Measure height (mm) (may or may not be possible in the exam)
Discharge
Serous (clear), blood, purulent
Deformity
Surroundings
Skin changes
Arterial
Pallor
Shiny skin
Hair loss
Venous
Hemosiderin staining
Varicose veins
Lipodermatosclerosis
Nail changes
Colour
Scars and deformities
Bunions
Charcot arthropathy
Venous Ulcer
Common Medical History
Varicose veins
Thrombosis
Leg fracture
Right-sided heart failure
Common Examination Findings
Varicose veins
Edema
Venous flares
Hemosiderin staining (dark purple or rusty skin discoloration of lower legs)
Features of lipodermatosclerosis (Inverted champagne bottle leg)
Common Ulcer Features
Located on the lower third of the leg
Shallow, poorly defined edges that are usually sloping
Granulating and sloughy base
Heavy exudate with maceration and hyperkeratotic skin
Location: Gaiter Area (lower third of the leg over the medial or lateral malleolus)
Edge: Usually sloping and may be irregular
Base: Granulating and sloughy
Exudate: Usually heavy with maceration and hyperkeratotic skin
Arterial Ulcer
Common Examination Findings
Signs of ischemia
Cold & pale extremities
Hair loss
Nail changes
Pallor on leg elevation
Red on dependence
Femoral bruit
Absence of one or more pedal pulses
Pain
Aggravated by leg elevation
Relieved by hanging the leg over the side of the bed
Common Ulcer Features
Located on toes, bony prominences, sides of feet, heel
Punched-out edges
Sloughy base or covered by eschar
Minimal exudate
Diabetic Ulcer
Similar to arterial ulcers
On pressure points
Painless
Palpation
Palpation of the ulcer
Palpation of the peripheral pulses
Posterior tibialis
Auscultation
Femoral artery for bruit
High positive predictive value for the detection of peripheral arterial disease
Measure ABPI using doppler
Less than 0.5 indicates critical ischemia is likely.
Less than 0.8 indicates occlusive arterial disease is likely.
0.8 to 1.3 indicates normal arterial flow is likely.
More than 1.3 indicates calcified and incompressible arteries.
Occlusive arterial disease cannot be excluded through ABPI alone. Arrange duplex ultrasound for further assessment.
Approach to the Examination
General appearance
Patient in pain or distress
Vitals
BP
Temperature
Respiratory Rate
Heart Rate
Oxygen Saturation
CRT (Capillary Refill Time)
Capillary refill time is the time it takes for blood to return to the area after pressure is applied and released. Normal capillary refill time should be less than 2 seconds.
Inspection
Describe Ulcer
Can ask if the ulcer is painful or not
Check for hairless, shiny skin
Palpation
CRT
Pulse
Start from distal and move to proximal
Dorsalis Pedis
Posterior tibialis
Popliteal
Femoral
Temperature
Cold clammy skin: PAD
Increased Temperature: Infection
Tenderness
Around ulcer
Movement
Ankle
Toes
Special tests
Measure ABPI
Berger’s Test
Elevate the leg until you see pallor
Ask the patient to sit on the edge of the bed with the legs hanging
There will be reactive hyperemia
Listen for bruit at
Aortic bruits (over upper abdomen in the midline)
Renal bruits (over the upper abdomen, approximately 2cm superior and lateral to the umbilicus on either side)
Iliac bruits (over the lower abdomen, either side of the midline)
Mention sensory NE of lower limb, especially protective sensation with 10g monofilament
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