The Bothersome Case of Ms. E

HISTORY E.E. is a 74 year-old lady. Her chief complaint today is bilateral, intermittent lower leg pain of several weeks duration. The pain is an aching sensation. It began insidiously. It is worse later in the day. The skin itself seems to be sore and tender. Past medical history is remarkable for hypertension, myocardial infarction 2 years ago, and a stroke 5 years ago with moderate residual right hemiparesis. There is no history of SOB, DOE, orthopnea, or PND. There is no history of DVT or PE. Her medications are atenolol 25 mg daily, lisinopril 10 mg daily, and aspirin 325 mg daily. EXAM BP 150/80, P 76 & regular, T 98.30 F, Weight 172. She is alert and in no distress. Chest: clear to percussion and auscultation. Cardiac: PMI in left anterior axillary line; no murmur or gallop. Vascular: 2+ pulses in the feet, warm; varicose veins on thighs and legs. Skin/Extremities: scaly reddish-brown hyperpigmentation and mild tenderness of both lower legs; trace of edema in both ankles; scabbed over 3-4 mm shallow ulcer on right shin; fresh, clean 5 mm ulcer near left medial malleolus; dependent rubor that diminishes with elevation; no lesions on the toes or heels. Neurologic: monofilament sensation intact in the feet.

QUESTIONS 1. What is your diagnosis? 2. What are some predisposing conditions for this disorder? 3. What are common symptoms and signs? 4. How do you manage such a patient?


Epidemiology Prevalence ~1% ulcers are recurrent in 75% of patients Pathogenesis Normal physiology venous valves direct flow from superficial to deep and distal to proximal veins action of leg muscles pumps blood toward heart superficial venous pressure maintained at 20-30 torr Predisposing conditions deep vein thrombosis (postphlebitic syndrome) injury or surgery disorders of veins (e.g., varicose, incompetent) obliteration of lymphatic network employment or lifestyle requiring prolonged standing or sitting impaired calf muscle pump function (e.g., immobility, obesity, joint disease) Pathophysiology venous hypertension - pressures 60-90 torr Clinical Manifestations Symptoms most are asymptomatic skin irritation, sensitivity, or itching leg heaviness or aching ulcers are not as painful as ischemic ulcers Signs varicose veins - engorgement of cutaneous veins tan or reddish-brown pigmentation dermatitis - erosions, weeping, excoriations, crusting dependent edema

ulceration: breakdown of fibrotic skin, often medially, single or multiple typically tender, shallow, red, + exudate borders irregular and not undermined end-stage: lipodermatosclerosis edematous foot hide-bound, indurated, heavily-pigmented ankle edematous leg Complications Bacterial cellulitis Differential Diagnosis of Lower Leg Ulcers Venous insufficiency (>80%) Arterial insufficiency (ischemia) Neuropathy (e.g., diabetes mellitus) Pressure Other (e.g., injury, malignancy, infection, vasculitis) Diagnostic Testing – do selectively Duplex ultrasonography to identify DVT, popliteal cysts, hematomas, tumors Doppler measurement of ankle-to-brachial blood pressure ratio (ABI) normal > 0.9 10-20% have concomitant arterial insufficiency Biopsy for culture and histology - if an ulcer is present >3 months Management Dressings for ulcers dry nonadherent or wet changed by patient once or twice daily occlusive, hydrocolloid (e.g., DuoDerm [cost >$30 each]) changed by patient every 3-7 days

Mechanical therapy to resolve and prevent recurrence of edema elevation of legs rest supine, raise ankles above the heart level for 30 minutes a.c. b.i.d. compression wraps multi-layer, elastic, applied by visiting nurse, to achieve 40 mmHg pressure at the ankle zinc-paste impregnated bandages (i.e., Unna boot) applied by visiting nurse every 3-7 days compression stockings knee-high, exert 8-15 up to 20-30 torr at the ankle & less at the knee (e.g., Jobst socks for men and women - see Sources below) intermittent pneumatic compression pump - rarely needed Nutrition to promote ulcer healing and edema resolution protein/calorie supplementation Drug therapy aspirin 325 mg daily - may speed ulcer healing diuretics - occasionally and for a short period of time antibiotics - only with obvious infection or superimposed cellulitis antiseptics - more toxic to human cells than to microbes - avoid debriding enzymes - evidence for efficacy lacking growth factors - results of clinical trials inconsistent Surgery limited role - few studies have assessed the effect on ulcer healing

Sources of Compression Stockings Jobst compression socks for men or women: retail - to find a local retailer e.g., ABC Orthopedic & Prosthetic, Birmingham Limb & Brace, MASH, Eastern Valley Drugs on-line -

References Alguire PC, Mathes BM. Chronic venous insufficiency and venous ulceration. J Gen Intern Med 1997; 12: 374-383. de Araujo T, Valencia I, Federman DG, Kirsner RS. Managing the patient with venous ulcers. Ann Intern Med 2003; 138: 326-334. Takahashi PY, Kiemele LJ, Jones JP Jr. Wound care for elderly patients: advances and clinical applications for practicing physicians. Mayo Clin Proc 2004; 79: 260-267. Simon DA, Dix FP, McCollum CN. Management of venous leg ulcers. Brit Med J 2004; 328: 1358-1362. Bergan JJ, Schmid-Schonbein GW, Smith PDC, Nicolaides AN, Boisseau MR, Eklof B. Chronic venous disease. N Engl J Med 2006; 355: 488-498.

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