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ulcer work up

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steps of physical examinationexamination

1.Greetings to examiner
2.Ask for pre requisits (privacy screen, attendance,chair)
3.Greetings to patient

4.self introduction,confirmation of identity and address,intro with examiners and attendence,

5.explanation,assurance,consent

6.Positioning

7.exposure

8.re assurance

9.hand wash

10.examination

i.local

inspection and simaltaneus history

There is an ulcerated growth over dorsum  of left leg

Measuring about 6×6 cm
Initially was small but attained the current size in last 6 months(size)
Cauliflower /irregular in shape(shape)
Surface is ulcerated (surface)
Border is irregular(spread/extent)
There is no scar, visible engorged vein, pigmentation/colour change, oedema and abnormal hair distribution(skin condition

palpation
Temparature is normal
Non tender
Margin is indurated
Edge is raised,everted
Floor contains moist necrotic material
Base is indurated and fixed with underlying sractures(cant be moved on contraction of underlying muscle)
Foul smelling straw coloured haemorrhagic discharge

percussion

auscultation

ii.other systemic
for neck-face ulcer/for cervical LN
for lower limb ulcer-inguinal lymohnode
I will talk to patient to evaluate
dysphagia/Hoarseness
I will examine the oral cavity

I will examine the chest

.I will examine the abdomen

Examination of oral cavity revealed normal findings
Distal pulse sensation and joint movements are well intact and draining lymphnodes(popliteal/inguinal/cervical/subclavian) are enlarged/not palpable
If enlarged/palpable
Painful/painless
Soft/firm/firm to hard
Descrete/matted
11.provisional diagnosis
My provisional diagnosis is non specificis (malignant ulcer)due to SCC with± secondary lymphadenitis/reactive lymphadenitis

12.differentials
i.BCC(typical site and edge raised and rolled)
ii.Marjolins ulcer(if there is

long History of burn
Long standing venous stasis
Chronic infection
H/O trauma

13.investigation

a.For confirmation of diagnosis
1.Local part
Discharge for CS
Local part Xray
Excision biopsy/wedge biopsy(small lesion)
Incision biopsy(large lesion)
2.LN
Biopsy

b.For detection of distant Extension
Examination of oral cavity
Examination of chest
Chest Xray
USG-WA

c.For diagnosis of Co morbidities/end organ damage

d.For Fitness

e.For follow up /prognosis

f.For planning

14.confirmatory diagnosis

15.treatment plan

• a.general management
• b.control of symptom
• c.control of co morbidities
• d.definitive management planning and execution

1.confirm the primary site

2.For local part/For ulcer

Incision/excision biopsy with 1/ 1.5/2cm free margin in case of BCC,SCC,MM respectively ±skin graft
Radiotherapy
Amputation-if involves bones and tendons
Excisional biopsy(if small lesion)
Incisional biopsy(if large)
3.Lymphnode
FNAC (–ve)=antibiotic for 3 weeks and follow up
FNAC(+ve)
mobile-excision/radical block dissection
fixed-radiotherapy
4.definitive treatment for primary site

FOLOW UP:

3monthly for ist 3years

then 6monthly for next 2 years

look for primary site

LN

for recurrence and metastasis

if LN metastasis found go for inguino pelvic dessection

Indication of surgery
Small
Large
Close to eye
Scalp
Refractory to radiotherapy

16.cross

common questions
1.Name age address occupation
2.Whats your sufferings
3.How long you are suffering from this
4.How it started
5.Is it painful at all
6.Is there any thing alike any where else
7.Does it go back/changes in size
8.Did you have any treatment before for this

9.family history

10.any other relevant query

 

 

oral ulcer(SCC)

recurrent SCC

marjolin’s ulcer

marjolin’s ulcer

basal cell carcinoma

 

basal cell carcinoma

working tools

arterial ulcer
Intermitten claudication
Rest pain
Old age
Smoker
Irregular shape
Anterior /lateral aspect of leg,toe,dorsum of foot and sole of foot,heel
Dry pale sheen,lost hair,fissured nail,thin skiny(features of ishchaemia)
Edge –punched out(healing by surrounding tissue is poor)
Margin-grey blue
Floor-grey yellow slough
Discharge-serosanguinous
Temp-not raised
Tender
Base-fixed on contraction of underlying muscle
Pulse-poor/absent
Burger’s -+ve
Cyanosis on lowering down the leg
Sensation-intact
Muscle bulk,power,joint movement-intact

13.investigation

a.For confirmation of diagnosis
1.Local part
Discharge for CS
Local part Xray
Excision biopsy/wedge biopsy(small lesion)
Incision biopsy(large lesion)

 

doppler USG

duplex USG

Contrast Angiography(for planning of Intervention)

MRA

substraction angiography
2.LN
Biopsy

b.For detection of distant Extension

if ulcerative growth is suspected
Examination of oral cavity
Examination of chest
Chest Xray
USG-WA

c.For diagnosis of Co morbidities/end organ damage

d.For Fitness

e.For follow up /prognosis

f.For planning

14.confirmatory diagnosis

15.treatment plan

• a.general management

avoid

smoking

fat

improve walking distance

regular ASPIRIN(45mg) daily

vasodilator(nifedipine)
• b.control of symptom

NSAID
• c.control of co morbidities

control DM

control dyslipidemia
• d.definitive management planning and execution

 

Local Care:

Regular dressing

Non adherent dressing

Avoid compression bandage

Topical antiseptics

Surgical:

Angioplasty(young adult)

Bypass

Critical ishchaemia

Rest pain

Tissue loss

(bone-tendon   exposed)

Amputation

Small vessel disease

Diabetic

Infection

gangreene

 

 

 

venous ulcer

venous ulcer over gailer area of right leg

Long History
Painless ulcer
Oval in shape
Medial aspect of leg
Shallow(never penetrates deep fascia)
Pale granulation tissue
Seropurulant/blood stained discharge
fixed

15.treatment plan

• a.general management
• b.control of symptom
• c.control of co morbidities
• d.definitive management planning and execution

Duplex doppler

Arterial-inv+Rx of insufficiency

Venous

i.superficial- sugery

ii.deep-COMPRESSION

                                         BANDAGE for 12 wks

(3 layers=30mmHg, 4 layers= 45mmHg)

ABPI     >0.9-venous-full compression

ABPI 0.7-0.9-mixed –light compression+Revasculariza

If

Healing-Rx continue

Non Healing-Excision Grafting(skin/pinch split)

Follow up after 12 wks

 

If still not healing think as

NON HEALING Ulcer

i.marjolins(over malleoli with raised edge bleeds easily)

ii.Vasculitis

Debrimentation +culture sp syst Antibiotic(never topical) fld by Compression Bandage for 12 wks

 

Infected: Debrimentation +culture sp syst Antibiotic(never topical)

Thrombophlebitis:elevation+ NSAID

 

 

Indication of skin split graft

   ABPI>0.5

   >10sq cm lesion

 
diabetic ulcer


Like arterial ulcer but less painful and lost sensation

 

15.treatment plan

• a.general management
• b.control of symptom
• c.control of co morbidities
• d.definitive management planning and execution

Patient education

Good control of DM

Wear accommodative footwear(soft leather)

Nail and skin care

Surgery: Amputation

Metatarsal

toe

neuropathic/neurogenic/perforating ulcer

H/O trauma
Painless
Heel, ball of foot
Punched out edge
Offensive slaugh
Necrotic discharge
Tendon, bones seen
Surrounding unhealthy tissue
Temp-not raised
Non tender
Base-indurated
Fixed
Decrease sensation
Muscle bulk,power joint movement decreased
All pulses normal

15.treatment plan

• a.general management
• b.control of symptom
• c.control of co morbidities
• d.definitive management planning and execution

Debriment and offloading of pressure
coz of diabetic ulcer
DM
Spina bifida
Peripheral nerve injury
Tabes dorsalis
Syringomyelia
Bed sore
Transverse myelitis
Meningocele

comparisons
Arterial-IC/RP+painful ulcer over ant/lat aspect of leg,toe,dorsum of foot/sole/heel
Punched out
Grey yellow slough serosanguinous discharge/dry
No pulsation

Venous- long standing painless ulcer over gaiter area shallow
Sero purulent/bloody discharge
oedema

DU-same as arterial but painless
Neuropathic-painless heel ball of foot
Necrotic discharge unhealthy surroundings lost sensation,muscle bulk and joint movement lost
Non healing-irregular pale granulation and necrotic slough with offensive discharge and

healing ulcer

Pink red healthy granulation tissue

 

healing ulcer with slopping edge and granulation tissue on floor

chronic non healing ulcer

Pale granulation tissue,necrotic slough

spreading ulcer
Surrounding inflammation
Offensive necrotic slough
With(pale)/without granulation tissue

DM leads to
Ishchaemia
Atherosclerosis
Microvascular occlusion
Peripheral neuropathy
Glucose laden tissue
Decrease resistant to trauma and infection
undermined edge
TB
Pressure sore
curbuncle

sloping edge

Venous
healing

punched out

Arterial
Neurogenic
Trophic
DM
Leprosy
syphilis

raised rolled=BCC

raised everted=SCC

 

 

non healing ulcer

 

 

 

OriginNumberSpread 

 

Site

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type

 

 

 

Size

 

shap

BASAL CELL CARCINOMABasal cell of epidermisHair follicleSebaceous glandSingle /multipleBurrows deeper tissuesCentrifugalLocal-bones and cartilagesLymphnodeBlood- very rare

 

 

Nose

Inner and outer canthus

Naso labial fold

Fore head(female)

Scalp

Pinna

Trunk

Limbs

Very rare

Squamous cell mucous membrane

Tongue

Oesophagus

Anal canal

 

Most rare

Center of face

Post auricular

Pinna

Fore head

 

Nodule-solid but look cystic

F;uctuation –negative

Plaque-firm,raised,red plaque

Ulcerative

 

 

 

Initially circular then irrwegular

 

 

Raised rounded

Beaded(pearly opalescent nodule)

Partially heals and extending to other adge

 

Not everted

 

Indurated

Fixed

Barely perceptible

 

 

 

≤1cm-excision biopsy

≥1cm-incision biopsy

Wedge biopsy

 

 

Radiotherapy(40-60gy)

Early lesion

Surgery

≤1cm

small

Contra indicated for radio therapy

Recurrence after radio therapy

 

 

 

Wide excision with 3-5mm clear margin

Reconstruction by

Split/full thickness graft

If deep

Rotation/advancement

Pedickle graft

 

Local chemotherapy(15FU)

Locally for flat lesion

Curettage followed by diathermy

Cryo surgery

Leaserbeam destruction

 

Wide excision(with 2mm free margin)followed by reconstruction by simple suturing

Wedge excision-pinna

Amputation

If penis

Foot involving bones

 

Lymph node management

 

 

Sun burn

Arsenic

Xeroderma

Immune suppression

Basal cell naevus syndrome

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCUAMOUS CELL CARCINOMAPrickle cell layerLocalLymphnode-more from footFrequently from face

 

 

Any part of body

Junctional region of skin and mucous membrane

Trachea

Larynx

Vagina

From collamnar metaplasia

GB

Bronchus

Cardiac end of stomach

 

Transitional metaplasia

Urinary bladder

Kidney

Pelvis

 

 

 

 

 

 

Nodular

fungating

Proliferative(cauliflower type)

Ulcerative-commonest

 

 

 

 

 

 

 

 

 

Rolled and evwerted

 

 

 

 

Induration

Fixed

 

 

 

 

≤1cm-excision biopsy

≥1cm-incision biopsy

Wedge biopsy

 

Radiotherapy

Early lesion

Surgery

Larger size

Contra indicated for radio therapy

Recurrence

Pinna

Eye

Muscle,bone,cartilage involved

 

Wide excision(with 2mm free margin)followed by reconstruction by simple suturing

Wedge excision-pinna

Amputation

If penis

Foot involving bones

 

Lymph node management

Mobile-preop antibiotic

For 3 weeks

If not treated-RBD

Hard/fixed-RBD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exposure to pitch,tar,soot

Prolonged exposure to chemical

 

Sun

Carcinogen

Immune suppression

Lupus vulgaris

Pre malignant conditions

 

(SCILUP)

 

 

Solid irregularstrands of columnar cell

Cell nests

Epithelial pearls

Central keratosis surrounded by peri eosinophilic bejoar

 

Contra indication of radio therapy

 

Closer to bones and cartilage

Close to eyes

Back of hand

extreme cold(frost bite)

 

Originated from oral cavity but fungated out side

 

Fungating SCC

Measured in relation to teeth in oral cavity

Ill fitted denture

Decayed / sharp teeth

Stained teeth (evidence of smoking and betel nut chewing ,the predisposing factors)

Surface is velvety or fungating

 

DD for oral SCC

Viral wart

Chronic candidiasis

BCC(very unlikely)

 

For any oral cancer

Never forget to see the facial nerve status for record keeping in medicolegal point of view as they might be damaged after surgery

 

 

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