EXAMINATION OF ULCER

ULCER
“An ulcer is a persistent discontinuity of an epithelial surface that can occur in the skin or in the
mucosa”
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. Base
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

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 color. 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.

HISTORY

The questions to be asked concerning an ulcer follow a pattern similar to those asked about a lump.
1. When was the ulcer first noticed?
Ask the patient when the ulcer began and whether it could have been present for some time before
it was noticed. The latter often occurs with neurotrophic ulcers on the sole of the foot.
2. What drew the patient’s attention to the ulcer?
The most common reason is pain, but the ‘sore’ or defect may be visible. Occasionally, the presenting
feature is bleeding, or a purulent discharge, which may be foul smelling.
3. What are the symptoms of the ulcer?
The ulcer may be painful. It may interfere with daily activities such as walking, eating or defaecation.
Record the history of each symptom.
4. How has the ulcer changed since it first appeared?
The patient’s observations about changes in size, shape, discharge and pain are likely to be accurate.
If the ulcer has healed and broken down, record the features of each episode.
5. Has the patient ever had a similar ulcer on the same site, or elsewhere?
Obtain a complete history of any previous ulcer.
6. What does the patient think caused the ulcer?
Many patients believe they know the cause of their ulcer, and they are often right. In many cases, it is
trauma. When possible, the severity and type of injury should be assessed. A large ulcer following a
minor

Dr. Wasif Majeed Chaudhry

MBBS, FCPS, MHPE
Associate Professor, General Surgery, LMDC