Ulcer Examination (OSCE Guide)

1/03/2020

Ulcer Examination (OSCE Guide)

Ulcer Examination is a basic short case OSCE skill for all doctors and medical students.

Firstly, introduce yourself and get consent before you proceed to examine the patient. Examination of an ulcer is more or less similar to an examination of a lump. But some additional features have to be kept in mind.


ULCER EXAMINATION

Inspection
1. Site.
2. Size (Extent).
3. Margin (Shape) – Regular? Irregular?
4. Edge – Sloping? Punched-out? Undermined? Rolled-out? Everted?
5. Floor – Healthy? Granulation tissue? Slough?
6. Discharge? – Serous? Serosanguinous? Purulent? Amount and smell?

Palpation (With a gloved hand)
1. Palpate the margin and edge.
2. Palpate the base – Muscle? Bone?

Palpation (Without gloves) – depending on the type of suspected ulcer from above
1. Temperature of the surrounding skin.
2. Regional lymphadenopathy.
3. Peripheral pulses.
4. Peripheral sensation and joint position sensations (JPS)


PRESENTATION

Venous Ulcer
There is an ulcer over the right ankle just above the medial malleolus (Gaiter’s area). It is oval in shape, approximately 2cm x 3cm in size. Its margin is irregular, edge is sloping and the floor contains healthy granulation tissue. There is a serous discharge from the ulcer. The ulcer is superficial and the base contains subcutaneous tissue. The surrounding skin is warmer, pigmented and thickened. There are associated varicose veins. Peripheral pulses and sensation are normal and there is no inguinal lymphadenopathy.

Neuropathic Ulcer
There is an ulcer over the sole of the right foot which is oval in shape, approximately 3cm x 4cm in size. Its margin is regular, edge is punched-out and floor contains healthy granulation tissue. There is no discharge from the ulcer. Ulcer is painless, the base contains flexor tendons of toes, surrounding skin and peripheral pulses are normal. Peripheral sensation to pain is absent up to ankles and joint position sensation is impaired.

Ischemic Ulcer
There is an ulcer over the tip of the 2nd toe of the right foot which is round in shape, approximately 1cm x 1cm in size. Its margin is irregular, edge is punched out and floor contains slough. There is a purulent discharge from the ulcer. The base contains bone of the distal phalanx. The surrounding skin is colder and blackish in colour. Dorsalis pedis and posterior tibial pulses are absent and the femoral pulse is weak on the right side. The peripheral sensations are normal and there is no inguinal lymphadenopathy.

Malignant Ulcer
There is an ulcer over the dorsum of the right foot which is irregular in shape, with a maximum diameter of 6cm. There is a purulent discharge from the ulcer. Its margin is irregular, the edge is raised & everted. Floor is reddish-brown and contains slough. There is hard inguinal lymphadenopathy on the right side. Peripheral pulses and sensation are normal.



FREQUENTLY ASKED QUESTIONS

1. What is an ulcer?

It is a break in the continuity of an epithelial surface.

2. Explain the terms margin, floor, edge and base of an ulcer.

1. Margin – The line of demarcation between normal and affected tissue.
2. Floor – Exposed bottom of the ulcer.
3. Edge – It connects the margin to the floor.
4. Base – The area in which the ulcer rests.

3. What are the types of edges and examples for each one?

1. Sloping – Venous ulcer.
2. Punched-out – Ischemic ulcer.
3. Undermined – Tuberculous ulcer.
4. Rolled-out – Basal cell CA.
5. Everted – Squamous cell CA.

4. What are the common causes of leg ulceration?

1. Peripheral vascular disease.
2. Varicose veins.
3. Peripheral neuropathy.
4. Squamous cell carcinoma.
5. Sickle cell disease.
6. Syphilis.
7. Tuberculosis

5. What are the causes for neuropathic ulcers?

1. Uncontrolled diabetes.
2. Chronic alcoholism.
3. Vitamin B12 deficiency.
4. Leprosy.
5. Vasculitis

6. How do you differentiate a neuropathic ulcer from an ischemic ulcer?

1. Painless ulcers.
2. Associated glove & stocking type of sensory loss.
3. Normal surrounding skin.

7. What are the risk factors in diabetics for foot ulceration?

1. Peripheral neuropathy.
2. Peripheral vascular disease.
3. Immunodeficiency.

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