History and Examination of an Ulcer

Question 1

What is an ulcer?

Answer 1

An ulcer is a solution (break) of the continuity of an epithelium (i.e. an epithelial deficit, not a wound).
- Unless it is painless and in an inaccessible part of the body, patients notice ulcers from the moment they
begin, and will know a great deal about their clinical features.

Question 2

What questions do you ask when taking history of an ulcer?

Answer 2

1. When was the ulcer first noticed?
2. What drew the patient’s attention to the ulcer?
3. What are the symptoms of the ulcer?
4. How has the ulcer changed since it first appeared?
5. Has the patient ever had a similar ulcer on the same site, or elsewhere?
6. What does the patient think caused the ulcer?

Question 3

When was the ulcer first noticed?

Answer 3

Ask the patient when the ulcer began and whether it could have been present for some time before it was noticed
- The latter often occurs with neurotrophic ulcers on the sole of the foot.

Question 4

What drew the patient’s attention to the ulcer?

Answer 4

1. pain (most common)
2. bleeding
3. purulent discharge, which may be foul smelling.

Question 5

What are the symptoms of the ulcer?

Answer 5

The ulcer may be painful
- It may interfere with daily activities such as walking, eating or defaecation. - Record the history of each symptom

Question 6

How has the ulcer changed since it first
appeared?

Answer 6

The patient’s observations about changes in size, shape, discharge and pain are likely to be detailed and accurate
Note: If the ulcer has healed and broken down, record the features of each episode.

Question 7

Has the patient ever had a similar ulcer on the same site, or elsewhere?

Answer 7

Obtain a complete history of any previous ulcer.

Question 8

What does the patient think caused the ulcer?

Answer 8

Most patients believe they know the cause of their ulcer, and are often right
- in many cases it is trauma
- When possible, the severity and type of injury should be assessed
- A large ulcer following a minor injury suggests that the skin was abnormal before the injury

Question 9

Describe an ulcer with an irregular shape?

Answer 9

1. draw it on your notes and add the dimensions
2. When an exact record of size and shape is needed, place a thin sheet of sterile transparent plastic sheet over the ulcer and trace around its edge with a felt-tipped pen.

Question 10

Components of the examination of an ulcer?

Answer 10

1. record thethe site, size and shape of the ulcer
2. examine the base (surface), edge, depth
3. examine the discharge and surrounding tissue
4. examine the the state of the local lymph glands and local tissues
5. complete the general examination.

Question 11

Describe the base of an ulcer?

Answer 11

The base, or floor, of an ulcer usually consists of slough or granulation tissue (capillaries, collagen, fibroblasts, bacteria and inflammatory cells), but recognizable structures such as tendon or bone may be visible

Question 12

What does the base of an ulcer indicate?

Answer 12

The nature of the floor occasionally gives some indication of the cause of the ulcer.

Question 13

Describe different ulcer bases and what they indicate in terms of cause?

Answer 13

1. Solid brown or grey dead tissue
   - indicates fullthickness skin death.
2. Syphilitic ulcers
   - have a slough that looks like a
   yellow-grey wash-leather.
3. Tuberculous ulcers
   - have a base of bluish unhealthy granulation tissue.
4. Ischaemic ulcers
   - often contain poor granulation
   tissue, and tendons and other structures may lie bare in their base.

Question 14

The redness of the granulation tissue on the base indicates?

Answer 14

reflects the underlying vascularity and indicates the ability of the ulcer to heal.

Question 15

What does healing epidermis look like?

Answer 15

Healing epidermis is seen as a pale layer extending in over the granulation tissue from the edge of the ulcer.

Question 16

Name the 5 types of edges?

Answer 16

1. sloping
2. punched out
3. undermined
4. rolled
5. everted

Question 17

Describe a sloping edge?

Answer 17

a flat, gently sloping edge
- This indicates that the ulcer is shallow and this type of ulcer is usually superficial often only half-way through the skin.
e.g. Venous ulcers, a healing ulcer
Note: The new skin growing in around the edge of a healing ulcer is pale pink and almost transparent

Question 18

Describe a punched out edge?

Answer 18

rapid death and loss of the whole thickness of the skin without much attempt at repair of the defect.
- This form of ulcer is most often seen in the foot where pressure has occurred on an insensitive piece of
skin i.e. a trophic ulcer secondary to a neurological defect

Question 19

Name ulcers that have a punched out edge?

Answer 19

1. trophic ulcer secondary to a neurological defect
2. the ulcer of tertiary syphilis,
3. ulcer due to neuropathy of diabetes and peripheral arterial ischaemia
4. leprosy

Question 20

Describe an undermined edge?

Answer 20

When an infection in an ulcer affects the subcutaneous tissues more than the skin, the edge becomes undermined
- This type of ulcer is commonly seen in the buttock as a result of pressure necrosis, because the subcutaneous fat is more susceptible to pressure than the skin
e.g. the tuberculous ulcer

Question 21

Describe a rolled edge?

Answer 21

This develops when there is slow growth of tissue in the edge of the ulcer
- The edge is usually pale pink or white, with clumps and clusters of cells visible through the paper-thin superficial covering of squamous cells
e.g. is typical and almost diagnostic, of a basal cell carcinoma (rodent ulcer)
Note: Telangiectases are commonly seen in the pearly edge

Question 22

Describe an everted edge?

Answer 22

This develops when the tissue in the edge of the ulcer is growing so rapidly that it spills out of the ulcer to overlap the normal skin
e.g. typical of a carcinoma and is seen in those organs where carcinomata occur
i.e. the skin, in the bowel, in the bladder and in the respiratory tract.

Question 23

Examining depth of an ulcer?

Answer 23

Record the depth of the ulcer in millimetres, and anatomically by describing the structures it has penetrated or reached.

Question 24

Describe discharge of an ulcer?

Answer 24

1. serous
2. sanguinous,
3. serosanguinous
4. purulent
   - There may be a considerable quantity of discharge which is easily visible, or it may only be apparent from inspection of the patient’s dressings, and you may not be able to see the features of the ulcer at all if it is covered with coagulated discharge (a scab)
   Note: This may have to be removed to examine the ulcer properly

Question 25

Describe the relations of an ulcer?

Answer 25

Describe the relations of the ulcer to its surrounding tissues, particularly those deep to it
- It is important to know if the ulcer is adherent or invading deep structures such as tendons, periosteum and bone — which may indicate the presence of osteomyelitis.
Note: The local lymph glands must be carefully examined
- They may be enlarged because of secondary infection or secondary tumour deposits and they may be tender.

Question 26

Describe the state of the local tissues?

Answer 26

Pay particular attention to the local blood supply and innervation of the adjacent skin
- Many ulcers in the lower limbs are secondary to vascular and neurological
disease
- There may also be evidence of previous ulcers that have healed

Question 27

Describe the general examination of an ulcer?

Answer 27

This is very important because many systemic diseases as well as many skin diseases present with skin lesions and ulcers
- Examine the whole patient with
care, looking especially at their hands and face, which can supply important clues to the