Ulcer

Question 1

What things do you look for on inspection?

Answer 1

Number of lesions - arterial disease = often multiple
Site - ie varicose ulcers = vertical ovals over medial malleolus
Size - tape measure, estimate depth in mm
Shape - ie above and malignant = irregular
Margin - skin:ulcer junction
Edge - sloping/punched out/undermined/raised/rolled/everted
Floor - granulation tissue/slough/scab/fat/muscle/tendon/[periostum/bone
Discharge - qualities ie colour/smell and quantity
Skin - hyperpigmentation/oedema/erythema/wrinkling
Limb - venous/arterial insufficiency and neurological disease

Question 2

What do you look for on palpation?

Answer 2

Tenderness
Temperature of surrounding skin
Edge of ulcer - induration (thickening) - chronic benign ulcers and malignancy
Bleeds on gentle touch? (malignancy)

Question 3

What do you look for on movement?

Answer 3

Gently attempt to move the base of the ulcer using your thumb and forefinger - fixity to deeper structures may indicate malignancy

Question 4

What else do you have to do?

Answer 4

Examine the regional lymphatic drainage (??)
Palpate peripheral pulses
Examine light touch and pressure sensation (10g MF)
If evidence of bony involvement, examine nearby joints

Question 5

How do you differentiate between venous and arterial ulcers?

Answer 5

Venous - shallow, superficial, irregular border, lower leg/ankle, contact dermatitis/lipodermatosclerosis
Arterial - full thickness, punched out, smooth borders, nocturnal pain relieved by lowering leg over bed edge, lateral foot (or anywhere in lower leg), cold and pallor of limb, hairless