Ulcer examination MM sep 24.pptx

Examination of an Ulcer Mr. Mohamed Maatouk MRCS MSC advanced surgical practice Cardiff University, UK Diploma of laparoscopic surgery Strasbourg university, France GMC-MDU-EMS Objectives 🞂By the end of this session, we...

Examination of an Ulcer Mr. Mohamed Maatouk MRCS MSC advanced surgical practice Cardiff University, UK Diploma of laparoscopic surgery Strasbourg university, France GMC-MDU-EMS Objectives 🞂By the end of this session, we will have basic understanding of how to assess an ulcer 🞂Hand outs will be given Welcome slide ⮚ 5 min introduction ⮚ Breaking the ice ⮚ To improve communication and interaction ⮚ Get the sessions objectives and involving the students Cost of success should be paid in advance The reality The most important Definition of ulcer 🞂A break down in the epithelial continuity of tissues, either the skin or mucous membrane. 🞂Discontinuity of the skin or mucous membrane which occurs due to the microscopic death of the tissues We have learned in medicine Mnemonic 🞂 Tool for learning 🞂 A pattern of letters, ideas, or associations that assists in remembering something, 🞂 Examples: ABC — airway, breathing, and circulation We have to understand the ULCER 🞂The ulcer has components, we have to cover on our comments either in history taking or during clinical examination. 🞂So always remember DRESSINGS (Mnemonics) You can remember the mnemonic "DRESSINGS" to record the various findings of clinical examination of an ulcer. 🞂 D: Discharge and Depth of ulcer 🞂 R: Relation to underlying structure 🞂 E: Edge and Margin 🞂 S: Site, Size, Shape, Surface, Surrounding area 🞂 S: Solitary or multiple? 🞂 I: Induration at the base and Impairment of circulation 🞂 N: Nodes enlarged? Neurologic deficit? 🞂 G: General examination to note the evidence of malnutrition, TB, cardiac failure, etc. 🞂 S: Slide (biopsy), Smear or swab for culture and antibiotic sensitivity testing, Special investigations as necessary (X-ray chest, blood sugar, biopsy of tissue from margin, etc.) Parts of ulcer: ⮚ Margin: The junction between normal epithelium and ulcer Clinical significance Important when take biopsy ⮚ Edge: The area between margin and floor Clinical significance may be sign of malignancy ⮚ Floor: Exposed surface of ulcer ⮚ Base: Where ulcer rests  Classification Ulcers can be classified base on either clinical or pathological classifications: 🞂 A. Clinical 🞂 B. Pathological A. Clinical classification 🞂Spreading (Active) : (Edge - Inflamed & Edematous) 🞂Healing : (Edge is sloping with healthy red granulation tissue & serous discharge) 🞂Callous : (Floor contains pale unhealthy granulation tissue with indurated edge) Spreading ulcer Healing ulcer Callus ulcer B.Pathological 🞂1. Nonspecific 🞂2. Specific ( to special infection or diseases) 🞂3. Malignant 1. Non specific 🞂Traumatic Ulcer 🞂Arterial Ulcer 🞂Venous Ulcer 🞂Neurogenic Ulcer 🞂Infective Ulcer 2. Specific 🞂Tuberculosis 🞂Syphilis 🞂Actinomycosis 🞂Meleney’s ulcer (type of Necrotising fascititis) 🞂Soft sore 3. Malignant 🞂Squamous cell ca 🞂Basal cell ca 🞂Malignant melanoma Sq.C.C B.C.C M.M The Tatra Mountains lie on the border of Slovakia and Poland HISTORY 🞂 Mode of onset 🞂 Duration 🞂 Pain 🞂 Discharge 🞂 Associated disease Physical Examination 🞂General survey 🞂Inspection 🞂Palpation 🞂Examination of lymph nodes 🞂Vascular insufficiency 🞂 Nerve lesions INSPECTION 🞂 SIZEAND SHAPE 🞂 NUMBER 🞂 POSITION 🞂 EDGE 🞂 FLOOR 🞂 DISCHARGE 🞂 SURROUNDING AREA  POSITION OF THE ULCER Arterial ulcer Tip of the toes, dorsum of the foot Long saphenous Medial side of the varicosity with ulcer leg. Short saphenous Lateral side of the varicosity with ulcer leg. Perforating ulcers Over the sole at pressure points. Nonhealing ulcer Over the shin  EDGE DEF: This is between the floor of the ulcer and the margin. The margin is the junction between the normal epithelium and the ulcer. These two parts represent areas of maximum activity. A. Sloping edge All healing ulcers like traumatic ulcers, venous Ulcers B. Punched Gummatous out edge ulcers and trophic ulcers. C. Tuberculous Undermined ulcers edge D. Raised Rodent ulcers edge (beaded or basal cell edge) carcinoma. E. Everted Squamous edge cell (Rolled out) carcinoma. FLOOR OF THE ULCER DEF : This is the part of the ulcer which is exposed or seen. Red granulation Healing ulcer tissue Necrotic tissue, Spreading ulcer slough Pale, scanty Tuberculous ulcer granulation tissue Wash-leather Gummatous ulcer slough  DISCHARGE FROM THE ULCER Serous discharge Healing ulcer Purulent discharge Spreading ulcer Bloody discharge Malignant ulcer Discharge with Osteomyelitis bony spicules Greenish Pseudomonas discharge infection SURROUNDING AREA Thick and Varicose ulcer. pigmented Thin and dark Arterial ulcer. Red and Spreading oedematous ulcers like dia­- betic ulcer. PALPATION 🞂 TENDERNESS 🞂 EDGE AND MARGIN 🞂 BASE 🞂 INDURATION 🞂 BLEEDING 🞂 RELATIONS WITH DEEPAR STRUCTURES SURROUNDING SKIN EDGE 🞂Induration (hardness) of the edge is very characteristic of squamous cell carcinoma. 🞂It is said to be a host defense mechanism. 🞂Tenderness of the edge is characteristic BASE 🞂It is the area on which ulcer rests. 🞂Marked induration at the base is diagnostic of squamous cell carcinoma.  INDURATION Maximum induration Squamous cell carcinoma Minimal induration Malignant melanoma. Brawny induration Abscess. Cyanotic induration Chronic venous congestion as in varicose ulcer. The edge, base and the surrounding area should be examined for induration. BLEEDING 🞂Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds. 🞂 Granulation tissue as in a healing ulcer also causes bleeding. SURROUNDING AREA 🞂Thickening and induration is found in squamous cell carcinoma. 🞂Tenderness and pitting on pressure indicates spreading inflammation surrounding the ulcer. RELEVANT CLINICAL EXAMINATION 🞂 REGIONAL LYMPH NODES Tender and Acute secondary enlarged infection. Non-tender and Chronic enlarged infection. Non-tender and Squamous cell hard carcinoma. Non-tender, Malignant large, firm, melanoma. multiple Iguazu Falls, Brazil We are almost done (Nearly there) 🞂 We will take home message 🞂 Assess the session (Feedback) 🞂 Answer any question Questions 🞂 What is the mnemonics for examination of ulcer? 🞂 How can we classify ulcers? 🞂 What are the different parts of ulcer? 🞂 How can we assess the ulcer? Take home message "DRESSINGS“ What is the mnemonics for examination of ulcer? 🞂 D: Discharge and Depth of ulcer 🞂 R: Relation to underlying structure 🞂 E: Edge and Margin 🞂 S: Site, Size, Shape, Surface, Surrounding area 🞂 S: Solitary or multiple? 🞂 I: Induration at the base and Impairment of circulation 🞂 N: Nodes enlarged? Neurologic deficit? 🞂 G: General examination to note the evidence of malnutrition, TB, cardiac failure, etc. 🞂 S: Slide (biopsy), Smear or swab for culture and antibiotic sensitivity testing, Special investigations as necessary (X-ray chest, blood sugar, biopsy of tissue from margin, etc.)  How can we classify ulcers? Ulcers can be classified base on either clinical or pathological classifications: 🞂 A. Clinical (Spreading, healin & callus) 🞂 B. Pathological (Sp, non sp, malig) What are the different parts of ulcer? ⮚ Margin: The junction between normal epithelium and ulcer Clinical significance Important when take biopsy ⮚ Edge: The area between margin and floor Clinical significance may be sign of malignancy ⮚ Floor: Exposed surface of ulcer ⮚ Base: Where ulcer rests How can we assess the ulcer? 🞂General survey 🞂Inspection 🞂Palpation 🞂Examination of lymph nodes 🞂Vascular insufficiency 🞂 Nerve lesions  Useful lik https://gpnotebook.com/en-GB/pages/surgery/clinical-examination-of-ulcers Thank you Any questions Contact Mohamed Maatouk Mobile/whats app +201221228020 E_mail: [email protected]