Summary of Common Conditions Seen in OSCEs
| Type of ulcer | Signs on examination | Management |
| Arterial | See Chapters 14 and 15 | |
| Venous | ||
| Diabetic/neuropathic | Punched-out ulcer Amputations Charcot joints Scars from bypass surgery Insulin by bedside | Educate patient about the illness Lifestyle modification (diet, exercise and smoking) Medical (optimise monitoring and antihyperglycaemic regimens) Surgical (bypass surgery and amputation) |
| Pressure | Over pressure points (e.g. sacrum) Walking aids Signs associated with reduced mobility or peripheral neuropathy (altered sensory perception) | Educate patients and carers Encourage movement Frequent repositioning Special mattresses |
| Basal cell carcinoma (rodent ulcer) | On the face Rolled edge Pearly colour Overlying telangiectasias Necrotic centre Local spread (rarely associated with lymphadenopathy) | Medical (topical 5-fluorouracil) Surgery (resection) |
| Keratoacanthoma | Central necrosis and horn | Reassure as lesion should resolve spontaneously Surgery may leave a scar that is bigger than the lesion! |
Describing the Edges of an Ulcer
Hints and Tips for The Exam
The ulcer examination station may be encountered as a medical, surgical or dermatology case in finals. It is a short station, and in most cases candidates will have a brief viva or questions to answer.
Find Out About Function/Activities of Daily Living
Before attending to the ulcer, remember to inspect the patient and the surroundings. A walking aid or wheelchair will aid in your functional assessment and guide your management plan when you come to summarise. Looking at the patient from a holistic and functional perspective will help you stand out as a candidate for merit or distinction.
Be Clear and Systematic in Your Description of the Ulcer
The key to this station is in the description of the ulcer, and that is where most of your marks can be gained. The best way to master this is through practice!
When you embark on describing the ulcer, be sure to use the correct terminology, as in most cases it is likely be a spot diagnosis. Use the internet (when not on the wards) to look up and describe pictures of ulcers with a friend. Try not to skip parts of the description because they are ‘obvious’. The point is to engrain the method of describing an ulcer, rather than the description itself.
To begin with, comment on the site of the ulcer as a distance from a bony landmark or obvious point of reference (e.g. the medial malleolus). The distribution of an ulcer may give you a clue to its cause so it is important to mention this too.
You should then attempt to measure the size and shape of the ulcer. Look around as there may be a ruler to help with this (if not have a guess). The larger an ulcer, the longer it will take to heal and the more likely it will be to become infected. Mentioning this rather obvious fact in your summary will show the examiner you are thinking of both the current clinical picture and the prognosis.
The edge of an ulcer is one of its most defining characteristics (at least for finals!). It can allow you to show the examiner you are aware of the diagnosis and also the pathological processes underway within the ulcer (see the table above).
When palpating, use the back of your hand to assess the temperature of the surrounding skin.
After thanking the patient, remember to cover them appropriately and complete your examination, tailoring any further examination to your most likely diagnosis, such as an examination of the peripheral nerves if a neuropathic ulcer is found, or a peripheral vascular examination if arterial or venous insufficiency is the suspected aetiology.
Here is one example of describing an ulcer:
There is a single lesion 1 cm above the left nostril. It is round and approximately 1 cm by 1 cm in size, and 3 mm deep, with a rolled edge. The border is well circumscribed and shiny (opalescent) with several overlying telangiectasias. The base is necrotic. The surrounding skin is not erythematous. There is no associated lymphadenopathy.
This is the classical description of a basal cell carcinoma (rodent ulcer).
Figure 16.1 Chronic venous ulcers before appropriate dressing
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