Physician's Assistant

Refined clerking Tue 06 January 2026 07:33

Last Modified: 90 days ago

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Medical ST5 Miller Clerking
06/01/2025 07:00

Presenting Complaint:
Bilateral leg oedema

History of Presenting Complaint:
82-year-old lady presented with severe bilateral leg oedema with profuse weeping and ulceration. Symptoms commenced in November, the day she returned home following elective right total hip replacement surgery.

Initially noticed blood and fluid draining from the operated leg during the night. Over the subsequent weeks, both legs have become progressively swollen with thin, fragile skin that breaks easily, causing painful ulceration and continuous fluid leakage. The right shin has developed a non-healing wound.

Patient reports the fluid drainage creates "puddles" and significantly limits her mobility. She is unable to walk far due to pain and fear of falling, requiring walking frame. Symptoms worsen when legs are down and improve somewhat with elevation. Previously mobile and house-proud, now requires assistance with activities of daily living. Husband (age 90) is her registered carer but currently unwell with viral illness.

GP concerned about possible cardiac or circulatory causes. Patient tried furosemide for 10 days with no improvement. Recent chest symptoms with breathlessness prompted rescue steroid pack usage.

Past Medical History:
• Right total hip replacement (November 2024)
• Hip osteoarthritis (August 2024)
• Severe chronic peripheral arterial disease with right CIA stenosis, mid SFA occlusion, runoff disease with occluded ATA and PTA
-  Previous vascular MDT decision: conservative management unless critical limb ischaemia develops
• COPD (2017) - still smoking
• Prediabetes
• Breast cancer (2005) - Grade 3 ductal carcinoma, left breast
• Hypothyroidism (1983)

Drug History:
• Spiriva Respimat 2.5 micrograms per dose - 2 puffs OD
• Ferrous sulphate 200mg PO OD
• Clopidogrel 75mg PO OD
• Monoprost 50 micrograms per ml eye drops - 1 drop both eyes at night
• DuoResp Spiromax 320/9 micrograms - 1 puff BD
• Colecalciferol - 1 tablet OD
• Bisacodyl 5mg - 1-2 tablets at bedtime PRN
• Acetylcysteine 600mg PO OD
• Ventolin inhaler PRN
• Lansoprazole 30mg PO OM
• Chlordiazepoxide 5mg PO OD
• Levothyroxine 100 micrograms PO OM

Recently Stopped Medications:
• Furosemide - stopped after 10-day trial showed no improvement

Allergy History:
NKDA

Social History:
Lives at home with 90-year-old husband who is her registered carer but currently unwell. Very house-proud and previously independent with housework and gardening. Now requires assistance - has care worker twice weekly for washing and cleaning. Uses walking frame for mobility. Daughter assists with meals and appointments when possible.
Smoking: Current smoker - 15 per day for 65 years

On Examination:
• Cardiovascular: Heart sounds normal, significant bilateral oedema extending to hips
• Respiratory: Scattered creps bilaterally
• Legs: Severe bilateral pitting oedema with weeping, fragile skin. Large non-healing ulcer on right leg at hip operation site. Left leg also oedematous with threatened skin integrity
• Abdomen: Distended, tympanic, constipated

Investigations:
• Creatinine 34
• Sodium 131
• LFTs normal
• Amylase normal
• CRP 10
• Urea normal
• AST normal
• FBC: WBC 11.2, Neutrophils 9.4, Platelets 671, Hb 124
• Previous chest X-ray pre-operatively: Normal
• Previous vascular studies: Confirmed severe peripheral arterial disease

Impression:
Multifactorial bilateral oedema with 
- chronic inflammatory state secondary to non-healing ulcer.
- likely cardiac failure or cor pulmonale,
- peripheral arterial disease, 
- immobility post-surgery, 
and paper-thin vulnerable skin secondary to ongoing smoking and steroid use.
COPD with previous low oxygen saturations

Management Plan:
1. Chest X-ray [/]
2. BNP [/] +/- Echocardiogram [/]
3. Retrial furosemide
4. Oral flucloxacillin for infected leg ulcer 
5. MC+S of wound
6. Continue conservative wound care with tissue viability input if needed and consider vascular re-referral if non-healing
7. Patient to discuss with family regarding inpatient vs outpatient management
8. AMU or Short Stay
9. If admitted needs TEP discussion

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Refined clerking Tue 06 January 2026 07:33

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