An 82-year-old woman is brought to the clinic by her caregiver for a new leg wound. The patient has had chronic lower-extremity swelling for many years. Over the past 2 weeks, she developed a small, shallow opening on her right anterior lower leg that has slowly expanded. She has no fever, chills, warmth, or purulent drainage. The patient says that her legs often feel tired and heavy, especially when sitting for extended periods, but they improve with walking.
Her past medical history includes hypertension, degenerative joint disease, and obesity.
Vital sign signs normal. Cardiovascular examination shows normal rate and rhythm and no murmurs. Estimated jugular venous pressure is normal. The patient's lungs are clear. Lower extremities have symmetric edema bilaterally; the wound is shown in the image below. The feet are warm with palpable dorsalis pedis pulses bilaterally.

In addition to wound dressing recommendations, what is the best next step in management of this patient?

Question

An 82-year-old woman is brought to the clinic by her caregiver for a new leg wound.  The patient has had chronic lower-extremity swelling for many years.  Over the past 2 weeks, she developed a small, shallow opening on her right anterior lower leg that has slowly expanded.  She has no fever, chills, warmth, or purulent drainage.  The patient says that her legs often feel tired and heavy, especially when sitting for extended periods, but they improve with walking.
Her past medical history includes hypertension, degenerative joint disease, and obesity.
Vital sign signs normal.  Cardiovascular examination shows normal rate and rhythm and no murmurs.  Estimated jugular venous pressure is normal.  The patient's lungs are clear.  Lower extremities have symmetric edema bilaterally; the wound is shown in the image below.  The feet are warm with palpable dorsalis pedis pulses bilaterally.

In addition to wound dressing recommendations, what is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9769_bf59_853d_9d8efef061bb_MD0002_00 This patient has lower-extremity ulceration from chronic venous insufficiency (CVI). Symptoms of CVI are variable, but characteristic findings include aching or heavy pain in the legs, visible varicosities, chronic edema, and brawny discoloration of the lower legs. Risk factors include smoking, prior thromboembolic disease, older age, family history, and obesity. Prior ulceration is a strong predictor of future recurrence. First-line treatment for CVI should include lower-extremity elevation (at least 20-30 minutes 3 or 4 times a day), leg exercise, weight loss, and continuous compressive therapy. Prescription graduated compression stockings increase healing, with improvement rates up to 97% in compliant patients. This is thought to be due to improved venous hemodynamics, optimized fibrinolysis, and reduction of inflammation. Contraindications include moderate-to-severe peripheral arterial disease or active cellulitis. Aspirin therapy also has been shown to accelerate the ulcer healing process and is recommended. (Choice A) Ankle brachial indices are an effective screening assessment for patients with symptomatic peripheral arterial disease (PAD). Features suggesting PAD include nonpalpable pulses, claudication, or rest pain. This patient's improvement with walking is not consistent with PAD. (Choice C) Furosemide and other diuretics have no role in the treatment of lower-extremity edema due to CVI. A thorough physical examination should be performed to exclude other potential etiologies such as heart failure, for which this treatment would be indicated. (Choice D) This patient's skin changes are most consistent with chronic venous stasis dermatitis with ulceration rather than an acute cellulitis or wound infection. As a result, treatment with either oral or topical antibiotics is not warranted. Findings suggesting superimposed cellulitis include a sudden increase in pain or erythema, fever, leukocytosis, or significant warmth on palpation. (Choice E) Supplementation with oral zinc sulfate has been proposed for the treatment of arterial and venous lower-extremity ulcers, but trials to date have found no significant beneficial effect. Educational objective: Management of chronic venous insufficiency (with or without ulceration) consists of lower-extremity elevation, leg exercise, weight loss, and continuous compressive therapy. Aspirin accelerates ulcer healing. Topical antibiotics, zinc sulfate, and hyperbaric oxygen therapy are not effective. __________ References: Compression and venous ulcers. (http://www.ncbi.nlm.nih.gov/pubmed/23482538) Influence of aspirin therapy in the ulcer associated with chronic venous insufficiency. (http://www.ncbi.nlm.nih.gov/pubmed/22437068)

An 82-Year-Old Woman Is Brought to the Clinic by Her