Leg ulcers Flashcards

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1
Q

Probability diagnosis

A

Venous insufficiency 52%

Arterial insufficiency 13%

Mixed arterial and venous disease 15%

Pressure sore

Trauma with chronic infection

Systemic disease esp. diabetes

Secondary to peripheral oedema

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2
Q

Serious disorders not to be missed

A

Vascular:

  • Skin infarction (thrombotic ulcer)
  • Vasculitis-RA, SLE, scleroderma

Infection:

  • Post herpetic ulcer
  • Tuberculosis
  • HIV/AIDS
  • Tropical ulcer
  • Post cellulitis

Cancer:

  • Primary-SCC, melanoma, malignant change in ulcer
  • Secondary-ulcerating metastases

Other:

  • Haematological e.g. sickle cell
  • Chronic scarring—sun damaged skin
  • Pyoderma gangrenosum
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3
Q

Pitfalls (often missed)

A

Insect and spider bites

Factitious (neurotic excoriations)

Rarities:

Tropical infections e.g. leprosy

Myobacterium ulcerans

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4
Q

Masquerades checklist

A

Diabetes: neurotrophic

Drugs—systemic reaction

Anaemias: hereditary anaemias

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5
Q

Is the patient trying to tell me something?

A

Consider: Factitious ?dermatitis artefacta ?neurotic excoriation

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6
Q

Key history

A

Look for a cause:

  • venous—previous DVT
  • varicose veins
  • peripheral arterial disease

Seek history of systemic disease such as;

  • diabetes
  • inflammatory bowel disease
  • connective tissue esp. RA.

Hx of intermittent claudication or ischaemic rest pain; chronic ulcers including sun damage; tropical residence.

Drug hx, esp. beta blockers, corticosteroids, ergotamine, nifedipine.

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7
Q

Key examination

A

General features: appearance of pt, vital signs esp. temp

Full cardiovascular assessment esp. lower limb

Assess characteristics of the ulcer, esp.

  • shape
  • edge
  • floor
  • discharge
  • surrounding skin
  • regional lymph nodes

Neurotip or similar for skin sensation

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8
Q

Key investigations

A

First line:

  • FBE
  • ESR/CRP
  • blood sugar

Consider:

  • wound swabs (if evidence infection)
  • duplex ultrasound
  • ankle brachial index
  • biopsy
  • KFTs
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9
Q

Diagnostic tips

A

Be cautious of almenotic melanoma if undertaking biopsy.

If the ulcer and site is painful, consider arterial insufficiency.

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