Patient Details

Wendy Butterworth

72

F

Telmisartan 40mg PO mane

Atorvastatin 40mg PO nocte

Digoxin 62.5microg PO nocte

Metformin XR 2g PO nocte

Lantus 20units S/C nocte

Novorapid 10/12/12units S/C TDS

Pantoprazole 40mg PO mane

Mrs Butterworth is a 72-year-old woman who has presented to the Armidale Hospital Emergency Department with a worsening right leg ulcer. This ulcer had continued to worsen after a mechanical fall two months ago. The ulcer is on the lower anterior aspect of the right leg. It is currently a full thickness ulcer with no tendon or bony involvement. She presented to ED due to some new minor exudate which looked purulent. This ulcer has not been giving her any pain. She was nervous to present to hospital as she has previously had an ulcer that required amputation of the right 5^th toe. Due to her last presentation to hospital resulting in an amputation, she has been reluctant to present and trying to manage this ulcer at home.

Mrs Butterworth also had varicose veins which is associated with dry and often itchy skin, oedematous legs and complains about them being heavy. She also suffers with insulin-dependent diabetes which is poorly controlled. She rarely checks her BSLs at home and admits to sometimes forgetting to use her insulin.

Right 5^th toe amputation -> Pressure ulcer

Left inguinal hernia repair

Hypertension

Dyslipidaemia

AF -> Not anticoagulated

T2DM -> Insulin dependant

GORD

Varicose veins

Overweight -> BMI 29

NKDA  

Mrs Butterworth’s mother and father are both deceased. Her mother died of a large ischaemic stroke at the age of 75 and her father suffered with Alzheimer’s dementia and died at age 77. She has a younger sister in Armidale who had ischaemic heart disease and 3 children who are well.  

Mrs Butterworth is a retired baker and has been a widow since her husband passed away four years ago after a long fight with pancreatic cancer. She has lived alone since her husband passed and is independent with all ADLs. She has her younger sister and a son who live locally and are very supportive.

Mrs Butterworth does not drink any alcohol but smokes. She has a 25 pack year smoking history, roughly half a pack per day.