TCP wound template

Specialty: General Practitioner 1 November 2024 Referrer: Dr. Sarah Jenkins GP: Dr. Thomas Kelly Re: Mrs. Eleanor Vance Date of birth: 15/03/1955 Social History: Mrs. Vance is a 69-year-old retired teacher who lives alone in a ground-floor flat. She is generally independent but uses a walking frame for longer distances due to mild osteoarthritis in her knees. She has good cognitive function and is fully cooperative with her care. She has provided informed consent for all procedures discussed and performed today. Medical History: Mrs. Vance has a history of type 2 diabetes mellitus, diagnosed 10 years ago, currently managed with oral hypoglycaemics. She also has essential hypertension, managed with ACE inhibitors. She underwent a left total knee replacement five years ago. There is no history of peripheral vascular disease. Equipment: Currently, Mrs. Vance is using standard wound dressings for her left lower leg ulcer. She has a pressure-reducing cushion on her armchair at home, though this was not specifically prescribed for this current issue. Nutrition: She follows a diabetic-friendly diet but sometimes struggles with consistent meal times. Nutritional supplements (Fortisip Compact Protein) were recommended to aid wound healing, with instruction to take one twice daily. Medications: Metformin 500mg twice daily, Ramipril 5mg once daily. Reviewed her medication list; no new medications were introduced. Both current medications are compatible with wound healing, and her diabetes management is critical for the ulcer's resolution. Allergy: Penicillin (causes rash). On Examination: *General Assessment:* Mrs. Vance is alert, oriented, and cooperative. She appears comfortable and is in no acute distress. Her mucous membranes are moist, and her sclera and conjunctiva are clear. Capillary refill time is less than 2 seconds. No overt signs of systemic infection were noted. *Vascular:* No rubor or pallor observed. Mild pitting oedema noted around the left ankle. Dorsalis pedis and posterior tibial pulses are palpable bilaterally, 2+. No varicosities. Skin on lower legs is dry with some scaling. Doppler assessment showed triphasic waveforms in both lower extremities. ABPI was attempted but inconclusive due to severe arterial calcification, however, palpable pulses and good Doppler signals suggest adequate arterial inflow. Wounds: *Left Medial Malleolus Ulcer:* This is a chronic venous ulcer, approximately 3cm x 2.5cm, with irregular margins. The wound bed consists of 70% granulation tissue and 30% slough. Exudate is moderate, serosanguinous, and there is no foul odour. Surrounding skin is hyperpigmented and indurated, consistent with venous insufficiency. No overt signs of local infection were observed, though there is some erythema at the wound edges. Impression: Chronic venous leg ulcer, left medial malleolus, likely exacerbated by poor diabetic control and inadequate compression. The aetiology appears primarily venous, with no significant arterial compromise identified on clinical assessment. The current wound is in the proliferative phase, but slough needs debridement. No clear signs of infection currently, but continued monitoring is essential. Recommendations: Conservative management to include regular wound cleansing with normal saline. Application of a hydrocolloid dressing (DuoDerm Extra Thin) to the wound bed to promote autolytic debridement and maintain a moist wound environment. Compression therapy with a multi-layer bandage system (Coban 2 Lite) to manage oedema and support venous return. Regular blood glucose monitoring and tight control are paramount. Review in one week for wound reassessment and dressing change. Regime: Cleanse wound with normal saline at each dressing change. Apply DuoDerm Extra Thin directly to the wound. Apply Coban 2 Lite compression system from the foot to just below the knee. Dressings to be changed twice weekly, or sooner if exudate soaks through. Monitor for signs of infection (increased pain, redness, warmth, purulent exudate, fever) and report immediately. Final Opinion: Mrs. Vance presents with a chronic venous ulcer on her left medial malleolus. Initial classification as a venous ulcer with potential diabetic influence has been reinforced by today's findings. The adopted management approach focuses on wound debridement, compression, and strict diabetic control. Ongoing follow-up and monitoring will be crucial to track healing progress and address any complications.