Examination of an Ulcer

Question 1

What are the 10 areas involved in the look stage of the examination of an ulcer?

Answer 1

Number of lesions: single or multiple. Multiple ulcers are commonly seen in arterial disease.

• Site. For example, varicose ulcers are typically vertically oval and are located over the medial malleolus.
• Size. Use a tape measure to measure the ulcer. Estimate the depth in millimetres.
• Shape. This may be important diagnostically. For example, varicose ulcers are typically vertically oval and are located over the medial malleolus. Malignant ulcers are typically irregular in shape.
• Margin. The junction between normal and abnormal skin.
• Edge. The tissue between the margin and the floor of the ulcer e.g. sloping, punched out, undermined, raised, rolled, everted. Note whether the marginal epithelium is attempting to grow over the surface.
• Floor. The ulcer floor may comprise healthy or unhealthy granulation tissue, slough, scab, fat, muscle, tendon, periosteum or bone.
• Discharge. Assess the quantity, consistency, colour, composition, and odour. For example, wound discharge may be serous (watery), sanguineous (bloodstained), purulent or green (which usually indicates Pseudomonas colonization / infection).
• Surrounding Skin. Look for hyperpigmentation, oedema, erythema, stretch marks, and wrinkling (which may indicate resolving inflammation)
• Whole Limb. Look for signs of venous and arterial insufficiency and neurological disease. Muscle wasting may be present

Question 2

What is involved in the feel stage of the examination of an ulcer?

Answer 2

• Check for tenderness.
• Palpate the temperature of the ulcer and the surrounding skin using the back of the hand.
• Palpate the edge of the ulcer for induration, which is a feature of chronic benign ulcers and of malignant ulcers.
• Determine whether the ulcer bleeds on gentle touch or not. This is often a feature of malignancy

Question 3

What is involved in the move stage of the examination of an ulcer?

Answer 3

• Gently attempt to move the base of the ulcer using your thumb and forefinger. Fixation to deeper structures may be suggestive of malignancy.

Question 4

Why do we palpate the regional lymph nodes in the examination of an ulcer?

Answer 4

to look for infection or malignancy

Question 5

What special tests are done in the examination of an ulcer?

Answer 5

• Palpate the peripheral pulses
• Examine light-touch and pressure sensation.
• If there is evidence of bony involvement, you will need to examine the nearby joints