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Probability diagnosis

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Venous insufficiency 52%

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Arterial insufficiency 13%

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Mixed arterial and venous disease 15%

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Pressure sore

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Trauma with chronic infection

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Systemic disease esp. diabetes

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Secondary to peripheral oedema

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Serious disorders not to be missed

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Vascular:

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  • Skin infarction (thrombotic ulcer)

  • Vasculitis-RA, SLE, scleroderma

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Infection:

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  • Post herpetic ulcer

  • Tuberculosis

  • HIV/AIDS

  • Tropical ulcer

  • Post cellulitis

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Cancer:

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  • Primary-SCC, melanoma, malignant change in ulcer

  • Secondary-ulcerating metastases

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Other:

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  • Haematological e.g. sickle cell

  • Chronic scarring—sun damaged skin

  • Pyoderma gangrenosum

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Pitfalls (often missed)

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Insect and spider bites

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Factitious (neurotic excoriations)

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Rarities:

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  • Tropical infections e.g. leprosy

  • Myobacterium ulcerans

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Masquerades checklist

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Diabetes: neurotrophic

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Drugs—systemic reaction

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Anaemias: hereditary anaemias

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Is the patient trying to tell me something?

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Consider: Factitious ?dermatitis artefacta ?neurotic excoriation

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Key history

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Look for a cause: venous—previous DVT, varicose veins; peripheral arterial disease. Seek history of systemic disease such as diabetes, inflammatory bowel disease, connective tissue esp. RA. Check for a history of intermittent claudication or ischaemic rest pain; chronic ulcers including sun damage; tropical residence. Include a drug history, esp. beta blockers, corticosteroids, ergotamine, nifedipine.

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Key examination

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  • General features: appearance of patient, vital signs esp. temperature

  • Full cardiovascular assessment esp. lower limb

  • Assess characteristics of the ulcer, esp. shape, edge, floor, discharge, surrounding skin, regional lymph nodes

  • Neurotip or similar for skin sensation

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Key investigations

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First line:

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  • FBE

  • ESR/CRP

  • blood sugar

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Consider:

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  • wound swabs (if evidence infection)

  • duplex ultrasound

  • ankle brachial index

  • biopsy

  • KFTs

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Diagnostic tips

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Be cautious of almenotic melanoma if undertaking biopsy. If the ulcer and site is painful, consider arterial insufficiency.

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