Diagnosis of Ulcer
Ulcer Diagnosis: Book Excerpts
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FOOT ULCERATION:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Are there diminished or absent peripheral pulses? The finding of poor peripheral pulses would suggest that the lesion is secondary to ischemia from arteriosclerosis, Buerger's disease, diabetic arteriolar sclerosis, familial hyperlipidemia, and cryoproteinemia.
- Are there abnormalities on neurologic examination? The presence of good peripheral pulses should make one look for a neurologic explanation for the ulcer, and if there is diminished sensation to touch and pain in the periphery, peripheral neuropathy is very likely. Ulcers may also form in paraplegia of any cause, leprosy, and tabes dorsalis.
- Is there a history of diabetes? A history of diabetes makes the diagnosis of diabetic arteriolar sclerosis very likely. Remember, the pulses may be normal in this condition.
- Is there a positive smear or culture? The presence of good peripheral pulses should prompt one to do a smear and culture of material from the lesion, and if this is positive, then the diagnosis is made. We would consider, in addition to the normal bacteria, blastomycosis, sporotrichosis, maduromycosis, and syphilis.
DIAGNOSTIC WORKUP
Diminished pulses is a clear indication for Doppler ultrasound studies. Routine tests include a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, and glucose tolerance test. An x-ray of the involved foot should be done to rule out osteomyelitis. A bone scan is even more sensitive to osteomyelitis and other disorders of the bone that may be causing the ulcer. A smear should be made of the ulcer material and a culture done also, not just for the common pathogens, but for AFB and fungi. A dark field preparation may be necessary. Skin testing for blastomycosis and other fungi should be done. A nerve conduction velocity study of the lower extremities will be helpful in differentiating neurologic causes. Femoral angiography may be valuable in determining the exact level of the lesion and whether it can be approached surgically.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
LEG ULCERATION:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Are the peripheral pulses diminished or absent? Presence of poor peripheral pulses suggests arteriosclerosis, diabetes mellitus, Buerger's disease, and femoral artery thrombosis.
- Are there abnormalities on the neurologic examination? Neurologic disorders associated with leg ulceration include tabes dorsalis, diabetic neuropathy, hemiplegia, and many other disorders.
- Is there a positive smear or culture of the material from the ulcer? A positive smear or culture of material from the ulcer may be found in osteomyelitis, tuberculosis, syphilis, anthrax, and other fungal diseases.
DIAGNOSTIC WORKUP
Routine studies include a CBC, sedimentation rate, sickle cell preparation, urinalysis, chemistry panel, VDRL test, smear and culture of the material from the ulcer, and x-rays of the involved area. A biopsy may be necessary to establish the diagnosis. Rarely, a dark field examination will be necessary. Arteriography or venography may establish the level of arterial or venous obstruction. A bone scan will help pin down the diagnosis of osteomyelitis.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
VULVAL OR VAGINAL ULCERATIONS:
Ask the Following Question:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the lesion or are surrounding lymph nodes tender? The presence of tenderness of the lesion or the surrounding lymph nodes would suggest chancroid, lymphogranuloma venereum, herpes genitalis, and carcinoma. On the other hand, if the lesions or the surrounding lymph nodes are nontender, chancre, yaws, condyloma latum, and lupus should be suspected.
DIAGNOSTIC WORKUP
The workup includes a CBC, sedimentation rate, urinalysis, and VDRL test. A smear and culture of material from the ulceration should be done. A dark field examination may also be necessary. The Frei test may diagnose lymphogranuloma venereum, but a serologic test for this disorder may also be ordered. Biopsy may be ultimately necessary. It is wise to enlist the help of a urologist or gynecologist in difficult cases.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
SKIN ULCERS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis of a skin ulcer involves an assessment of the vascular supply to the area, a neurologic examination, and a good history (especially important is venereal disease). The laboratory can support the diagnosis with a smear and culture, skin tests for tuberculosis and fungi, and serologic tests.
An x-ray of the bone may reveal the cause. A biopsy may be necessary. Radiographic and laboratory survey of other organs may be necessary if a systemic disease (e.g., collagen disease or ulcerative colitis) is suspected.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Dyspepsia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient complains of dyspepsia, begin by asking him to describe it in detail. How often and when does it occur, specifically in relation to meals? Do drugs or activities relieve or aggravate it? Has he had nausea, vomiting, melena, hematemesis, a cough, or chest pain? Ask if he's taking prescription drugs and if he has recently had surgery. Does he have a history of renal, cardiovascular, or pulmonary disease? Has he noticed a change in the amount or color of his urine?
Ask the patient if he's experiencing an unusual or overwhelming amount of emotional stress. Determine the patient's coping mechanisms and their effectiveness.
Focus the physical examination on the abdomen. Inspect for distention, ascites, scars, obvious hernias, jaundice, uremic frost, and bruising. Then auscultate for bowel sounds and characterize their motility. Palpate and percuss the abdomen, noting tenderness, pain, organ enlargement, or tympany.
Finally, examine other body systems. Ask about behavior changes, and evaluate the patient's level of consciousness. Auscultate for gallops and crackles. Percuss the lungs to detect consolidation. Note peripheral edema and any swelling of the lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Breast ulcer:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin the history by asking when the patient first noticed the ulcer and if it was preceded by other breast changes, such as nodules, edema, or nipple discharge, deviation, or retraction. Does the ulcer seem to be getting better or worse? Does it cause pain or produce drainage? Has she noticed any change in breast shape? Has she had a skin rash? If she has been treating the ulcer at home, find out how.
Review the patient's personal and family history for factors that increase the risk of breast cancer. Ask, for example, about previous cancer, especially of the breast, and mastectomy. Determine whether the patient's mother or sister has had breast cancer. Ask the patient's age at menarche and menopause because more than 30 years of menstrual activity increases the risk of breast cancer. Also ask about pregnancy because nulliparity or birth of a first child after age 30 also increases the risk of breast cancer.
If the patient recently gave birth, ask if she breast-feeds her infant or has recently weaned him. Ask if she's currently taking an oral antibiotic and if she's diabetic. All these factors predispose the patient to Candidainfections.
Inspect the patient's breast, noting any asymmetry or flattening. Look for a rash, scaling, cracking, or red excoriation on the nipples, areola, and inframammary fold. Check especially for skin changes, such as warmth, erythema, or peau d'orange. Palpate the breast for masses, noting any induration beneath the ulcer. Then carefully palpate for tenderness or nodules around the areola and the axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Corneal ulcers:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
A history of trauma or use of contact lenses and flashlight examination that reveals irregular corneal surface suggest corneal ulcer. Exudate may be present on the cornea, and a hypopyon (accumulation of white cells in the anterior chamber) may appear as a white crescent moon that moves when the head is tilted.
Confirming diagnosis Fluorescein dye, instilled in the conjunctival sac, stains the outline of the ulcer and confirms the diagnosis.
Culture and sensitivity testing of corneal scrapings may identify the causative bacteria or fungus, and may indicate appropriate antibiotic or antifungal therapy.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Peptic ulcers:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
CONFIRMING DIAGNOSIS Esophagogastroduodenoscopy confirms the presence of an ulcer and permits cytologic studies and biopsy to rule out H. pylori or cancer.
Diagnosis may be confirmed by the following tests:
❑ Barium swallow or upper GI and small-bowel series may reveal the presence of the ulcer. This is the initial test performed on a patient whose symptoms aren’t severe.
❑ Laboratory analysis may detect occult blood in stools.
❑ Serologic testing may disclose clinical signs of infection such as an elevated white blood cell count.
❑ Carbon 13 (13C) urea breath test results reflect activity of H. pylori.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Pressure ulcers:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Pressure ulcers are obvious on physical examination. Wound culture and sensitivity testing of the exudate in the ulcer identify infecting organisms and antibiotics that may be needed. If severe hypoproteinemia is suspected, total serum protein values and serum albumin studies may be appropriate.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Ulcerative colitis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
CONFIRMING DIAGNOSIS Sigmoidoscopy showing increased mucosal friability, decreased mucosal detail, and thick inflammatory exudate suggests this diagnosis. Biopsy can help confirm it.
Colonoscopy may be required to determine the extent of the disease and to evaluate strictured areas and pseudopolyps. (Biopsy would then be done during colonoscopy.) Barium enema can assess the extent of the disease and detect complications, such as strictures and carcinoma.
A stool sample should be cultured and analyzed for leukocytes, ova, and parasites. Other supportive laboratory values include decreased serum levels of potassium, magnesium, hemoglobin, and albumin as well as leukocytosis and increased prothrombin time. An elevated erythrocyte sedimentation rate correlates with the severity of the attack.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Dyspepsia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of dyspepsia, begin by asking him to describe it in detail. How often and when does it occur, specifically in relation to meals? Do any drugs or activities relieve or aggravate it? Has the patient had nausea, vomiting, melena, hematemesis, cough, or chest pain? Ask if he’s taking any prescription drugs and if he has recently had surgery. Does he have a history of renal, cardiovascular, or pulmonary disease? Has he noticed any change in the amount or color of his urine?
Ask the patient if he’s experiencing an unusual or overwhelming amount of emotional stress. Determine the patient’s coping mechanisms and their effectiveness.
Focus the physical examination on the abdomen. Inspect it for distention, ascites, scars, obvious hernias, jaundice, uremic frost, and bruising. Then auscultate it for bowel sounds and characterize their motility. Palpate and percuss the abdomen, noting any tenderness, pain, organ enlargement, or tympany.
Finally, examine other body systems. Ask about behavior changes, and evaluate level of consciousness. Auscultate for gallops and crackles. Percuss the lungs to detect consolidation. Note peripheral edema and any swelling of lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Breast ulcer:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin the history by asking when the patient first noticed the ulcer and if it was preceded by other breast changes, such as nodules, edema, or nipple discharge, deviation, or retraction. Does the ulcer seem to be getting better or worse? Does it cause pain or produce drainage? Has she noticed any change in breast shape? Has she had a rash? If she has been treating the ulcer at home, find out how.
Review the patient’s personal and family history for factors that increase the risk of breast cancer. For example, ask about previous cancer, especially of the breast, and mastectomy. Determine whether the patient’s mother or sister has had breast cancer. Ask the patient’s age at menarche and menopause because more than 30 years of menstrual activity increases the risk of breast cancer. Also ask about pregnancy because nulliparity or a first pregnancy after age 30 also increases the risk of breast cancer.
If the patient recently gave birth, ask if she breast-feeds her infant or has recently weaned him. Ask if she’s currently taking an oral antibiotic and if she’s diabetic. All these factors predispose the patient to candidal infections.
Inspect the patient’s breast, noting any asymmetry or flattening. Look for a rash, scaling, cracking, or red excoriation on the nipples, areola, and inframammary fold. Check especially for skin changes, such as warmth, erythema, or peau d’orange. Palpate the breast for masses, noting any induration beneath the ulcer. Then carefully palpate for tenderness or nodules around the areola and the axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Genital Ulcer:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Herpes simplex
❑ Trauma
❑ Syphilis
❑ Fixed drug eruption
❑ Behçet syndrome
❑ Candida balanitis
❑ Granuloma inguinale
❑ Chancroid
❑ Lymphogranuloma venereum
❑ Bowen disease
❑ Carcinoma of the penis
Diagnostic Approach
A sexually transmitted infection is by far the most likely cause; therefore, a careful sexual history must be taken. Because the patient is often embarrassed or ashamed, cooperation with accurate information can best be gained by first clearly explaining the purpose of the questions. Therapy is usually initiated based upon a clinical diagnosis. Although classic presentations are useful guides, the appearance of ulcers can be atypical (particularly in HIV), overlap, and multiple agents may be acquired simultaneously.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Leg Ulcer:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Venous insufficiency
❑ Arterial insufficiency
❑ Diabetes/neuropathy
❑ Decubitus ulcer
❑ Hypertension
❑ Squamous cell cancer
❑ Carbuncle
❑ Vasculitis
❑ Pyoderma gangrenosum
❑ Syphilis chancre
❑ Fistula
❑ Blood disorders
❑ Brown recluse spider bite
Diagnostic Approach
Painful necrosis in a cold foot is the result of ischemia. Painless necrosis at a pressure area (MTP heads, heels, toes) is caused by neuropathy.
Ulcerations of the fingertips can be caused by Raynaud syndrome, especially in scleroderma, and by ergots, or bleomycin.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Corneal ulcers:
Diagnosis
(Handbook of Diseases)
A history of trauma or use of contact lenses and a flashlight examination that reveals an irregular corneal surface suggest corneal ulcer. Exudate may be present on the cornea, and a hypopyon (accumulation of white cells in the anterior chamber) may appear as a half-moon.
Fluorescein dye, instilled in the conjunctival sac, delineates the outline of the ulcer. Culture and sensitivity testing of corneal scrapings, which may identify the causative bacteria or fungus, indicate appropriate antibiotic or antifungal therapy.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Peptic ulcers:
Diagnosis
(Handbook of Diseases)
A patient with dyspepsia may have an upper GI series to help diagnose a peptic ulcer. For a patient with a confirmed gastric ulcer, an upper endoscopy should be performed to help distinguish between benign and malignant disease. An endoscopy should also be performed in a patient with GI bleeding to identify areas of ulceration. In a patient with a history of peptic ulcer disease, H. pylori may be diagnosed with urease breath testing or serologic testing. H. pylori can also be diagnosed by biopsy via upper endoscopy.
Other tests may disclose occult blood in the stools and a decreased hemoglobin level and hematocrit from GI bleeding.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Pressure ulcers:
Diagnosis
(Handbook of Diseases)
Pressure ulcers are obvious on physical examination. Wound culture and sensitivity testing of the exudate in the ulcer identify infecting organisms and antibiotics that may be needed. If severe hypoproteinemia is suspected, total serum protein values and serum albumin studies may be appropriate.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Ulcerative colitis:
Diagnosis
(Handbook of Diseases)
❑ History and physical examination should include questions regarding frequency of stools, rectal bleeding, cramps, abdominal pain, weight loss, and tenesmus. Peritoneal inflammation should be assessed, as well as volume status and nutritional levels.
❑ Sigmoidoscopy establishes a diagnosis by demonstrating increased mucosal friability, decreased mucosal detail, edema, and erosions. Biopsy can help confirm the diagnosis.
❑ Colonoscopy may be used both to determine the extent of the disease and for cancer surveillance after the patient’s flare-up has resolved.
CLINICAL TIP: Colonoscopy should not be performed during an acute episode because of the risk of perforation.
❑ Stool specimen should be cultured and analyzed for leukocytes, ova, and parasites.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Dyspepsia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient complains of dyspepsia, begin by asking him to describe it in detail. How often and when does it occur, specifically in relation to meals? Do any drugs or activities relieve or aggravate it? Has he had nausea, vomiting, melena, hematemesis, cough, or chest pain? Ask if he’s taking prescription drugs and if he has recently had surgery. Does he have a history of renal, cardiovascular, or pulmonary disease? Has he noticed any change in the amount or color of his urine?
Ask the patient if he’s experiencing an unusual or overwhelming amount of emotional stress. Determine the patient’s coping mechanisms and their effectiveness.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Dyspepsia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of dyspepsia, begin by asking him to describe it in detail. How often and when does it occur, specifically in relation to meals? Do drugs or activities relieve or aggravate it? Has he had nausea, vomiting, melena, hematemesis, a cough, or chest pain? Ask if he's taking prescription drugs and if he has recently had surgery. Does he have a history of renal, cardiovascular, or pulmonary disease? Has he noticed a change in the amount or color of his urine?
Ask the patient if he's experiencing an unusual or overwhelming amount of emotional stress. Determine the patient's coping mechanisms and their effectiveness.
Focus the physical examination on the abdomen. Inspect for distention, ascites, scars, obvious hernias, jaundice, uremic frost, and bruising. Then auscultate for bowel sounds and characterize their motility. Palpate and percuss the abdomen, noting tenderness, pain, organ enlargement, or tympany.
Finally, examine other body systems. Ask about behavior changes, and evaluate the patient's level of consciousness. Auscultate for gallops and crackles. Percuss the lungs to detect consolidation. Note peripheral edema and any swelling of the lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Breast ulcer:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin the history by asking when the patient first noticed the ulcer and if it was preceded by other breast changes, such as nodules, edema, or nipple discharge, deviation, or retraction. Does the ulcer seem to be getting better or worse? Does it cause pain or produce drainage? Has she noticed any change in breast shape? Has she had a skin rash? If she has been treating the ulcer at home, find out how.
Review the patient's personal and family history for factors that increase the risk of breast cancer. Ask, for example, about previous cancer, especially of the breast, and mastectomy. Determine whether the patient's mother or sister has had breast cancer. Ask the patient's age at menarche and menopause because more than 30 years of menstrual activity increases the risk of breast cancer. Ask about pregnancy because nulliparity or birth of a first child after age 30 also increases the risk of breast cancer.
If the patient recently gave birth, ask if she breast-feeds her infant or has recently weaned him. Ask if she's currently taking an oral antibiotic and if she's diabetic. All these factors predispose the patient to Candidainfections.
Inspect the patient's breast, noting any asymmetry or flattening. Look for a rash, scaling, cracking, or red excoriation on the nipples, areola, and inframammary fold. Check especially for skin changes, such as warmth, erythema, or peau d'orange. Palpate the breast for masses, noting any induration beneath the ulcer. Then carefully palpate for tenderness or nodules around the areola and the axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
SKIN ULCERS:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis of a skin ulcer involves an assessment of
the vascular supply to the area, a neurologic examination, and a good
history (especially important is venereal disease). The laboratory can
support the diagnosis with a smear and culture, skin tests for tuberculosis
and fungi, and serologic tests.
An x-ray of the bone may reveal the cause. A biopsy may be necessary.
Radiographic and laboratory survey of other organs may be necessary if a
systemic disease (e.g., collagen disease or ulcerative colitis) is
suspected.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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