EXAMINATION OF AN ULCER 1. The situation of the ulcer. 2. Is the ulcer single or multiple? 3. Note the size of the ulcer.

4. Examine the shape of the ulcerUlcers may be round, oval, crescentic, serpiginous, irregular, punched out, etc. 5. Note the base of the ulcer. 6. The floor of the ulcer may be covered by: a. Granulations. These may be red, pale or fabby that may or may not bleed b. The floor may be smooth. c. It may be covered with slough, membrane, scab, etc. d. The floor may be adherent to soft parts or bone. e. The floor may be fungating as seen in some clinical varieties of malignant disease. 7. The edge of the ulcer may be: a. Undermined (as seen in tubercular ulcers) b. Punched out (as found in gummatous ulcers) c. Rolled out (as characteristically occurs in rodent ulcers) d. Rolled, raised and everted (as characterized by malignant ulcers) 8. The condition of the parts surrounding the ulcers must be examined. 9. If there is a discharge from the ulcer, its colour and smell should be noted and bacteriological smear taken for culture. 10. Is the ulcer painful. 11. The general conditioning the patient must always be considered

Definition of an Ulcer An ulcer is defined as a break in the continuity of surface epithelium with superadded infection. Clinical Classification of Ulcer Spreading- with surrounding inflammation Healing Slopping edge with red granulation tissue Callous- Ulcer with no tendency to heal-with pale granulation tissue.

Pathological Classification of Ulcer Specific- Tuberculous, Syphylitic,Actinomycotic Non specific- Traumatic( Mechanical, Physical,Chemical) Cryopathic, Arterial, Venous, Neurogenic, Trophic, Tropical, Bazins, Martorells, Meleneys ulcer Malignant- Squamous cell carcinoma, Basal Cell Carcinoma, Melanoma Classification of Ulcer based on duration Acute Ulcers < 12 weeks Chronic Ulcers > 12 weeks Classification Based on Pain Painful Ulcers Tuberculous Arterial Advanced Painless UlcersSyphilitic Trophic Early Malignancy Modes of Onset of Ulcer Traumatic Spontaneous Secondary changes on a Swelling-Tuberculous lymphadenopathy From a Previous Scar-Marjolins Ulcer Causes for Chronic Ulcers 1. Malnutrition 2. Anemia Malignancy

3. Immunosuppression 4. Systemic Diseases (Diabetes) 5. Site & Size of an Ulcer 6. Arterial / Venous Disorders 7. Neurological Disorders 8. Infection 9. Chronic Irritation ( Dental Ulcers ) or Lack of Rest ( Ulcer over a Joint ) 10. Malignancy Discharge from the ulcer Note the Colour, Amount & Smell Serous-Healing ulcer Sanguinous ( Blood Stained )- Malignant/Chronic Purulent-Bacterial infection Greenish- Pseudomonas infection Yellowish - Sulphur Granules ( Actinomycosis ) Parts of an Ulcer Margin-line of demarcation between normal and abnormal Floor-the exposed part of an ulcer ( Inspection) Edge-the part between the margin and the floor of an ulcer Base-the structure on which the ulcer rests (Palpation) Types of Floor of an Ulcer Slough-Moist dead tissue Scab-Dry dead tissue Unhealthy granulation tissue Healthy granulation tissue Subcutaneous fat Muscle/tendons Bone Types of Edges of an Ulcer

 Slopping- Healing ulcer Punched out-Decubitous ulcer/Gummatous ulcer Undermined- Tuberculous ulcer Raised / Beaded- Basal cell carcinoma Rolled out / Everted- Squamous cell carcinoma Examination of an Ulcer-Inspection Site Size Shape Number Margin Edge Discharge Importance of Site of Ulcer

Face-Basal Cell Carcinoma Neck-Tuberculous/Actinomycotic Decubitus ulcer-Over pressure points like sacral/occiput/heel Shin-Gummatous Medial malleolus-Varicose ulcer Examination of an Ulcer Palpation Local rise of Temp & tenderness Exact dimensions - depth

 Induration ( thickening ) of edge-in chronic ulcer and in malignancy Base fixity to underlying structures Bleeding on touch-is a feature of malignant/ Chronic ulcer Examination of the Surrounding Area of an Ulcer Skin Adjacent Joint Regional Lymph nodes Arterial pulse Varicose veins Neurological deficit Gait of the patient A Golden Rule Whenever you see a lesion look for an enlarged draining lymph node; Whenever you come across an enlarged lymph node in our body look for a lesion in the area of its lymphatic drainage.