biopsy if appropriate.
Consider referral to be seen at the hospital and for bloods if the patient is systemically unwell: FBC, CRP, U&E, LFT, Bone Profile, culture and perform sepsis 6
Consider assessing diabetic control: BM, serum glucose, hba1c
Consider XR, USS, or MRI for assessing the spread of infection, e.g. bone, gas in subcutaneous tissue, abscesses, or involving foreign bodies…etc., at the hospital.
Management: