CCE-CE-057.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including ulcer duration, risk factors, previous treatments, and impact on daily life.

The competent candidate should:

• Elicit a detailed ulcer history, including:
  • Duration (six months, persistent, non-healing).
  • Onset (following minor trauma, progressively worsened).
  • Characteristics (shallow, 5 cm, yellow slough, weeping clear fluid, no severe pain).
• Assess risk factors, such as:
  • Venous insufficiency (long-standing varicose veins, leg swelling, improved with elevation).
  • Peripheral vascular disease (history of mild arterial narrowing, ex-smoker, family history of vascular disease).
  • Limited mobility (due to knee osteoarthritis, affecting venous return).
• Review previous management, including:
  • Use of antibiotic creams and dressings (without significant improvement).
  • Compression stockings not worn regularly due to difficulty putting them on.

Task 2: Differentiate between venous, arterial, and other types of ulcers, identifying any red flags for complications.

The competent candidate should:

• Differentiate ulcer types:
  • Venous ulcer (most likely):
    • Located on the gaiter region of the lower leg.
    • Associated with varicose veins, leg swelling, and aching that improves with elevation.
    • Shallow, irregular border, exudative, surrounding skin changes (haemosiderin staining, lipodermatosclerosis).
  • Arterial ulcer (less likely but should be ruled out):
    • Painful, deep ulcer with punched-out edges.
    • Located over pressure areas (toes, heels, lateral malleolus).
    • Associated with cold, pale extremities, weak pulses, and intermittent claudication.
• Recognise red flags:
  • Signs of infection (increased pain, warmth, spreading erythema, purulent discharge, fever).
  • Features suggestive of malignancy (non-healing ulcer despite optimal treatment, raised irregular borders, bleeding, rapid growth).

Task 3: Provide a diagnosis and discuss an initial wound care and management plan.

The competent candidate should:

• Explain the most likely diagnosis:
  • Venous ulcer, due to chronic venous insufficiency.
  • Not infected at present, no need for antibiotics.
• Outline management:
  • Wound care:
    • Regular dressing changes with appropriate moisture control.
    • Use of non-adherent dressings to promote healing.
  • Compression therapy:
    • Encourage proper use of compression stockings.
    • Consider referral to a wound care clinic if needed.
  • Address underlying causes:
    • Leg elevation to reduce swelling.
    • Encourage regular walking to improve circulation.
    • Assess need for vascular review (Doppler ultrasound, ankle-brachial index [ABI]).

Task 4: Educate the patient on wound healing strategies, prevention of recurrence, and the need for follow-up care.

The competent candidate should:

• Provide lifestyle advice:
  • Elevate legs regularly to improve venous return.
  • Encourage daily movement to enhance circulation.
  • Moisturise surrounding skin to prevent breakdown.
• Explain long-term strategies to prevent recurrence:
  • Ongoing compression therapy.
  • Regular follow-up with vascular assessment if needed.
• Safety-netting advice:
  • Return if signs of infection develop (increased pain, redness, pus, fever).
  • Follow up in two to four weeks to reassess healing progress.

SUMMARY OF A COMPETENT ANSWER

• Takes a structured ulcer history, assessing duration, risk factors, and treatment history.
• Differentiates venous ulcers from arterial and other causes.
• Identifies red flags requiring urgent referral, such as infection, malignancy, or significant arterial disease.
• Provides a structured wound care plan, including compression therapy, dressing selection, and vascular assessment.
• Educates the patient on long-term prevention and importance of follow-up care.

PITFALLS

• Failing to identify venous insufficiency as the primary cause, leading to inadequate management.
• Not considering arterial insufficiency, which could lead to inappropriate use of compression therapy.
• Prescribing antibiotics unnecessarily, as there are no clear signs of infection.
• Neglecting lifestyle modifications, such as leg elevation and regular mobility.
• Failing to arrange follow-up, leading to poor monitoring of ulcer healing.

REFERENCES

• RACGP Guidelines on Chronic Wound Management
• Science Direct Australia on Venous Ulcer Management
• Therapeutic Guidelines on Wound Care and Compression Therapy
• Australian and New Zealand Society for Vascular Surgery on Chronic Venous Insufficiency

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 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured history, including ulcer duration, risk factors, and previous treatments.
2.2 Identifies red flags for complications (e.g., infection, arterial insufficiency).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between venous, arterial, diabetic, and pressure ulcers.
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based wound care plan.
4.2 Addresses underlying causes (e.g., venous insufficiency, diabetes).

5. Preventive and Population Health

5.1 Identifies risk factors for ulcer recurrence and provides preventive advice.
5.2 Encourages lifestyle changes to improve wound healing and reduce recurrence.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate referrals to wound care specialists, vascular surgeons, or podiatrists as needed.

8. Procedural Skills

8.1 Orders and interprets relevant investigations, such as ankle-brachial index (ABI), Doppler studies, and swabs for infection.

9. Managing Uncertainty

9.1 Recognises when ulcers may have an atypical or malignant cause.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages chronic ulcers while screening for complications (e.g., osteomyelitis, cellulitis).

Competency at Fellowship Level

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