Venous Ulcer:: Attempt 1:: A PLAB 2 Mock

examiner mla
Jul 19
2 min read

Updated: Jul 20

Summary:

This scenario centers on a patient with a chronic venous ulcer unresponsive to initial compression therapy. The aim is to assess treatment efficacy, explore ongoing symptoms, and plan appropriate further management while demonstrating sound clinical reasoning, empathetic communication, and effective time use.

Key Points:

Vascular System / Venous Insufficiency

Chronic venous ulcers arise from venous hypertension due to valve incompetence, obstruction (e.g., intra-abdominal pressure), or weak calf muscle pump function.
Ankle Brachial Pressure Index (ABPI) must be >0.8 before applying compression stockings.
Lymphodermatosclerosis and inverted champagne bottle appearance are classic signs.
Venous ulcers typically improve with compression therapy; lack of improvement in 2–3 months suggests need for specialist input.

Current Presentation & Assessment

Patient has ongoing symptoms for 2 months despite compression therapy.
Discomfort with stockings suggests incorrect sizing.
Must assess ulcer’s size, discharge, odor, and pain to rule out infection or arterial compromise.

Risk Factors

Smoking as a key modifiable vascular risk.
Other considerations include lifestyle habits, diabetes, autoimmune disorders, and family history of venous diseases.

Important Considerations:

Rule out arterial insufficiency before applying compression.
Assess for infection or progression: warmth, redness, increasing size, discharge.
Determine the impact on quality of life (mobility, sleep, work).
Stockings should be correctly sized and comfortable.
Consider early referral if healing stagnates despite conservative therapy.

Diagnostic Approach:

Confirm diagnosis with history and inspection.
Check ABPI to rule out PAD.
Investigate for infection: FBC, ESR, CRP, wound swab.
Evaluate glycemic and nutritional status: HbA1c, albumin.
Assess for risk factors: smoking, immobility, comorbidities.

Management:

Conservative/Supportive:

Educate on leg elevation, avoid prolonged standing.
Re-size or consider alternative compression options (Velcro wraps, lighter stockings).
Provide patient information leaflets.

Medical:

Pentoxifylline improves venous circulation and healing.
Prescribe analgesics for symptom control.
Monitor for adverse effects and compliance.

Referral:

Routine referral to vascular team if no improvement after 2–3 months.
Refer to tissue viability nurse for dressing optimization.

Surgical:

Foam sclerotherapy or laser ablation if conservative measures fail.

Communication Skills:

Use open-ended questions to elicit complete information.
Validate patient’s frustration and show empathy for slow healing.
Avoid excessive stock phrases; be natural and sincere.
Summarize and signpost throughout consultation.
Check understanding and encourage questions.

Ethical Considerations:

Ensure valid consent for examination and interventions.
Respect patient autonomy in decisions about management.
Avoid overpromising outcomes or referrals.

Additional Resources:

NICE Guidelines: Chronic venous leg ulcers
GMC “Good Medical Practice” guidance on communication and patient care.
“Understanding Your Results” and “Examiner Tips” documents for PLAB 2 strategy.