Clinical examination of ulcer

1. DR.SUGANYA MS
ASST PROFESSOR.
EXAMINATION OF ULCER

2. Contents
1. What is ulcer???????
2. Classification of ulcers
3. Examination of ulcer
a) . History of patient
b) . Physical examination
c) . Local examination
d) . Examination of lymph nodes
e) . General examination
f) . Differential diagnosis
4. Related Investigation
5. Some rare ulcers

3. What is ulcer:
ulcer is the breakin the continuity of the surface
epithelium - skin or mucus membrane. It may
either follow molecular death of the epithelium
or its traumatic removal.

4. Classification of ulcers
1. Clinical classification
2. Pathological classification
Clinical classification:
1. Spreading
2. Healing
3. Callous or chronic ulcer

5. 1. Spreading ulcer:
when the surrounding skin of the ulcer is
edematous and the floor is covered with
profuse and offensive slough without any
evidence of healthy granulation tissue. The
edge is inflamed, edematousandragged.
Very painful. Regional lymph nodes are
enlarged.

7. 2. Healing ulcer:
The Floor is covered with pinkish and red
healthy granulation tissue. The edge is reddish
with granulation and margin is bluish due to
growing epithelium. The discharge is serous and
slight.

8. Healing ulcer with red granulation
tissue

9. 3. Callous or chronic ulcer:
ulcershow no tendency toward healing. The floor
is covered with pale granulation tissue or awash-
leather slough as in gummatous ulcer. Discharge
is scanty or absent. The floor is often indurated.

10. 2. Pathological classification:
A. Non specific ulcer
B. Specific ulcer
C. Malignant ulcer
A. Non specific ulcer
- Traumatic ulcer
- Arterial ulcer
- Venous ulcer
- Neurogenic ulcer / trophic ulcer (related to nutrition):
- Tropic ulcer(related to geographical area) :
- Associated with some diseases: diabetes, gout,
anemia, rheumatoid arthritis etc.
- Rare ulcers : Bazin’s ulcer, martorell’s ulcer

11. Traumatic ulcer:
caused by trauma. Trauma may be physical,
mechanical and chemical.
Mechanical trauma such as dental ulcer of the
tongue caused by jagged tooth.
Physical trauma such as trauma by electric
burn and x-irradiation.
chemical trauma such as ulcers caused by
strong acids.

12. Arterial ulcer:
arterial occlusion may give rise to decreased
blood supply to distal part and will cause
ischemia that will lead to ulceration. example :
burger's disease, Reynaud's disease,
atherosclerosis.

13. Arterial ulcer:

14. Neurogenic ulcer /
trophic ulcer (related to
nutrition): They occur
due to repeated trauma to
the insensitive part of the
body.
venous ulcer:
arising as an involvement
of varicosity and DVT.

15. venous ulcer: Neurogenic
ulcer

16. Tropic ulcer / Aden ulcer / Jungle rot
(related to geographical area) :
which occur mostly on the legs.
Infection by Bacteroide Fusiformis on a
small abrasion on the leg may cause the
ulcer. This type of ulcers occur mostly in
tropical regions

17. Tropic ulcer / Aden ulcer / Jungle
rot (related to geographical area) :

18. B. Specific
ulcer
Syphilitic ulcer,
Tubercular ulcer,
Chancroid and
Actinomycosis.

19. Examination of ulcer
1. HISTORY
I. Mode of onset
II. DURATION
III. PAIN
IV. DISCHARGE
V. ASSOCIATED DISEASE
2. INSPECTION
3. PALPATION

20. HISTORY
Mode of onset
•Ulcer from trauma:
They heal spontaneously after removal of traumatic
agent but can transform into chronic ulcer if traumatic
agent persists. Example: dental ulcer of the tongue.
•Ulcer starting spontaneously:
They start with swelling and the swelling maybe
matted tuberculus lymph node and rapidly growing
malignant tumour such as epithelioma and malignant
malenoma. They may be found due to vascular
insufficiency.

21. HISTORY
Duration
Acute ulcer
Acute ulcer will be present for a shorter
duration such as chancroid/ soft sore
I.P 3-4 days.
Chronic ulcer
Chronic ulcer will be present for a longer
duration such as syphilis/ huntarian
chancre
I.P 3-4 weeks

22. HISTORY
Pain
Painful ulcer: ulcer associated with inflammatory
reactions are painful.
Slight painful ulcer: tubercular ulcer
Painless ulcer: syphilitic ulcer, nerve disease(
tabes dorsalis, syringomyelia, peripheral
neuropathy),malignant ulcer (squamous cell
carcinoma, basal cell carcinoma)

23. Serous discharge - healing ulcer
Purulent discharge - inflamed and spreading
ulcer.
Serosanguinous discharge - tubercular ulcer,
malignant ulcer.
Greenish discharge - infection with B-
pyocyanea.
HISTORY
Discharge

24. Nervous diseases (trophic ulcer/perforating ulcer)
Syringomyelia, peripheral neuropathy, tabes dorsalis etc.
They all form ulcer
Metabolic diseases
Diabetic mellitus - peripheral vasculopathy, neuropathy
and sugar laden tissues.
Infection
Syphilis- first stage: chancre
Second stage: mucus patches and chondyloma lata
Third stage: gummatous ulcers
Tuberculosis- tubercular ulcer.
Associated disease
HISTORY

25. INSPECTION
INSPECTION
1. SIZE AND SHAPE
2. NUMBER
3. POSITION
4. EDGE
5. FLOOR
6. DISCHAREGE
7. SURROUNDING AREA

26. Size and shape
Oval shape:
Tubercular ulcer are oval in shape but
their coalescence may give rise to
irregular crescentic border.
Circular/semicircular:
Syphilitic ulcer are circular or
semicircular in shape in initial stage but
their coalescence may give rise to
serpiginous ulcer.
INSPECTIO
N

27. INSPECTION
Vertically oval in shape:
varicose ulcer are vertical oval in shape mostly
present on medial aspect of upper part of the ankle
joint.
Irregular:
carcinomatous ulcer are irregular in shape.
Size of the ulcer is important to know the time
required for healing.
The size maybe estimated by keeping the dry gauze
piece on the ulcer and measuring its area of wetting.

28. INSPECTION
Number
Tubercular, syphilitic and
varicose ulcer maybe more
than 1 in number.
Position
Position is important to
know as it may give a clue
to the diagnosis.

29. INSPECTION
Position
VARICOSE ULCER :
Above the medial malleolus of
the lower limb.
RODENT ULCER :
Found on the face above the line
joining the angle of the mouth
to the lobule of the ear specially
near the inner canthus of the
eye.

30. INSPECTION
Position
TUBERCULAR ULCER :
They are seen where tubercular
lymphadenopathy is more
common such as neck, axilla and
groin.
LUPUS VULGARIS:
Found on face, fingers and hands.

31. SYPHYLITIC ULCER:
Huntarian chancre/ soft sore
on external genitalia.
Mucucspatches on mucucs
membrane of mouth and
chondyloma lata on and lips, nipple
and vulva.
Gummatous ulcer on subcutaneous
bone such as tibia, sternum and
skull.
INSPECTIO
N
Position

32. TROPHIC ULCER/
PERFORATING ULCER:
Mostly found on the part of
the body which carries
maximum body weight such
as heel and bail of foot.
INSPECTIO
N
Position

33. EDGES
INSPECTION
Edges gives clue to the
diagnosis and tells about
the condition of the ulcer.
FIVE types of the edges
1. Undermined edges
The disease causing the ulcer
destroys subcutaneous tissue
more faster than it destroys
the skin. The overhanging
skin is thin, red, friable and
healthy.

34. 2. Punched out edges
The edges of the ulcers drops
down at 90 degree to the skin
surface as if it has been
punched out. The disease
causing the ulcer is limited to
ulcer itself.
INSPECTIO
N
edges

35. 4.Pearly white and beaded edge
Seen in rodent ulcer.
Seen in invasive cellular dieasese.
They become necrotic at the centre.
3.Sloping edge
Seen in healing ulcers and venous
ulcers. It contains reddish purple
healthy granulation tissue.
INSPECTIO
N
edges

36. INSPECTION
edges
5.Rolled out/ everted edges
Seen in squamous cell
carcinoma and ulcerated
adenocarcinoma.
The growing portion at the
edge heaps up and spills over
the healthy skin to become
everted edge

37. INSPECTION
Floor
Floor is the exposed surface of the ulcer.
Red granulation tissue at the floor - healing ulcer.
Pale and smooth tissue - slowly healing ulcer.
Washed leather floor - gummatous ulcer.
Black tissue at the floor - malignant malenoma.
Floor reaching upto the bone - trophic /perforating
ulcer.

38. INSPECTION
Discharge
Serous discharge - healing ulcer
Purulent discharge - inflamed and spreading
ulcer.
Serosanguinous discharge - tubercular ulcer,
malignant ulcer.
Greenish discharge - infection with B-
pyocyanea.

39. INSPECTION
Surrounding area
Red edematous and glossy - acutely
inflamed ulcer
Eczematous and pigmented - vascular
ulcer
Wrinkled skin - tubercular ulcer

40. Palpation:
1. Tenderness
2. Edge and margins
3. Base
4. Depth
5. Bleeding
6. Relation with deeper structure
7. Surrounding skin.

41. Palpation
Tenderness
Tender - acutely inflamed ulcer
Slightly tender - tubercular ulcer,
varicose ulcer
Non tender - syphilitic ulcer,
malignant ulcer and Ulcer from nerve
diseases such as Transverse neurirtis
Syringomyelia
Tabes dorsalis
Peripheral neuropathy

42. Palpation
Edges and margins
Careful palpation gives to the diagnosis.
Induration
Syphilitic ulcer, trophic ulcer and chronic ulcer.
Marked induration
Malignant ulcer such as squamous cell
carcinoma and ulcerated adenocarcinoma.
Slight induration Tuberculosis

43. Palpation
Base
Base is better felt than inspected.
To feel the base an attempt is made to pick
the ulcer between the index finger and
thumb. Indurations of the base is assessed.
Marked induration -
Malignant ulcer
Syphilitic ulcer
Slight induration-
Chronic ulcer.

44. Depth
Depth is important as it
gives clue to diagnosis.
Depth can be measured in
millimeter.
Trophic ulcer/ perforating
ulcers are deep reaching
upto the bone or tendon.
Bleeding
Malignant ulcer mostly
bleed during palpation.
Palpation

45. Palpation
Relation with deeper structures
An ulcer is made to move over the underlying
structure to know whether it is fixed or not.
Fixed over the underlying bone- gummatous
ulcer.
Fixed over the underlying tissue- malignant
ulcer.

46. Palpation
Pulsation
Dorsalis pedis
Anterior tibial artery
Posterior tibial artery
Popliteal artery
Femoral artery

47. Examination of the lymph nodes
Palpation
Acutely inflamed ulcers - Regional lymph nodes are
enlarged and tender.
Tubercular ulcer - regional lymph nodes are matted,
enlarged and slightly tender.
Huntarian chancre- firm, discrete and shotty.
Malignant ulcer- stony hard and fixed to the
neighboring structure.
Gummatous ulcer- lymph nodes not usually
involved.
Rodent ulcer- lymph nodes not usually involves
because of early obliteration of the lymphatics by
neoplastic cells.
General examination

48. When ulcer is suspected to be
tuberculuos
All lymph nodes should be examined.
Examination of the chest should be done.
Examination of the abdomen should be
done.
When the ulcer is suspected to be ischemic
Examination should be done to find the presence of
atherosclerosis.
When the ulcer is suspected to be
trophic/perforating
Examination should be done to find the presence of
the nervous disease or any malnutrition.

49. Investigations
Routine examination of the blood
TLC - increased in acute infection
DLC - lymphocytes are increased in chronic
infections
HB - decreased hemoglobin maybe suggestive
of trophic ulcers
ESR - increased in acut and chronic
infection

50. Investigations
Blood sugar - to exclude diabetes mellitus
Urine - to exclude presence of sugar
Bacteriological examination of the discharge
to find out that what type of organism is present in
discharge and its sensitivity to particular antibiotic

51. Differential diagnosis:
Traumatic ulcer
Three reasons are there mechanical, physical and
chemical.
Mechanical : dental trauma of the tongue caused by
jagged tooth.
Physical: Burn and X-irradiation.
Chemical trauma: cause by strong acid and base.

52. Differential diagnosis:
Ischemic ulcer(arterial ulcer)
Pain and intermittent claudication is the main complaint
Site anterior and outer aspect of the leg such as dorsum of the
foot and toe.
Punched out edges, deep perforating ulcer reaching up to the
bone and tendon.
Floor contains minimal granulation tissue
Signs of ischemia such as dry skin, pallor, loss of hairs and
fissuring of the nail.
Pulsation: either absent or feeble but not clearly defined.
When present on the inner aspect of the lower leg, a venous
ulcer should always be excluded. Venous ulcer is present above
the medial malleolus. Arterial ulcer is present below the medial
malleolus.

53. Venous ulcer:
Differential diagnosis
Age : mostly seen in older age.
History of prolonged standing and walking
often associated varicose vein.
Main complaint is pain in initial stage only
which later subsides.
Site : above the medial malleolus
Shape: vertical oval in shape
Edges : sloping
Floor: thick granulation tissue with slight
oozing of serous discharge.
Surroundings: Eczematous and pigmented.
No signs of ischemia.

54. Differential diagnosis
Trophic ulcer/ neurogenic ulcer
Trophic ulcers are caused by repeated trauma to the
insensitive part of the body.
Trophic and gummatous ulcers both have punched
out edges but main differential point is that trophic
ulcers occur on the part of the body which carry
maximum body weight whereas gummatous ulcers
occur on subcutaneous bones such as tibia, sternum
and skull.
History : H/o DM and neurological disorders.
Complaints: Pain may not be present because of
peripheral neuropathy.

55. Differential diagnosis
Complaint of loss of sensation is present.
Site: heel and bail of the foot.
EDGES: punched out and deep.
Floor : tendon and bone maybe exposed with
foul smelling slough.
Base : slightly indurated
Surroundings : no sensation

56. Differential diagnosis
DIABETIC ULCERS:
H/O DM present.
Three main factors play important role in
causation.
Diabetic neuropathy, diabetic vasculopathy
and glucose laden cells vulnerable to
infection.

57. Differential diagnosis
Tuberculuos ulcers:
Site : neck, axilla and groin.
Edges : undermined edges
Floor : contains pale granulation tissue
Discharge: serosanguinous discharge
Base : slightly indurated
Tenderness : slightly tender
Lymph nodes : enlarged, matted and slight
tender.
Caused by bursting of the caseus lymph
nodes.