Location for this role play: General Practice

• The student has been asked to take a history from a simulated patient
• Please kindly follow the script to simulate the consultation
• You will not be expected to undertake an examination
• Please answer in the negative to any specific questions about your condition where the answer is not outlined in the script

You first noticed an issue three months ago after you accidentally banged your leg on the kitchen table. The wound then didn’t heal and has gradually worsened. It has become particularly large in the past 2–3 weeks. You think it is an ulcer – refer to it as “what I think is an ulcer” when describing it to the doctor.

At an appropriate point:

Please ask students if they wish to see the wound, and provide the image to the student who is taking your history.

If asked to estimate size: you haven’t measured it – it seems a “good few centimetres” in width. Not sure how deep it is.

Initially sore when you banged the leg; the wound itself is not severely painful, but there is a dull aching sensation around it.

• ••• Accidentally caught left lower leg on the kitchen table 3 months ago.
• Initially very small wound which bled slightly at the time.
• Situated on the inside of the left ankle .
• Put a plaster over it and continued daily activities.
• Expected a scab to form and the wound to heal – instead it increased in size and has not healed. Now a large “open wound”.
• Bought dressings from the chemist (plasters no longer appropriate). Chemist insisted you make a GP appointment.
• ••• No yellow discharge or bad smell.
• Slightly red around the area – no severe or spreading redness.
• Skin not warm to touch.
• Both ankles tend to swell by the end of the day, particularly after standing for long periods (e.g. staffing checkouts at work).
• Otherwise feel well; no fever.

Image reference: Wikidoc – Venous Stasis Ulcer

• Ideas: Do not know why you have this ulcer. Could there be an infection?
• Concerns: Worried about how the ulcer will heal. It is unsightly and you worry about it becoming infected (if it is not already). Feel embarrassed at how large it has become. Feel you should have come much earlier but “hate making a fuss” and hoped it would improve. Tried several times to contact the surgery but were on hold a long time; when you got through, next routine appointment was three weeks away. Took it but feel you should have asked for urgent as the wound has worsened considerably.
• Expectations: Expect the doctor to confirm this is a leg ulcer, but unsure what treatment will be advised – how will this get better, especially as it is getting worse? Do you need antibiotics?

• High blood pressure (several years) – well controlled on medication
• Gout – started on a tablet a couple of years ago to “lower gout levels”; no attacks since
• History of “bad leg veins”: varicose veins in the past; about 2 years ago saw GP about dark discolouration on the shins and an itchy rash on the lower legs. GP said it was because of bad veins and prescribed a course of steroid cream. Still use OTC moisturiser (E45 cream). Fitted for “pressure socks” but do not wear them as they are uncomfortable.

• Amlodipine (high blood pressure)
• Allopurinol daily (gout prevention)
• OTC E45 cream for dry, flaky skin on the legs
• No known drug allergies

• Mother died with dementia in her 80s
• Father passed away from pneumonia in his 70s

• Divorced from partner 20 years ago; no current partner
• Still works at the local supermarket (past 10 years) – hoping to retire soon
• Lives with 40-year-old son in a terraced house
• Drinks alcohol only occasionally at social events
• Ex-smoker (teenager to mid-20s); cannot recall exact number – “only a few a day”

If the student asks about any other symptoms aside from those listed in the script above, please reply in the negative.

Location: venous typically over medial/lateral malleolus vs arterial near end arteries (toes, heels, lateral malleolus)

Management of venous ulcers:

Compression bandaging therapy; referral to District Nursing team. See

NICE CKS – Leg ulcer – venous

.

Other points: Referral criteria for varicose vein surgery on NHS; management of venous eczema / lipodermatosclerosis.

Useful links:

Clinical Skills Foundation Course · Phase 1 Term 3 · PVS Role Plays · Case last revised November 2024

• Top differential diagnosis: Likely venous leg ulcer (gaiter area, history of venous insufficiency – venous eczema, varicose veins, non-healing wound).
• Features distinguishing venous from arterial ulcer:
• Clinical features: venous – shallow, irregular borders with surrounding venous changes (haemosiderin); arterial – regular “punched-out” borders, hair loss, diminished pulses, cool surrounding skin
• ••• Geeky Medics – Leg ulcers
• NICE CKS – Varicose veins
• NICE CKS – Venous eczema & lipodermatosclerosis