Ref: Ulcers Exam

1. General considerations
2. History
3. Inspection
4. Palpation

General considerations

• Definition of ulcer: a break in epithelial surface, extending to all layers of epithelium.
• Types: VANITy:
  • Venous: deep or superficial insufficiency.
  • Arterial: large or small vessel dz.
  • Neoplastic: 1º or 2º.
  • Infective: TB, syphilis, leishmaniasis.
  • Traumatic. 
• Also some systemic causes:
  • Pyoderma gangrenosum [from RA, UC or Chron's].
  • Necrobiosis lipoidica diabeticorum [from DM].
  • Blood dz's [sickle cell anemia, TTP, PRV, thatlassemias].

History

• When arose.
• Change in size, appearance, etc.
• Whether previous ulcers.
• Painful vs. painless.
• PMH: varicose veins, DM, DVT, trauma, intermittent claudication, vascular dz, infections, CA.
• SH: smoking, occupation involving standing up for long periods.
• How often wound is being dressed.

Inspection

The warmup:

• Surrounding skin:
  • Venous: venous eczema, inverted champagne class, venous flares [spider nevi in feet], hemocidrin deposition.
  • Arterial: vasculitis.
• Number of ulcers visible.

The ulcer itself:

• Site:
  • Above the medial malleolus (venous).
  • Below a malleolus, pressure points, distal parts (arterial).
  • Shins (necrobiosis lipoidica diabeticorum).
• Size, shape, fluid discharges. 
• Depth.
• Base and floor: 
  • Color.
  • Sloughing of skin.
  • Granulation tissue.
  • Tissues exposed: ligaments, bone, etc.
  • It's like a house: the basement is the most lower part, like the bone, and the floor is above it, like the sloughed skin.
• Edge:
  • Sharply marginated.
  • Erythema around edge.
• Wall:
  • Slope inwards/ "undermined" (venous).
  • Slope outwards (TB).
  • Vertical edge/ "punched-out" (non-healing).
  • Raised.
  • Raised and everted.

Palpation

• Tenderness.
• Temperature:
  • Cold to touch (arterial).
• Local pulses:
  • Absent (arterial).
• Lymph nodes.