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Ulcer Examination for Medical Student OSCE

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Introduce, Identify, Explain, Consent

1. Inspection

   1. Site – anterior, posterior, medial, lateral etc. Measure distance from nearest bony prominence

   2. Size – w x l

   3. Shape – circular / oval / irregular

2. Ulcer features

   1. Base

      1. Colour – pink / yellow / white

      2. Penetration – tendon / muscle / bone

      3. Tissue – granulation tissue / dead / tumour

   2. Edge

      1. Flat sloping

Epithelium is growing in from edges, attempting healing: often = venous. Surrounding skin red/blue – haemosiderin deposition

1.  
   1.  

      1. Punched-out

Rapid death of full thickness of skin: usually due to pressure on area of skin that lacks sensation, e.g. in DM / syphilis. Also: arterial, critical ischaemia ulcers.

1.  
   1.  

      1. Undermined

Infection has destroyed subcutaneous tissues more than superficial skin ? reddish-blue overhanging skin. Often in ulcers 2? to TB

1.  
   1.  

      1. Rolled upwards

Necrotic centre; slow-growing tissue at ulcer edge ? heaped-up peripheral tissue. Classical for rodent ulcer – BCC basal cell carcinoma

1.  
   1.  

      1. Everted

Tissue at edge growing fast, such that the edges of the ulcer spill out. SCC squamous cell carcinoma, and adenocarcinoma

1.  

   1. Depth – in mm

   2. Discharge – bacterial swab. Serous, sanguineous or purulent

   3. Lymph nodes – tenderness or enlargement (infection, malignancy)

   4. Local tissues – oedema, thickening, lack of hair, erythema, cracked skin, dryness.

2. Assess local blood supply

   1. Temperature – bimanual, backs of hands. Note point of temperature change.

   2. Capillary refill – normal: press 2s, refills <2s

   3. Pulses – dorsalis pedis, posterior tibial, popliteal, femoral – compare strengths side to side

   4. Request to perform ABPI

3. Assess local nerve supply

   1. Light touch – first check for numbness or pain, compare to sternum

   2. Pain

   3. Proprioception

   4. Vibration – 1-2-8- vibrate!

4. Request to perform BM test / urinalysis – DM – and check diabetic control via HbA1c levels.

5. Leg ulcer DD

   1. Neuropathic

2? to spinal cord disease or peripheral neuropathy (DM) ? due to trauma over pressure areas: sole of foot, between toes, beneath heads of metatarsals. Deep, painless, infected, punched out. No eschar. There is an adequate blood supply ? warm, pulses palpable.

1.  

   1. Ischaemic

Due to inadequate blood supply – usually underlying atherosclerosis or vasculitis. At pressure points / tips of toes. History: pain may interfere with sleep; claudication + rest pain; extremely painful – unlike venous or neuropathic ulcers. Deep, painful, punched out, coin shaped. Often: associated black eschar; base contains dead tissue, often penetrating to the bone. Discharge: serous / pus. Peripheral pulses absent, surrounding tissue cold.

1.  

   1. Venous

Due to incompetent venous valves ? ↑capillary pressure ? blood pooling ? capillary damage, fibrosis and easily damaged skin. Maybe lipodermatosclerosis + haemosiderin pigmentation. At gaiter area, esp. above medial malleolus. Shallow, flat, irregular pale purple/blue sloping edge. Base may penetrate to tendons and bone; usually contains fibrous or granulation tissue; seropurulent discharge.

1.  

   1. Neoplastic

      1. Basal cell carcinoma: rolled up edge, pearly pink base

      2. Squamous cell carcinoma: everted edge, deep red-brown base. Faster growing

About the Author

by: Admin
Total views: 0
Word Count: 947
Date: Fri, 22 Jan 2010 Time: 4:06 PM
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