Examination of an ULCER 8.
Whole Limb: Presence of varicose veins, DVT- varicose ulcer,
Neurological insufficiency- Trophic ulcer
Name: Age: Sex: Occupation: Address:
‘An ulcer is a break in the continuity of the covering epithelium i.e. B. PALPITATION:
skin or mucous membrane following either molecular death of 1. Tenderness:
surface epithelium or its traumatic removal.’ 2. Edge and Margin: Marked induration (hardness of edge) –carcinoma
Slight induration- any chronic ulcer
HISTORY 3. Base: same as edge and margin
1. Mode of onset: Traumatic/ Spontaneous/ Following swelling or 4. Depth: Check in mm, Trophic ulcer may be deep till bone
tumour/ over varicose veins or venous insufficiency/ over scar, 5. Bleeding: Malignant ulcer bleeds to touch.
burns (Marjolin) 6. Relation to deeper structures: Fixed to underlying structures,
2. Duration: Malignant ulcer fixes to deeper structures by infiltration.
Acute/Chronic, Incubation period: between exposure and onset of 7. Surrounding Skin: Temperature, tenderness, (inflamed)
ulcer. 3-4 days = chancroid (soft sore), 3-4 weeks = Hunterian chancre Mobility- fixed to deeper structures- malignant
(syphilis) Loss of motor or sensory-Nerve deficits
3. Pain: Painful= inflammatory Peripheral nerves for abnormal thickening, tenderness.
Painless= resulting from nerve disease (syphilis ulcers, trophic ulcers, Arteries (atherosclerotic, Raynaud’s, Buergers)
malignant BCC). Tuberculous ulcer is slightly painful. Veins: (varicose veins)
4. Discharge:
Nature of discharge: pus/blood/serum. C. Examination of Lymph Nodes:
5. Associated disease: Nervous diseases (tabes dorsalis, transverse Acute infmaled ulcer- enlarged, tender, acute lymphadenitis
myelitis, syringomelia, peripheral neuritis), TB, Syphilis, Nephritis, DM TB ulcer- Enlarged, matted, slightly tender
Hunterian chancre-discrete, frim, shotty.
PHYSICAL EXAMINATION Gummamatous and Rodent ulcer-not involved
1. GENERAL SURVEY. Malignant ulcer-stony hard, fixed to structures.
- Cachexia? Signs of Malnutrition
-General Atherosclerosis, Syphilis, TB. D. Examination of Vascular insufficiency:
Veins- Varicose Veins, DVT
LOCAL EXAMINATION-ULCER Arteries- Atherosclerosis, Raynaud’s, Buerger’s
A. INSPECTION:
1. Size and Shape: TB-oval but can coalesce to be irregular, Syphilis- E. Examination of Nerve Lesions:
circular but can become serpiginous, Varicose- vertically oval, Trophic ulcer- Repeated trauma with sensory deficit seen in Tabes
Carcinomatous ulcer- irregular dorsalis, transverse myelitis, peripheral neuritis.
2. Number
3. Position: Varicose ulcer- over medial malleolus, Rodent ulcer- upper
part of face, usually line joining angle of mouth to ear lobule near inner GENERAL EXAMINATION:
canthus of eye. TB- near lymphadenopathy (neck, axilla, groin)
Lupus vulgaris of TB-face, fingers, hands. Syphilitic stigma, TB, Atherosclerosis (Look for whole body)
Hunterian chancre/soft sores- Genitalia, Trophic Ulcer do nervous examination.
Gummamatous ulcer- Subcutaneous bones like tibia, sternum, skull
Perforating or trophic ulcer- Heel or ball of foot which carries maximum
weight of the body
Malignant Ulcer- more common on lips, tongue, breast, penis.
4. Edge: Spreading ulcer-edge is inflamed oedematous, Healing ulcer-
Inside centre-Red= granulation tissue, Periphery- blue- thin growing
epithelium, and a white core-due to fibrosis and scar.
5 common types of edge. i. Undermined Edge- TB
ii. Punched out edge-Gummamatous or deep trophic ulcer,
iii. Sloping edge= Healing ulcer.
Iv. Raised or Pearly white beaded edge-Invasive cellular disease
(BCC/Rodent ulcer)
v. Rolled out/Everted Edge- SCC
5. Floor: Healthy and healing- Red granulation tissue,
Slow healing ulcer-smooth and pale granulation ulcer,
Gummamatous ulcer- Wash leather slough,
Malignant Melanoma-Black mass
6. Discharge: Character, amount, smell. Healing Ulcer- scanty serous,
Inflamed spreading ulcer- purulent,
Malignant or TB- serosanguinous discharge
Infected with B pyocyanea- greenish
7. Surrounding area: Acutely inflamed-glossy red oedematous,
Varicose-eczematous and pigmented
Old TB- scar or wrinkling
