Clinical Examination of an Ulcer

                  Clinical Examination of an Ulcer

 

 

Definition of an Ulcer

—  An  ulcer  is  defined  as  a  break   in  the  continuity  of   surface  epithelium   with     superadded    infection.

Clinical Classification of Ulcer

—  Spreading- with surrounding inflammation

—  Healing – Slopping edge with red granulation tissue

—  Callous- Ulcer with no tendency to heal-with pale granulation tissue.

Pathological Classification of Ulcer

—  Specific- Tuberculous, Syphylitic,Actinomycotic

—  Non specific- Traumatic( Mechanical, Physical,Chemical)

Cryopathic, Arterial, Venous, Neurogenic, Trophic, Tropical, Bazin’s, Martorell’s, Meleney’s ulcer

—  Malignant- Squamous cell carcinoma, Basal Cell Carcinoma, Melanoma

Classification of Ulcer based on duration

—  Acute  Ulcers    < 12 weeks

—  Chronic  Ulcers  > 12 weeks

Classification Based on Pain

—  Painful Ulcers

        Tuberculous

        Arterial

        Advanced Malignancy

—  Painless Ulcers-

       
        Syphilitic

        Trophic

        Early Malignancy

Modes of Onset of Ulcer

•      Traumatic

•      Spontaneous-

•      Secondary changes on a Swelling-Tuberculous lymphadenopathy

•      From a Previous Scar-Marjolin’s Ulcer

Causes for Chronic Ulcers

1.     Malnutrition

2.     Anemia

3.     Immunosuppression

4.     Systemic Diseases (Diabetes)

5.     Site & Size of an Ulcer

6.     Arterial / Venous Disorders

7.     Neurological Disorders

8.     Infection

9.     Chronic Irritation ( Dental Ulcers )  or  Lack of Rest ( Ulcer over a Joint )

10.   Malignancy

Discharge from the ulcer – Note the Colour, Amount & Smell

—  Serous-Healing ulcer

—  Sanguinous ( Blood Stained )- Malignant/Chronic

—  Purulent-Bacterial infection

—  Greenish- Pseudomonas infection

—  Yellowish - Sulphur Granules ( Actinomycosis )

Parts of an Ulcer

•      Margin-line of demarcation between normal and abnormal

•      Floor-the exposed part of an ulcer ( Inspection)

•      Edge-the part between the margin and the floor of an ulcer

•      Base-the structure on which the ulcer rests (Palpation)

Types of Floor of an Ulcer

—  Slough-Moist dead tissue

—  Scab-Dry dead tissue

—  Unhealthy granulation tissue

—  Healthy granulation tissue

—  Subcutaneous fat

—  Muscle/tendons

—  Bone

Types of Edges of an Ulcer

—  Slopping- Healing ulcer

—  Punched out-Decubitous ulcer/Gummatous ulcer

—  Undermined- Tuberculous ulcer

—  Raised / Beaded- Basal cell carcinoma

—  Rolled out / Everted- Squamous cell carcinoma

Examination of an Ulcer-Inspection

—  Site

—  Size

—  Shape

—  Number

—  Margin

—  Edge

—  Discharge

Importance of Site of Ulcer

 

Face-Basal Cell Carcinoma

 

Neck-Tuberculous/Actinomycotic

Decubitus ulcer-Over pressure points like sacral/occiput/heel

Shin-Gummatous

Medial malleolus-Varicose ulcer

Examination of an Ulcer – Palpation

—  Local rise of Temp & tenderness

—  Exact dimensions - depth

—  Induration ( thickening ) of edge-in chronic ulcer and in malignancy

—  Base – fixity to underlying structures

—  Bleeding on touch-is a feature of malignant/ Chronic ulcer

Examination of the Surrounding Area of an Ulcer

—  Skin

—  Adjacent Joint

—  Regional Lymph nodes

—  Arterial pulse

—  Varicose veins

—  Neurological deficit

—  Gait of the patient

A Golden Rule

Whenever you see a lesion look for an enlarged draining lymph node;

Whenever you come across an enlarged lymph node in our body look for a lesion in the area of its lymphatic drainage.