Alan Elstone: Diagnosing Leg Ulcers

If a patient presents, if they're usually referred from primary care to secondary care for assessment, what we normally do is see them in what we call a one-stop clinic setting in an outpatient-based setting. Those patients would normally undergo probably an arterial and a venous duplex to look at the blood flow to the lower limb and also to look at the deep and superficial vessels returning the blood back up to the heart to see if there's dysfunction, any stenosis or occlusion to flow in either direction, and also to look to see whether the veins are actually functioning effectively. We would then see them in the clinical setting. The ulcer would obviously be exposed. But I would start by taking a good story, a good patient history, really what is their presenting complaint. Yes, I might be told that they've got a leg ulcer, and the referral may say that. But what is the patient's most concern? It may well be that they've got pain, or they were leaking, or they've got itching. The ulcer, as we've said, is a symptom of the underlying problem. So it's finding out the patient's story, the patient's journey, where have they come from, what has happened, what management, what treatment have they had before we begin to look at how the ulcer's being managed, the effect on their everyday life, on the psychologically, physically, what differences it made, whether they've had ulceration in the past, before looking at all the other underlying medical conditions that they may well have, anything that's contributed towards venous disease. They may have had a DVT, a fracture, previous venous surgery. They may have a history of things like diabetes, heart disease, stroke, when you're looking from an arterial perspective, high blood pressure. So looking at all of the relevant comorbidities and taking a good past medical history. I'd then look at their drug history, any allergies that they have, their family histories. There are family history of venous disease, arterial disease, and everything that's linked with arterial disease and things like diabetes. I'd then also look at whether there's smoking, whether they've had children, alcohol, appetite, weight loss, all of those sorts of things. And also look at occupation. Not all of the patients that we see are retired, although a lot are in the sort of 60 to 80 bracket. But even that bracket are working. So a lot of these patients are perhaps still working, and the financial and psychological implications of living an everyday life with a leg also. Or I would move to a clinical examination, which would involve an assessment of the arterial and the venous system, both laying down and standing, and both an assessment of the tissue and the skin on the lower leg, and also of the ulcer itself. Once I'd done that, I'd then, therefore, look at the duplex scan to help to confirm my diagnosis and also to see whether there's any requirement for vascular intervention, whether that be arterial or venous. And then I'd go back and discuss my findings, my differential diagnosis with the patient, and look at, from a vascular perspective, what we can offer to try and treat under any underlying etiologies, and whether we need to intervene to improve the blood supply so that we can apply compression and then maybe treat the venous disease, or that the management may well be conservative. But for a lot of these patients, certainly with venous disease, we're dealing with a chronic disease process. So there's management for now, the acute management, and what we need to do is to try and treat the underlying venous disease to try and prevent recurrence in the future. But I'm quite passionate about the patients understanding the disease process so that we empower them to take some ownership of the disease process in the future and not just rely on the clinical practitioners to manage it, that they take some self-management. And we look at all of the other risk factors and contributory factors to try and prevent recurrence in the future.