Ulcerative lesion with Physical examination including the General and Systemic examinations step by step discussion along with all the possible differential diagnosis.
I. What are the differential diagnosis of an Ulcerative lesion :
A. Ulcers present on the leg :
B. Ulcers present on the Body :
II. What are the General examination of an Ulcerative lesion :
In the event of an ulcer, the examiner should not focus just on the ulcer. The patient’s genera examination must be given careful consideration. Malnutrition, general atherosclerosis, syphilis, and tuberculosis are all possible causes of ulcers.
- Perforated ulcer – When a trophic or perforated ulcer is suspected, a general examination is required to determine the type of neurological disease that is present.
- Syphilitic ulcer – When a syphilitic ulcer is detected, a comprehensive search should be conducted to look for other syphilitic stigmas in the body.
- Tuberculous ulcer – If the ulcer is found to be syphilitic, all lymph nodes in the body should be checked, as well as other areas such the chest, neck, and abdomen.
- Atherosclerosis – If the ulcer is caused by atherosclerosis, the entire body must be evaluated to establish the presence of atherosclerosis or its complications.
III. What are the Systemic examination of an Ulcerative lesion :
We have done four examination under the systemic examination part, and they are – Inspection, Palpation, including lymph nodes palpation, Vascular insufficiency, and Nerve lesion.
1. How to do the Inspection part :
1. Size and shape of the ulcerative lesion :
A sterile gauge can be put against an ulcer to obtain precise measurements of its size and shape. The size of an ulcer is crucial in determining how long it will take to heal. A larger ulcer will almost certainly take longer to heal.
- Varicose ulcer – The shape of these eats is usually vertically oval.
- Syphilitic ulcer – These ulcers are circular or semilunar at first, but they may join together to form a serpiginous ulcer.
- Tuberculous ulcer – They’re usually oval, although their coalescence can result in an uneven cresetic border.
- Carcinomatous ulcer – The size and shape of these lesions are uneven.
2. Number of the ulcerative lesion :
Another element to consider while determining the source of an ulcer is the number. Tuberculous, gummatous, and varicose ulcers exhibit more than one number. Soft chancres can sometimes display ulcers that are more than one in number.
3. Discharge from the ulcerative lesion :
- A healed ulcer will show signs of serous drainage.
- When the ulcer is infected with beta-pyocyanea, it produces a greenish discharge.
- Tuberculous ulcer or a malignant ulcer might cause sero-sanguineous discharge.
4. Surrounding area of the ulcerative lesion :
- When the ulcer’s surrounding area is shiny, red, and oedematous, the ulcer is acutely inflamed.
- The skin around a varicose ulcer is frequently eczema-prone and pigmented.
- A scar or wrinkling in the skin around an ulcer could indicate a previous bout of tuberculosis.
5. Situation of the ulcerative lesion :
Best tool or inspection to get the most probable diagnosis of an Ulcer.
- Lupus – This is a type of cutaneous TB that affects the face, fingers, and hands more commonly.
- Hungarian chancre and soft sores – This is clearly visible over the external genitalia.
- Varicose veins – Situation of an ulcerative lesion if presents on the medial malleolus of a lower limb, then it mainly suggests Varicose ulcer.
- Gummatous ulcers – These are frequently encountered over subcutaneous bones such as the tibia, sternum, and skull.
- Rodent ulcers – This usually occurs around the inner canthus of the eye and is limited to the top half of the face above a line connecting the angle of the mouth to the lobule of the ear.
- Perforating or trophic ulcers – These are more common on the heel or ball of the foot, where the body carries the most weight.
- Tuberculous ulcers – These are frequently seen in areas where tuberculous adenopathy is more common, such as the neck, axilla, or groyne.
- Carcinomatous ulcers – This can happen anywhere on the body, but the lips, tongue, breast, penis, and anus are the most prevalent spots.
6. Floor of the ulcerative lesion :
This is the ulcer’s exposed surface. There are three varieties of ulcer flooring that are commonly encountered. They are as follows:
- The ulcer is healthy and healing if the granulation tissue floor is red.
- A slow-healing ulcer will have pale and smooth granulation tissue.
- The ulcer is pathognomonic of gummatous ulcer if it has a wash-leather-like floor.
7. Edge of the ulcerative lesion :
The edge of a spreading ulcer is infalmed and oedematous, but the edge of a healing ulcer shows a blue zone and a white zone if traced from red granulation tissue to the periphery.
Undetermined edge, Punched out edge, Sloping edge, Raised and pearly-white beaded edge, Rolled out edge are the five sorts of edges.
2. How to do the Palpation part :
1. Tenderness of an ulcer :
There can be three types of ulcers based on the tenderness ; they can be :
- Acutely inflamed ulcer – This is always delicately tender.
- Chronic ulcer – These shows slight tenderness like Tuberculous and syphilitic ulcers.
- Varicose ulcers – Sometimes this shows tenderness and sometimes not.
- Neoplastic ulcer – This is always tender.
2. Surrounding skin of an Ulcer :
- Surrounding Skin – Palpate and inspect the skin around the ulcer. The ulcer is acutely inflammatory, as evidenced by the elevated temperature and discomfort of the surrounding skin. The surrounding skin’s mobility is assessed. The lesion’s fixation to deeper tissue implies that it is malignant. The surrounding skin is examined for signs of nerve damage.
- Primary arteries – The main arteries supplying the part should be felt. In the case of an arterial or ischemic ulcer, the artery may be stopped due to atherosclerosis, Buerger’s disease, or Raynaud disease.
- Venous Ulcer – Venous ulcers may or may not be linked with limb varicose veins.
- Peripheral nerves – We must try to feel the nerves in the area of abnormal thickness or soreness.
3. Floor of an ulcer :
The ulcer’s exposed surface is the floor, and the ulcer’s resting location is the base, which is better felt than seen.
In any chronic ulcer, picking up the base is expected, but in squamous-celled carcinoma and Hunterian chancre, considerable induration of the base is a prominent characteristic.
4. Edge and boundary of a ulcer :
- Margin/boundary – The ulcer’s boundary is defined as the point where normal epithelium meets the ulcer.
- Edge :This is the space between the ulcer’s edge and its floor.
A carcinoma, whether it’s a squamous-celled carcinoma or an adenocarcinoma, is distinguished by considerable induration or hardness of the edge. Any chronic ulcer, whether it’s a gummatous ulcer, a syphilitic chancre, or a trophic ulcer, should have some degree of thickness induration.
5. Depth of an ulcer :
The ulcer’s depth should be measured in millimetres. Trophic ulcers can go all the way down to the bone.
6. Bleeding of an ulcer :
It is a common feature of a malignant ulcer whether or not it bleeds to the touch.
7. Relations with deeper structures of an Ulcer :
The ulcer is made to move deeper structures in order to see if it is attached to any of them. It is frequently attached to a gummatous ulcer over a subcutaneous bone such as the tibia or sternum.
Infiltration will certainly fix the malignant ulcer to the deeper structure.
Lymph nodes palpation :
Lymph node examination is crucial since it mostly indicates the severity of an infection or cancer. As a result, one of the parts of the test is lymph node inspection.
There are four types of ulcers where the lymph nodes gets enlarged, they are :
- Acute inflamed ulcers – The lymph nodes in the region become energised, tender, and show indications of acute lymphadenitis.
- Tuberculous ulcer – The lymph nodes expand, become matted, and become slightly painful.
- Hunterian chancre – The regional lymph nodes are distinct, hard, and shotty in this area. This lymph node type is pathognomonic for hard chancre.
- Malignant ulcer – The nodes are rocky hard and, in later phases, may be attached to neighbouring structures.
In some cases the lymph node enlargement does not occur, they are – Rodent ulcer and Gummatous ulcer.
3. How to examine the vascular insufficiency part :
- If the Ulcer is on the lower leg, the examiner should look for varicose veins in the upper leg or thigh.
- If a varicose vein is not present and the origin of the ulcer is unknown, the doctor must assess the condition of the arteries proximal to the ulcer.
- Atherosclerosis, Buerger’s disease, Raynaud’s disease, and other circulatory disorders may be the cause of the ulcer.
4. How examine nerve lesion :
Trophic ulcers are caused by repetitive trauma to an insensitive area of the patient’s body.
- This is most common in the sole, as this is the weight-bearing zone when there is sensory loss, and ulcer formation is a possibility.
- The existence of a trophic ulcer implies a neurological problem, such as tabes dorsalis, transverse myelitis, or peripheral neuritis.
IV. What are the Investigations to be done of an Ulcerative lesion :
- A routine blood examination is performed, including total count, ESR, WBC count, and RBC count.
- Urine examination – A sugar level estimation is performed to determine whether or not the patient has diabetes.
- Mantoux test – The Mantoux test is more significant in children to identify tuberculosis than it is in adults to rule out tuberculosis.
- Bacteriological investigation of the secretion or discharge – Information regarding the precise causative agent can be obtained.
- Biopsy – In the case of malignant ulcers, this is critical.
- Radio-Imaging approach – The radioactive fibrinogen test, which uses Iodine-labeled fibrinogen, is quite accurate in detecting deep vein thrombosis, especially when it occurs in the early stages of creation. And technetium clearance is utilised to determine calf muscle blood flow.
- Contrast radiography – Arteriography can be used to determine whether an ulcer is arterial or ischemic. In the instance of a venous ulcer, ascending functional phlebography can assist diagnose deep vein thrombosis.
- Chest X-ray – In tuberculous ulcers, this is necessary to detect any primary focus in the lung. In the event of malignant ulcers, it is critical to rule out metastatic deposits in the lungs.