Liz Inoprill
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You are a Foundation doctor undertaking a taster week in General Practice. Your first patient is Liz Inoprill, a 76 year old lady who has come in to see you about a sore leg. You can see from your GP records system that her medications include losartan, simvastatin, aspirin and GTN spray.
Please take a history from Liz, focusing on her history of presenting complaint. Undertake the appropriate examination and consider your differential diagnosis. You will then be asked to discuss the acute management of this presentation.
You are Liz Inoprill, a 76 year old lady with a sore leg.
HPC: Over the past four days, you have noticed your left leg has gotten very sore and swollen. It looks very red and feels hot to the touch. It’s almost as if you have put your leg in the fire! It started off simply covering your big toe, but has since spread up to the middle of your calf. It is now really painful and you cannot put any weight on it at all. You also feel generally unwell and your daughter noticed that you felt very warm to the touch. You haven’t actually taken your temperature, though – you’re afraid of what you will find!
You have an ulcer on your left big toe because of “bad vein” in your leg. You think that it might have started from there. The nurse who normally comes to your house to sort out the dressing noticed a bit of redness a few days ago and told you to keep an eye on it. You have done so, but not really done anything about it!
Your legs are usually quite swollen anyway, but your left leg is now larger and redder than the right.
PMH: You have always been overweight and have had problems with your blood pressure for many years. You had a mini-stroke two years ago where your right arm went very numb for a while, but your arm is fine now. Your usual GP has also found out that you have high cholesterol, although you are quite proud because your blood sugar has never been high, despite you being overweight. You suffer with “vein problems” in both legs. You have lots of big veins and often get ulcers, which the nurse comes to your house to help dress.
Your usual GP has also diagnosed you with angina because you get chest pain. This comes on when you walk up the road to the corner shop. You have a spray which helps with this.
FH: Your father died age 75 of a heart attack and your mother died of brain cancer when you were a teenager.
DH: Losartan, simvastatin, aspirin, paracetamol. You have no allergies but ramipril gave you a cough.
SH: You live alone in a bungalow following the death of your husband 6 years ago. Your daughter lives locally and visits twice a week; sometimes with the grandchildren who you adore. You manage fairly well on your own, although it’s been getting harder the past few months. You use a stick to get around the house and can get up to the corner shop if you need anything, although you rely on your daughter to get to the supermarket. You are able to cook for yourself although this is getting more difficult and you often just have a ready meal for your dinner. You have a cleaner who comes in once a week to do the housework.
You’re feeling quite lonely at the moment. You used to paint a lot, and would donate your paintings to the local hospital. However, they’ve stopped taking your paintings because of ‘infection control’ – which you think is a shame. Now you can’t go out of the house to go to your painting class, which makes you sad.
You are an ex-smoker but quit when your grandchildren were born 10 years ago. Before this, you had smoked 20 a day for 50 years. You rarely drink nowadays, only on special occasions where you might have a glass of sherry. You have never worked.
ICE: You think that this might have spread from the ulcer on your toe. You are worried because your mobility had been getting worse anyway and you don’t want to lose the independence you have left. You are also worried in case it is something really serious as you want to see your grandchildren grow up. You are expecting to find out what is wrong and receive treatment.
Observe the student take a history from this patient. The appropriate examination would be a skin examination, which should be systematic and not limited to just the legs. Ask the student to summarise their findings concisely, and to present their differential diagnosis. This should sound something similar to:
“My differential diagnosis would firstly consist of an infective condition, specifically cellulitis. This is because of the existing ulcer and pattern of spread of this erythematous, painful rash. This lady is at risk of infection due to existing peripheral vascular disease. A second diagnosis to consider would be a vascular cause, specifically deep vein thrombosis. This may be more likely due to relative immobility and history of cardiovascular disease. Finally, it would be relevant to consider whether this presentation is actually varicose eczema, however the acute, painful nature would likely discount this possibility.”
Points for discussion: • What are the causative organisms of cellulitis? • What investigations would you like to undertake in the acute setting? • What is the acute management for cellulitis? • Are you aware of any scoring systems for DVT? • How do you manage a patient with suspected DVT? • What are the features of varicose eczema?
