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You are an F2 working in a GP practice. The next patient has come complaining of foot pain. You see on the system he is a diabetic, with HTN and IHD, and has missed his last two medication reviews. Please take a history and a perform an appropriate examination.

You are a 55yr old man called Max Faxx. You are presenting with foot pain. You are very frustrated with the service at your GPs. You keep on being told you have all these problems, given medication that make you feel no different. The pains in your legs that have been going on for a long time have never been fixed at all, and you’re getting fed up with it. You’re pleased you’re not seeing your normal GP, as you’ve given up on them, and were ready to give them a piece of your mind.

PC: Foot pain HPC

HPC: You’ve come in with pain in your left foot. Its shooting pain down the foot from the ankle, its there all the time, but you really notice it at night. The only things that really seems to help is hanging it over the side of the bed. It feels a bit similar to pains you’ve been having for years in that leg, but that has only ever when you’ve been walking, never at night. (if asked directly, you have noticed over the last few months that the distance needed to walk before the pain started has decreased. It was about 500m, the distance to the bus stop, but you were getting it by the time you got to the end of your road). You’ve tried all sorts of painkillers, but nothing really helps. You haven’t injured it at all recently. You’ve had the pain constantly for about a week now, and came on very gradually. You’ve also been getting a similar pain in your right bum cheek, but not nearly as bad and only when you’re walking. Apart from that, you’ve been feeling really lethargic and tired. Your legs feel very heavy. Between that and the pain, you just can’t be bothered to do anything. You have no breaks in the skin/ulcers, and sensation is normal.

ICE: You don’t know what it, that’s the reason you came here! Worried that is seems to have been getting worse, despite all the tablets your regular GP gives you. You always try them for a few days, but they never help. Want this problem fixed so you can go out of the house again

PMH Diabetes, ‘supposedly’ had it for about 5 years. Keep on being told to take these tablets and measure your sugars all the time. It’s a real pain in the arse, and everyone keeps telling me things are really badly controlled, but I feel fine. You feel worse when you do take the tablets, because they give you stomach problems. Shows what they know. Used to have high blood pressure, but don’t anymore. They still make me take the tablets though. Got angina, and have more attacks recently. Your regular GP has just sent me to a cardiologist, but I haven’t heard anything back yet. Had a mini stroke last year, the stroke doctor was really good. He saw you down in A&E and by the time you went up his ward everything had gone back to normal. You wish everyone could be as good as him.

DH: (reading off your list you keep in your wallet) Metformin Gliclazide Simvastatin Aspirin Ramipril Gabapentin Paracetamol Codeine GTN spray No known drug allergies

FH Don’t speak to them anymore, so you don’t really know. Pretty sure your dad had heart problems when you were younger though.

SH Lives alone with dog. Unemployed, used to work as a bus driver, but lost job a few years ago. Neighbour comes around to help tidy up and get the shopping in, especially now the pains have got worse. Tried walking with a stick, but just gave you terrible backache. Smokes 10 a day, ever since was a young lad. Drinks a litre of cider a day, maybe more at the weekend. Your diet isn’t that great, mostly take away pizzas these days as you really struggle going round the supermarket.

The student should take a detailed history of the patients problems, identifying risk factors for cardio-vascular diseases. They should perform a peripheral vascular exam, however a diabetic foot examination could be justified depending on their differential.

The student’s differential should sound something like this: ‘My top differential for this patient would be peripheral vascular disease, that has now reached a critical stage. He describes a history of intermittent claudication and has multiple risk factors for cardio vascular disease. Because of his diabetic history I would also consider diabetic neuropathy as a cause for this foot pain.’ Examples for discussion may include: • Initial management and investigation of PVD • If ankle/brachial pressure index is mentioned, discuss the different results of ABPI (normal range, different severity, how calcification might present) • Criteria for surgical intervention in PVD • CVD/PVD risk factors in this gentleman • Methods to improve this patients concordance with his medication • Presentation of critical ischaemia (6 P’s) and initial management • Different presentation of venous/arterial and diabetic ulcers