Ulcer Case

-By S.P.Kamthankar

A ___ Yrs. Old ___(religion) Female/Male patient

___________________________ (Name) _____ by occupation of Class __
Socioeconomic status according to Modified B.J.Prasad’s classification
Resident of ___________________ Admitted to the civil on ______ with
chief complaints of :-

1. Ulcer on the sole of left foot since 2 months

History of Present Illness :-

Patient was apparently all right 2 months back when he /she first noticed
the ulcer on the sole of left foot with slight pain associated with mild
purulent discharge
It increased in size for 5 days and is constant in size since then

Negative History
No h/o Pain & fever (Complications)
No h/o Bleeding (Complications)
No h/o Difficulty in walking (Complications)
No h/o inguinal pain & Swelling (Complications)

No h/o Trauma
No h/o Swelling preceding ulcer
No h/o Discharge of bony pieces (osteomyelitis)
No h/o Discharge of sulphur granules (Actinomycosis)
No h/o numbness in distal parts & surrounding skin a/w polyuria polyphagia
polydipsia (Diabetes neuropathy)
No h/o loss of sensation anywhere else in body & hypo pigmented
anaesthetic skin or nodules patches (Leprosy)
No h/o Pedal edema dragging pain & varicosities (Vericose Ulcer)
 No h/o Fever intermittent claudication at rest & Calf pain (DVT)
No h/o Loss of weight , cough with expectorations or hemoptysis,evening
rise of temperature (Tuberculosis)
No h/o prolonged bed rest & repeated trauma (trophic ulcer)
No h/o recent weight loss ,low grade fever , cachexia or profuse bleeding on
touch through ulcer (Malignancy)

Past History
Major surgical illness – Vericose veins
Major medical illness – DM ,HTN ,TB ,Leprosy ,Vericose veins
,Malignancy , prolongrd bed rest(All should be in chronologic order)
Treatment History

Family History - Not significant

Personal History
Diet -
Appetite -
Sleep -
Bowel & Bladder habits –
Menstrual & Obstetrical (female) – only if significant IMP here
Addictions -
 General Examination (not in short case)

Patient is conscious & well oriented in time, place and person

conscious & well oriented

Conscious not oriented
Drowsy / Semiconscious Verbal response
Stupor Response to pain only
Coma No response

Built (Skeletal growth) – average / poor

Nutrition (Muscular growth) – Good / poor

Attitude –
Peritonitis still
Colicky pain Restless in bed
Meningitis Neck rigidity

Gait –
Trendelenburg gait U/L coxa vara
Polio
Muscle dystrophies
Waddling gait B/L coxa vara
B/L Congenital dislocation of hip

Facies
Mask like Parkinsonism
Moon like Cushing disease
Hippocratic Peritonitis
Adenoid Adenoid hypertrophy
Decubitus – position in bed
Height
Weight
BMI

Temperature-
Pulse - …….. regular rhythmic normal volume equal on both sides
BP - …….mmHg measured in Right arm supine position
Respiratory Rate-
Colour of skin -
Pallor
Cyanosis
Icterus
Skin Eruptions
Macule
Papule
Pustule
Vesicles
Bullae
wheal

Clubbing
Oedema
Lymphadenopathy
 Local Examination
Inspection
1. Size – 2x5 cm
2. Shape - circular / oval / irregular
3. Number – single or multiple elsewhere in body
4. Location (anatomical)
Vericose ulcer Medial aspect of lower 1/3rd of
leg
Rodent ulcer On face above line joining
angle of mandible and ear
lobule especially at tear rolling
line lateral to nose
Tuberculous ulcer Neck at sites of tuberculous
lymphadenopathy
Trophic /Neuropathic ulcer Weight baring area eg Heal r
Sacrum
Arterial /Ischemic ulcer Dorsum of foot and toes

5. Margin – (Margin is the skin border or transitional zone of skin

around ulcer )
White (Outer) Due to newly cornified
epithelium
Blue (Middle) Due to growing line of bluish
epithelium (Squamous
without cornification)
Red (Inner) Due to granulation tissue
covered by single layer of
transparent epithelium
Examples.
Spreading ulcer

Red Irregular Inflamed

With inflamed surrounding skin
Chronic non healing ulcer

Prominent white line (Marked

Fibrosis)
 Rodent ulcer

Beaded

6. Edge - (Mode of union between the floor & the margin 3D both
inspected & palpated)

Sloping Healing Ulcer

Punched out Trophic Ulcer

Undermined Tuberculous
Ulcer

Raised & Everted Malignant

Ulcer
 Raised only Rodent Ulcer

7. Floor (Exposed surface of ulcer)

Observe 3 things – Type of granulation tissue
Slough- necrotic soft tissue which is not yet
separated from the living tissue
Discharge
Ulcer Type of Slough Discharge
granulation
tissue
Healthy ulcer Healthy No Serous small
amount
Spreading/Infected Unhealthy Yes Purulent
ulcer
Chronic non Pale & Flat No No
healing ulcer Not bleed
easily on
touch
Large ulcer not Hypertrophic No Serosanguinous
epithelialised in Exuberant or purulent
time (Proud flesh)
 8. Surrounding Skin –
Spreading & infected ulcer Shiny Red Oedematous (due
to cellulitis)
Vericose ulcer Dark pigmentation & eczema
Tuberculous ulcer Multiple scar & skin puckering
Non healing ulcer Hypo pigmented
Marjolins ulcer Ulcer within large scar

Palpation (Supine position)

1. Surrounding Skin – Temperature
Tenderness
(No Margin palpation as it is 2D structure only inspected)
2. Edge
Healing ulcer Soft
Non healing ulcer Firm
Malignant ulcer Hard

3. Floor palpate granulation tissue note whether it bleeds on touch &

slough attachment loose or firm
Healthy granulation tissue Pin point haemorrhagic spots
Malignant tissue Bleeds profusely on touch

4. Base – (tissue on which ulcer rests ) eg muscle , bone etc.

Palpate by pinching (if small) or by finger (if large)

Chronic non healing ulcer Firm (due to fibrosis)

Malignancy Hard feel & marked induration
 5. Fixity of Skin –
To skin – if skin is Puckered /ulcerated / Infiltrated – Fixed to skin
If not test by sliding / pinching the skin over the ulcer is
Fixed (infiltrated) – skin can not be pinched

To underlying tissue or muscle - fix the breast tissue by stretching

the skin over the breast tissue with thumb & middle finger of hand
and try to move the lump in all directions with opposite hand
If lump moves –not adherent to underlying tissue
If ulcer dose not moves – it is adherent to the breast tissue
(Malignant)
Muscle-Any restriction in the mobility in the direction of muscle
fibres after contraction of the muscle denotes fixity of the ulcer to
underlying muscle

Auscultation
Any Bruit over underlying vessel
Burgers test – in Ischemic limb elevation of leg to 15 to 30 degree for 30-60 sec cause pallor
Normally even on raising leg to 90 degrees in supine position circulation of
toes remains intact
Normal vascular angle / burgers angle – 30 degree
Ischemic limb – angle < 30 degree
Sever ischemia – angle < 20 degree

Focal Examination

Palpation of Regional Lymph nodes

Malignant Hard, discrete ,
Non-tender
Infected Soft ,Tender
Tuberculous Matted , Non tender

Note : If regional lymph nodes are palpable

Palpate higher group of lymph nodes also
In sitting position ask patient to hang her hand loosely by the side then palpate Axillary lymph nodes
on affected side first then on opposite normal side too
Along medial wall of Axilla – Central group
Then move hand higher up keep the other hand on the same sided or opposite shoulder to steady
the patient – Apical group
Under the anterior axillary fold – Pectoral group
Under the posterior axillary fold – Subscapular group
Lateral wall of axilla against upper end of humerus with opposite hand – Brachial group
Below the clavicle in delto-pectoral groove – infra-clavicular/ Deltopectoral group
Stand behind patient palpate the base of anterior triangle of the neck behind middle of clavicle (lift
up the patients same sided hand to relax the supraclavicular fascia ) – Supraclavicular group
if any group of Lymph node is palpable Note :-
Site -
Number -
Consistency –Soft/ Firm/ Hard / Matted
Mobility / Fixed
Examine the arm, forearm , Dorsum of hand on the affected side for Edema (pitting type) &
compare with other arm
This indicate Lymphatic obstruction due to metastasis / Axillary vein thrombosis

State of Arteries Veins & Nerves

Palpate all related Arterial pulses
Palpate nerves - Post Tibial nerve
(Leprosy) Ulnar nerve
Greater auricular nerve.
Check for any Hypo pigmented anaesthetic patches in body (Leprosy)
Test sensations for surrounding skin ( Diabetes )

For varicose ulcer- great short & saphenous veins

Calf tenderness
Homan’s sign
Moses sign
For trophic ulcer – detail neurologic examination
For Spinal cord lesion -

Movements of neighbouring joints

Check active and passive movement
Any restriction indicate – involvement of tendon or muscle / painful
inflammation
 Systemic Examination

CVS – S1 S2 Normal
No murmur heard
CHF delays ulcer healing
RS – upper GI tract
Normal vesicle sound head over lung parenchyma
Air entry equal on both sides (Tuberculosis)
Per Abdomen – soft non tender
No organomegaly (sleenomegaly in haemolytic anaemia
associated with leg ulcer)
No free fluid in the abdomen

Provisional diagnosis
My diagnosis is Dry Gangrene of second right toe with development of line of
demarcation due to peripheral vascular disease most probably burgers
disease and smoking is likely to be the aetiology
 Investigations

General
Specific

Clinical Diagnosis (Final)

Treatment