Clinical examination of ulcers

this upload will definitely improve the skills of how to examine clinically the non healing ulcers. this will help in making a proper diagnosis.

1. Examination of ulcer Presented by: Waseem ahmad معاونین جنید نزیر ،،محمد فیصل , دانش اختر P.G Scholar s DEPARTMENT OF ILMUL JARAHAT NATIONAL INSTITUTE OF UNANI MEDICINE, KOTTIGEPALYA, MAGADI MAIN ROAD. BANGALORE-91.

2. Contents What is ulcer??????? Classification of ulcers 3. Examination of ulcer . History of patient . Physical examination . Local examination . Examination of lymph nodes . General examination . Differential diagnosis 4 . Related Investigation 5 . Some rare ulcers

3. What is ulcer: ulcer is the break in 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. 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. T he edge is inflamed, edematous and ragged. Very painful. Regional lymph nodes are enlarged.

6. 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.

7. Healing ulcer with red granulation tissue

8. Callous or chronic ulcer : ulcer show no tendency toward healing. The floor is covered with pale granulation tissue or a wash-leather slough as in gummatous ulcer. Discharge is scanty or absent . The floor is often indurated.

9. 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

10. 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.

11. 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.

12. Arterial ulcer:

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

14. venous ulcer: Neurogenic ulcer

15. 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

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

17. B. Specific ulcer Syphilitic ulcer, T ubercular ulcer , C hancroid and A ctinomycosis .

18. Examination of ulcer 1. HISTORY Mode of onset DURATION PAIN DISCHARGE ASSOCIATED DISEASE 2. INSPECTION 3. PALPATION

19. 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 may be matted tuberculus lymph node and rapidly growing malignant tumour such as epithelioma and malignant malenoma . They may be found due to vascular insufficiency. HISTORY Mode of onset

20. 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 HISTORY

21. 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) HISTORY

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

23. Associated disease 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. HISTORY

24. INSPECTION SIZE AND SHAPE NUMBER POSITION EDGE FLOOR DISCHAREGE SURROUNDING AREA INSPECTION

25. 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 . INSPECTION

26. 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 may be estimated by keeping the dry gauze piece on the ulcer and measuring its area of wetting. INSPECTION

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

28. VARICOSE ULCER : A bove the medial malleolus of the lower limb . RODENT ULCER : F ound 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. INSPECTION Position

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

30. SYPHYLITIC ULCER: Huntarian chancre/ soft sore on external genitalia . Mucucs patches 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. INSPECTION Position

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

32. EDGES 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. INSPECTION

33. 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. INSPECTION edges

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

35. 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 INSPECTION edges

36. 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. INSPECTION

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

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

39. Palpation: Tenderness Edge and margins Base Depth Bleeding Relation with deeper structure Surrounding skin.

40. 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 Palpation

41. 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 Palpation

42. 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. Palpation

43. 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

44. 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. Palpation

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

46. Examination of the lymph nodes 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 Palpation

47. General examination When ulcer is suspected to be syphilitic then other syphilitic stigmas are searched for. Head – Alopecia / bossing of the head Eyes – Interstitial keratitis Nose – Depression of the bridge of the nose Septum – Perforation Ears – Otitis interna Hard palate – Perforation Teeth – Hutchinson ’ teeth Tongue – Glossitis Occipital lymph nodes are enlarged Epitrochlear lymph nodes are enlarged Testes – Gummatous orchitis Knee joint – Clutton’s joint Tibia – Sabre tibia

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 may be suggestive of trophic ulcers ESR – increased in acut and chronic infection

50. 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 Investigations

51. Discharge from syphilitic ulcer : Clean the ulcer with normal saline first then take sample from the discharge and place it on slide and cover with cover slip to examine under microscope with dark ground illumination. Laminated treponema pallidum will be observed . Wasserman reaction test for syphilis: syphilis non specific antibody react with phospholipids and hence are called anti phospholipid antibody. APA are raised in the patient. Investigations

52. Discharge from the tubercular ulcer : M. tuberculi has a physical property not to change their colour by acids during staining and hence are called acid fast bacilli. Montoux test: 5 units of tuberlin (0.1ml solution) is injected intradermally and read after 48 to 72 hours for assessment of induration . The area of induration is compared with the reference values. Investigations

53. Biopsy of the ulcer : Biopsy is taken from the edge of the ulcer taking a portion of the surrounding tissue and examined histologically to find out the type of the tumor. X-Ray chest and bone : to exclude the tuberculosis . Contrast radiography : to exclude vascular involvement in ulcers Investigations

54. 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 .

55. 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. Differential diagnosis:

56. Venous ulcer: 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. Differential diagnosis

57. 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. Differential diagnosis

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

59. 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. Differential diagnosis

60. 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. Differential diagnosis

61. Mountoux test, guinaepig inoculation test, X-ray chest are helpful to exclude tuberculosis . Differential diagnosis

62. Lupus vulgaris: They are superficial not deep. Site : face, hand and fingers They start as superficial nodules which later on burst forming superficial and cutaneous ulcers. They remain active at periphery thus continue to destroy the surrounding skin but at centre they become healed. Due to their destructive nature, they are called lupus which means wolf . Differential diagnosis

63. Syphilitic ulcers : Primary stage : Hard chancre are formed 3 to 4 weeks after infection. hard chancre are pathognomonic of the first stage. S ite : External genitalia specially on coronal sulcus and frenum of the penis . Base : indurated and feels like a button . Regional lymph nodes : enlarged, hard, discrete, painless and movable . Differential diagnosis

64. Secondary stage : Mucus patches : these are small, round, superficial and white pathes. Later they coalesce to form the snail track ulcer . They are found in the mucus membrane of the mouth. Chondyloma lata : these are small, round, raised and flat. They are found in mucocutaneous junction such as angle of the mouth, vulva and anal canal. Differential diagnosis

65. Third stage: gummatous ulcers These are punched out edges with wash-leather slough at the floor. They are caused by obliterative endarteritis, fibrosis and necrosis. They are present on subcutaneous bones such as tibia, sternum and skull. In third stage lymph nodes are seldom affected because lymphatics are early closed by perivascular inflammatory reaction. Differential diagnosis

66. Soft sore / chancroid / Ducrey’s ulcer IP – 3 to 4 days T hese are multiple, painful and acute ulcers whose edges are edematous and floor is filled with yellowish slough. Site – external genitalia Differential diagnosis

67. Bazin’s ulcers/ erythema induratum They are found in fatty adolescent girls particularly on the calf muscles. They start as puplish nodules which later transform into ulceration.

68. Martorell’s ulcer/ hypertensive ulcer This is a condition of old age and associated with atherosclerosis. It starts as a skin patch on legs in which necrosis occurs due to reduced blood supply leaving a punched out ulcer. This ulcer extends upto the deep fascia. The patients complains of severe pain.

69. Yaws/ polypapilloma tropicum The causative organism is treponema pertenue which enters through an abrasion on the skin or abrasion caused by walking barefooted. This ulcer is painless and heals spontaneously within few weeks leaving a tissue paper like scar.

70. Thank you