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Old 06-08-2011
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Question What is the appropriate management of this leg ulcer!

A 72-year-old man presents to an urgent-care clinic for evaluation and treatment of a sore on his left leg. He says that the sore first appeared several months ago but has recently increased in size, becoming painful within the last 2 weeks. The sore has also begun to drain yellowish fluid, over the past 3 weeks. He says that he has another sore on his right leg that is similar, but smaller, which has been present for about 4 weeks. His past medical history is significant only for hypertension, for which he takes hydochlorothiazide. On physical examination, you note a well-nourished, medium-build man who appears his stated age. Head and neck, chest, and abdominal examinations are normal. Cardiac sounds are normal. Lower extremities are noted to have varicose veins in the popliteal fossae and over both calves. Both legs are slightly edematous and purplish-red distally to about 5 cm distal to the knees. The skin over this area is mottled in appearance with purplish-brown discoloration in the skin creases about the ankles. A wound on the left, medial malleolus is shown in the figure and there is a similar, smaller, 1 x 2cm wound on the right medial malleolus. Which of the following would be appropriate for first-line treatment of the underlying condition?

What is the appropriate management of this leg ulcer!-legulcer.jpg
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A. Arterial bypass grafting of the affected area
B. Sclerotherapy of the varicose veins
C. Use of a broad-spectrum antibiotic
D. Use of oral hyperglycemic agents
E. Use of support stockings when upright
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Old 06-08-2011
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IMO
E. Use of support stockings when upright
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Old 06-08-2011
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I am not but I would start with Antibiotics C
It looks like an infected varicose ulcer since it is painful, edematous, discoloured (sign of inflammation). Of course other choices will come next. like support stocking
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Old 06-08-2011
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Venous ulcer.

I'm torn between antibiotics and compression bandages.

Putting constant pressure on veins help ulcer healing.

Also typically they are given antibiotics to control skin inflammation around the ulcers.

"Most appropriate first line treatment" I think I would go with compression bandages.
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Old 06-08-2011
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idid choose c too but the answer is E

Option E (Use of support stockings when upright) is correct. Support hose are a good first-line treatment for venous stasis of the legs, which occurs when incompetent valves in leg veins combined with higher blood pressures in the dependent extremities result in fluid accumulation in the tissues. Regular exercise and elevation of the legs when sitting are also helpful.

Option A (Arterial bypass grafting of the affected area) is incorrect. Bypass grafting is the treatment of choice for arterial insufficiency or occlusion. This man's presentation is more consistent with venous stasis.

Option B (Sclerotherapy of the varicose veins) is incorrect. Sclerotherapy is a useful treatment of cosmetically bothersome varicose veins, and involves injection of veins with a sclerotic agent. It is not useful for venous insufficiency.

Option C (Use of a broad-spectrum antibiotic) is incorrect. Skin ulcers such as these may become superinfected necessitating the use of antibiotics, but infection is not the cause of the ulcers.

Option D (Use of oral hyperglycemic agents) is incorrect. Although uncontrolled diabetes often contributes to development of skin ulcers, especially of the feet, this man's presentation is consistent with venous stasis and he has no history of diabetes.
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