History taking and examination of an ulcer

An ulcer is defined as a break in the continuity of the lining epithelium of tissue. Once an ulcer appears, it's usually noticed by the patients, unless it's painless, or located at non-accessible sites.

History taking

1) When do you notice the ulcer?
Remember that the ulcer might have been present for long before the patient actually notices it. This is usually in case of a neuropathic ulcer.

2) What draws your attention to the ulcer?
Usually is because of pain. Others includes : bleeding, discharge, may be foul-smelling.


3) How does the ulcer disturbs you?
The commonest symptom associated with an ulcer is pain. It might be interfering with eating, walking, defecating, etc

4) Any changes to the ulcer since you've noticed it?
Is there any increase in size, changes in shape, increased discharge, bleeding, or severity of pain?

5) Is there any similar ulcers noticed elsewhere in the body?
Asking for multiplicity.

6) What do you think is the cause of ulcer?
Most of the time the patient will get it right, and the commonest cause is trauma.

Examination

1) Inspect the floor 

The floor of an ulcer usually made up of granulation tissues or slough tissues. Sometimes, the underlying structures might been exposed, eg : bones, tendons, etc. Some characteristic contents of the floor are able to provide you a hint to your diagnosis :

Solid-Brown, greyish tissue - Full thickness death of tissue
Slough tissue resembles a yellow-grey wash leather - Syphilitic ulcers
Unhealthy, bluish granulation tissue - Tuberculous ulcers
Poor granulation tissue, with visible bones, tendons, periosteum - Ischaemic ulcer

2) Edge of the ulcer

The edge is the portion in between the floor and margin of an ulcer
There're 5 main types of edges for ulcer :

a) Slopping edge

Usually means the ulcer is superficial/shallow and has a good chance in healing. Healthy granulation tissue usually is pinkish, means it has a good vascularity. A healing epidermis is usually seen extending from the edge, over granulation tissue, either pale/pink in colour (almost transparent)
One example of such ulcer is - venous ulcer

b) Punch-out edge

It means there's rapid death over full thickness of tissue with minimal attempts of the body to repair it. A classical textbook example is the Ulcers seen in tertiary syphilis. Nowadays, ulcers with punch out edges are more commonly seen in neuropathic or peripheral arterial ischaemic ulcers. (PVD)

Hence, it's a must that you check for it's vascularity and innervation.

Category: Surgery Notes