EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Dorothy’s ulcer?

• Prompt: Can you differentiate venous, arterial, and neuropathic ulcers?
• Prompt: What red flag conditions need exclusion?

Q2. What further history would you elicit to confirm the diagnosis?

• Prompt: What risk factors for delayed healing should you explore?
• Prompt: How does her past medical history influence her ulcer?

Q3. What investigations would you order and why?

• Prompt: When is a Doppler ultrasound indicated?
• Prompt: Would you consider biopsy or blood tests?

Q4. Outline your management plan for Dorothy’s ulcer.

• Prompt: What is the role of compression therapy?
• Prompt: How would you optimise her wound care and lifestyle?

Q5. What are the follow-up and safety-netting considerations?

• Prompt: When should she be referred to a specialist?
• Prompt: What complications should she monitor for?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are your differential diagnoses for Dorothy’s ulcer?

A competent candidate should provide a structured approach to the differential diagnosis, considering:

• Venous ulcers (most likely) – typically shallow, located on the medial malleolus, associated with oedema and chronic venous insufficiency.
• Arterial ulcers – painful, with well-defined edges, located on pressure points (toes, heels), associated with peripheral arterial disease.
• Neuropathic ulcers – painless, commonly in diabetic patients, on weight-bearing areas.
• Pressure ulcers – occur over bony prominences due to prolonged pressure.
• Infectious ulcers – consider bacterial (necrotising fasciitis, pyoderma gangrenosum), fungal, or mycobacterial infections.
• Malignant ulcers – non-healing ulcers may indicate squamous cell carcinoma, basal cell carcinoma, or melanoma.

Red flags include rapidly worsening ulcers, significant pain, non-healing ulcers despite appropriate management, or suspected malignancy.

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Q2: What further history would you elicit to confirm the diagnosis?

• Wound history – duration, previous treatments, rate of healing, any trauma.
• Pain assessment – venous ulcers are usually painless, arterial ulcers are painful, neuropathic ulcers may be painless due to nerve damage.
• Associated symptoms – swelling, warmth, systemic symptoms (fever, night sweats).
• Risk factors for poor healing – diabetes, smoking, immunosuppression, malnutrition.
• Venous history – varicose veins, deep vein thrombosis, previous ulcers.
• Arterial history – intermittent claudication, rest pain, previous vascular procedures.

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Q3: What investigations would you order and why?

• Basic investigations:
  • Full blood count, inflammatory markers (infection/inflammation).
  • Fasting glucose and HbA1c (diabetes screening).
  • Wound swab if infection suspected.
• Vascular assessment:
  • Ankle-Brachial Index (ABI) to differentiate venous vs arterial ulcers.
  • Doppler ultrasound for venous insufficiency.
• Imaging if indicated:
  • X-ray if osteomyelitis suspected.
  • Biopsy if malignancy suspected.

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Q4: Outline your management plan for Dorothy’s ulcer.

• Wound care:
  • Compression therapy if venous ulcer (contraindicated in arterial ulcers).
  • Regular moist wound dressings (hydrocolloid, foam).
  • Elevation and leg exercises.
• Pain management:
  • Paracetamol or NSAIDs (if no contraindications).
• Address underlying causes:
  • Manage chronic venous insufficiency with compression stockings and lifestyle changes.
  • Treat arterial disease if contributing (vascular referral if needed).
• Infection control:
  • Oral antibiotics if infection present, guided by wound swab.
• Referral if necessary:
  • Wound clinic, vascular specialist, dermatologist (if malignancy suspected).

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Q5: What are the follow-up and safety-netting considerations?

• Regular review (1-2 weeks initially) to assess healing.
• Early escalation if no improvement – consider alternative dressings, referral.
• Monitor for complications – infection (increasing pain, purulent discharge), deterioration, signs of malignancy.
• Encourage adherence to wound care, leg elevation, and compression therapy.

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SUMMARY OF A COMPETENT ANSWER

• Uses a structured approach to differentiate venous, arterial, and neuropathic ulcers.
• Identifies chronic venous insufficiency as the most likely cause while considering red flags.
• Orders appropriate investigations, including vascular assessment and wound swab.
• Provides a comprehensive management plan, including wound care, compression therapy, and pain control.
• Implements safety-netting strategies, ensuring appropriate follow-up and escalation if needed.

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PITFALLS

• Failing to differentiate between ulcer types, particularly missing an arterial ulcer that requires a different approach.
• Overlooking vascular assessment, especially ABI and Doppler ultrasound.
• Not considering malignancy in a non-healing ulcer.
• Inappropriate use of antibiotics, treating colonisation rather than infection.
• Neglecting patient education on leg elevation, mobility, and compression therapy.

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REFERENCES

• Queensland Health – Chronic wound assessment and management
• GP Exams – Chronic Skin Ulcer

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Establishes rapport and effectively gathers information about symptoms and impact.
1.2 Explains the condition and management plan in a way that is appropriate for the patient’s health literacy.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including wound duration, risk factors, and past treatments.
2.2 Performs a targeted examination, including ulcer characteristics and vascular assessment.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies venous leg ulcer as the most likely diagnosis but considers arterial and neuropathic ulcers.
3.2 Recognises red flags for complications such as infection or malignancy.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a wound care plan including compression therapy and dressings.
4.2 Implements pain management strategies and referrals where necessary.

5. Preventive and Population Health

5.1 Provides education on ulcer prevention, including skin care, mobility, and lifestyle modification.

6. Professionalism

6.1 Demonstrates empathy and patient-centred care, addressing concerns about healing and quality of life.

7. General Practice Systems and Regulatory Requirements

7.1 Documents ulcer characteristics, treatment plan, and follow-up clearly in medical records.

8. Procedural Skills

8.1 Demonstrates proper wound assessment and dressing techniques.

9. Managing Uncertainty

9.1 Plans appropriate follow-up and escalation if healing is delayed or complications arise.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises signs of infection, arterial disease, or skin malignancy requiring further intervention.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD