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

Practice a case with the AI patient 🤖

Summary:

This scenario involves a follow-up consultation with a patient experiencing discomfort from compression stockings and delayed healing of a venous leg ulcer. The focus is on assessing wound progress, identifying contributing factors to poor healing, and tailoring a holistic management plan addressing both medical and lifestyle components.

Key Points:

History and Assessment

• Symptom Re-evaluation

  • Confirm any worsening symptoms: increased pain, discharge, odor, swelling.

  • Assess wound status compared to previous visits.

• Compliance Check

  • Confirm proper and consistent use of compression stockings.

• Contributory Factors

  • Screen for comorbidities: especially diabetes and venous insufficiency.

  • Review current medications and allergies.

  • Inquire about previous venous ulcers or chronic venous discharge.

Risk Factors and Lifestyle

• Lifestyle Assessment

  • Ask about smoking, alcohol, physical activity, and prolonged standing.

• Mobility and Impact

  • Assess effect on daily life, mobility, sleep, and work.

  • Discuss physical strategies like calf muscle exercises (e.g. tiptoe stance).

Important Considerations:

• Compliance and tolerability of compression therapy

• Identification of underlying comorbidities (e.g. diabetes, obesity)

• Lifestyle elements (diet, exercise, standing duration)

• Quality of life and daily function impact

Diagnostic Approach:

1. History Taking

   • Focus on wound progression, symptoms, and compliance.

2. Risk Identification

   • Check for diabetes control, lifestyle contributors, venous disease.

3. Clinical Evaluation

   • Look for signs of infection or complications.

4. Investigations

   • Blood tests to check for infection, diabetes control, anemia.

   • Wound swab if infection suspected.

Management:

Medical

• Adjust compression level if stockings are intolerable.

• Prescribe paracetamol for pain relief.

• Consider adding pentoxifylline to enhance healing (evidence-supported).

Supportive

• Refer to Tissue Viability Nurse for expert wound care.

• Educate on leg elevation, regular walking, calf exercises.

• Recommend dietary improvements for better healing.

Referrals

• Vascular team referral for advanced venous insufficiency.

• Consider diabetic care review if relevant.

Education and Safety Netting

• Provide leaflet on venous ulcers and compression stockings.

• Advise on signs of complications: infection, arterial insufficiency.

• Schedule nurse follow-up in 2 days, GP review in 2 weeks.

Communication Skills:

• Use empathetic language: acknowledge discomfort and concerns.

• Reassure and collaboratively plan next steps.

• Avoid overused phrases; be specific, clear, and concise.

• Involve patient in decision-making, invite questions, and encourage ongoing dialogue.

Ethical Considerations:

• Respect patient autonomy regarding treatment adherence.

• Maintain confidentiality, avoid unnecessary reassurance or unrealistic promises.

• Avoid using rehearsed or unnatural language that might reduce rapport.

Additional Resources:

• NICE guidelines: Venous leg ulcers

• SIGN guidelines on chronic wound management

• GMC Good Medical Practice on patient-centered care