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ulcers and swellings

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    Note especially the following points :-

    1- Duration :- This is short in acute ulcers and long in chronic ulcers in venereal ulcers, inquire about the incubation period :- 3-4 weeks in syphilitic chancre and 3-4 days in soft sore ( chancroid)

    2- mode of onset :- inquire whether the ulcer has followed trauma ( wound or burn) or has arisen in a previous local lesion, e.g. papule, lump, callosity or patch of dermatitis

    3- pain :- acute ulcers and tuberculosis ulcers are painful whereas syphilitic ulcers and trophic ulcers are entirely painless

    Pain is absent in the early stages of rodent ulcer and epithelioma

    4- discharge :- whether serum, pus or blood

    5- progress :- whether spreading, stationary, healing or showing remissions and exacerbationsinquire about any constitutional symptoms, such as fever and rigor, and about the effect of any treatment so far received.

    6- past history :- inquire about any history of specific infection (syphilis or tuberculosis), constitutional disease ( diabetes or nephritis ), peripheral vascular disease ( varicose veins or intermittent caludication) or neurological disease

    General examination

    Always examine the urine for sugar and albumin particularly in elderly people, look for signs of cardiovascular disease and in trophic ulceration carry out a full neurological examination in tuberculosis ulcer , search for other tuberculosis lesions in the skeleton, lymph nodes and viscera when syphilis is suspected look for syphilitic stigmata, viz. saddle nose , perforated palate, Hutchinson's teeth, wrinkling of the forehead, ptsosis of the eyelids, absence of tendon reflexes and bone sense, Argyll- Robertson pupil and sensory ataxia (Rombergism)

    Local examination

    Proceed systematically as follows :-

    1-Number :- most ulcers are solitary but tuberculosis and syphilitic ulcers may be multiple or recurrent

    2- site :- certain ulcers have a predilection for specific parts of the body varicose ulcers are commonest in the lower third of the inside of the leg, perforating ulcers in the sole of the foot and gummatous ulcers in the upper third of the legmost rodent ulcers occur on the upper part of the face while epithelioma is common on the lower lip and extragenital chancre on the upper tuberculosis ulcers are commonly found on the neck and soft and hard chancres usually occur over the genitalia ..

    3- size :- note the size of the ulcer in relation to its duration a carcinoma spreads more rapidly than a rodent ulcer but more slowly than a septic ulcer

    4- shape :- The contour may be round, oval, elongated, irregular or serpiginous tuberculosis ulcers are oval with an irregular crescentic border Gummatous ulcers are typically circular or semilunar but may unite to form a serpiginous ulcer A rodent ulcer is more regular than a carcinoma .

    5- Floor :- this is the visible area denuded of epithelium . Note its depth, the presence of sloughs and type of tissue present ; whether necrotic material, granulations or tumour tissue.

    6-Edge :- The edge is usually sloping or terraced in septic ulcers ; undermined in tuberculosis and sarcomatous ulcers ; punched out in callous and syphilitic ulcers ; rolled-in and beaded in rodent ulcers ; and raised , nodular and everted in carcinomatous ulcers

    The types of edge :- sloping ,, terraced,, punched out ,, undermined,,, rolled-in ,,, everted,,, fungating

    7-Margin :- This is the region between the edge and the normal surface around it may be healthy or the seat of congestion, oedema, inflammation, eczema, pigmentation, induration or outlying nodules if there is a healing scar, note whether healthy, thin and pappery or thick and keloidal ..

    8- dischare :- note its amount, consistence, colour and smell

    9- base :- this is the zone of tissue on which ulcer is situated it is invisible as it lies beneath the ulcer and around its edge it should be palpated for warmth, tenderness, consistency and mobility slight induration of the base may be present in any chronic ulcer but marked induration is characteristic of carcinoma

    10- regional lymph nodes :- they should be palpated for tenderness or enlargementif enlarged, note their number, size, consistency and mobility the glands are not affected in rodent and gummatous ulcers they are markedly inflamed in acute ulcers ; discrete , firm and shotty in Hunterian chancre; and stony hard in epitheliomatous ulcers.

    11- local circulation :- Examine the part thoroughly for any impairment of the arterial supply or venous drainage.

    12- Nerve supply :- the sensations should always be tested in the surrounding skin and if a nerve lesion is suspected,, the nerve system should be thoroughly examined.

    Special investigations:-

    1- urine :- should always be examined for sugar and albumin

    2- blood :- special tests are carried out as indicated, e. g. blood sugar for diabetes, sedimentation rate for tuberculosis and W.R. for syphilis

    3- bacteriological examination :- the discharge is examined for specific organisms such as spirochaetes ( dark- ground illumination), tubercle bacilli ( Ziehl-Neelsen stain, culture and animal inoculation) or pyogenic organisms ( culture and antibiotic sensitivity )

    4-Biopsy :- in doubtful cases a wedge history should be taken from the edge of the ulcer under local anaesthesia

    5- X-ray examination :- plain radiography is carried out if the ulcer is fixed to a bone or joint and angiography if peripheral vascular disease is suspected..

    Differential diagnosis

    Search on internet for meaning of these English concepts ( simple ulcers ,,, a spreading ulcer ,,, a healing ulcer ,,,a callous ulcer,,,, varicose ulcer ,,, trophic ulcers,,,, bedsores (decubitus ulcers) ,,,,,, perforating ulcers,,,, tuberculous ulcers,,,,syphilitic ulcers,,, mucous patches and snail track ulcers,,,,Gummatous ulcerssoft chancre (sore),,,, oriental sorerodent ulcer,,,,, carcinomatous ulcer ,,,,)))

    ... .