Chronic Leg Ulcer

Question 1

A 25yrs old patient presents with history leg ulcer 2 months duration. Take a focused history

Answer 1

GRIP + BIODATA
PRESENTING COMPLAIN

Question 2

5Cs. Course (Doctor)

Answer 2

When did the leg ulcer appear?
Did it start suddenly or gradually?
Is the ulcer located on the right or left leg? Where exactly on the affected leg?
Is it a single or multiple ulcer?
How big is the ulcer ?
Any associated discharge? If yes how much? What is the color
Any smell or odor?
Have you noticed any temperature change at the site of the ulcer ?
Has it progressively worsen ?
Did it develop spontaneously or was there any history of swelling, scars or burns injury to the site of the ulcer?

R/o margerine cancer usually occur in scar of a burn

Is it a new or recurring ulcer ?
Any history of associated fever, pain , itching, blister at ulcer site?
Have you noticed any lost of appetite, weight loss or swelling in any part of your body?

Question 3

CAUSES

Answer 3

Any history of recurrent blood transfusions? If yes how many times? Any complications of transfusion? How was it managed? Was it associated with bone pain?
R/o sickle cell disease

Any history of increased thirst, appetite and increased frequency in urinating
Or are you a known diabetic?

Any history of leg trauma?
Any history of chronic cough, drenching night sweats, ?
Have you noticed weight loss, do you get tired easily? R/o malignancy

Do you know your HIV status
Have you had any history of sore on your genitalia, mouth or lips before the onset of this ulcer ( syphilis)

Any history of mosquito bite? Do you swim in dirty water? ( Burulis ulcer )
Burulis ulcer is a tropical ulcer caused by mycobacterium ulcerum, caused by mosquito bite or when you swim in dirty water

Any history of loss of sensation or abnormal sensation like walking on pebbles on the legs before onset of ulcer? ( neuropathic ulcer)

Any history of pain while walking, with cold feet ( arterial ulcer )
Any history of dilated vein or painful swelling following prolonged sitting or immobility ( venous ulcer)

Question 4

COMPLICATIONS

Answer 4

Any history of fever, rapid heart beat with associated confusion? ( sepsis)
Any redness with painful swelling and increase warmth at site of ulcer ? (Osteomyelitis )
Any darkening of ulcer with associated dryness ( dry gangrene)
Any stiffness with decreased ability to move?( contracture)
Have you noticed any low mood with lack of interest to socializing with people since onset of ulcer? (Depression)

Question 5

CARE SO FAR

Answer 5

What have you done so far? E.g herbal concoction, over the counter medications etc?

Hospitals visited, prayer house, or traditional doctors?

What investigations was done? Example fasting blood sugar, wound swab for microscopic examination, culture and sensitivity, fbc, Doppler ultrasound, genotype, mantoux for Tb, or biopsy

Treatment received? Like antibiotics, wound debridement, and dressing, herbal concoction

Question 6

PAST MEDICAL HISTORY

Answer 6

Have you had similar symptoms in the past
Do you have any chronic liness lIke hypertension, epilepsy, asthma, diabetes or sickle cell disease . HEADS
Have you have any surgery. hospitalization or blood transtusion
in the past
Do you have any known drugs or food allergies?

Question 7

DRUG HISTORY

Answer 7

Are you on any long term medication
Are you on any current medication
Do you have any drug allergies

Question 8

FAMILY AND SOCIAL HISTORY

Answer 8

is there any one in your family with similar diseases ( HEAD)

Do your drink alcohol, do you smoke Do vou have multiple sexual partners
Are you on any long term medication
Are you on any current medication
Do you have drug or food allergies

Question 9

SYSTEMIC REVIEW

Answer 9

Ma. just to be sure I didn’t miss out any symptoms . I would like you to say yes or no to the following questions
UNS: any headache, any blurry vision , any loss of consciousness
ENDO: any neck swelling? Do you feel hot when other are cold.
any unexplained weight loss or weight gain
RESP: any cough, chest pain, difficulty breathing
CVS: are you aware of your heart beat, have you noticed that you are easily out of breathe any swelling on your bodv
especially the lower limbs
DIGESTIVE: and nausea, vomiting, and constipation, blood in stool
GUS: bloody urination, abnormal discharge . increased frequency in urination
MSS: any bone pain, joint pain, and difficulty walking, skin rash