Leg Ulcers
Leg ulcers are chronic open wounds on the lower extremities, most commonly caused by venous insufficiency, arterial disease, or neuropathy, that fail to heal within the expected timeframe.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Venous ulcer | Gaiter area, shallow, sloping edge, hemosiderin staining, signs of CVI [1][2][5] | 「隻瘡喺腳眼對上嗰度？附近皮膚有冇啡色？」 |
| Arterial ulcer | Pressure areas (toes, heel, lateral malleolus), deep, punched-out, painful, absent pulses [1][3] | 「隻腳凍唔凍？腳趾有冇變色？」 | |
| Neuropathic (diabetic) ulcer | Plantar foot, painless, DM history, loss of sensation, callus [1][6] | 「隻腳底有冇硬皮？踩嘢有冇感覺？」 | |
| Serious Not To Miss | Marjolin's ulcer (SCC) | Long-standing ulcer now enlarging, everted edge, malodorous, inguinal LN [2][5] | 「隻瘡最近有冇突然變大或者痛多咗？」 |
| Critical limb ischaemia | Rest pain, gangrene, tissue loss, ABPI < 0.4 [4] | 「瞓覺隻腳痛到瞓唔到？腳趾有冇變黑？」 | |
| Vasculitis ulcer | Lower limbs + pressure sites, palpable purpura, systemic features [7] | 「隻腳有冇出紅色粒粒？有冇關節痛？」 | |
| Pitfalls | Pyoderma gangrenosum | Rapidly enlarging, undermined violaceous edge, a/w IBD [3] | 「隻瘡有冇好快變大？你有冇腸道問題？」 |
| Pressure ulcer | Bony prominence (heel, sacrum), immobility [1] | 「你有冇長期臥床或者坐輪椅？」 | |
| Masquerades | Diabetes (undiagnosed) | Non-healing ulcer + polyuria, polydipsia, weight loss [6] | 「你最近有冇飲多咗水、去多咗廁所、瘦咗？」 |
| Drugs (hydroxyurea, steroids) | Medication-related ulcer, leg ulcer in myeloproliferative disease [8] | 「你有冇食緊任何特別嘅藥？」 | |
| Trying to Tell Me Something? | Fear of amputation / cancer | Anxiety, delayed presentation, prior family experience | 「你最擔心隻瘡會變成咩？」 |
| Social isolation / carer burden | Elderly, lives alone, cannot manage wound care | 「屋企有冇人幫你照顧隻瘡？」 |
Leg Ulcers — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, ID, set agenda | 「你好，我係X醫生，今日想同你傾下你隻腳嘅問題，大概傾六分鐘，可以嗎？」(Hi, I'm Dr X, let's talk about your leg issue for ~6 min, OK?) | Builds rapport; scores interpersonal marks for greeting + permission + signposting |
| 0:30–2:00 | HPI: ulcer characteristics — site, onset, duration, pain, discharge, progression, precipitant (trauma), previous ulcers | 「隻瘡喺邊度㗎？幾時開始？有冇痛？有冇嘢流出嚟？之前有冇試過生過？」 | Core symptom analysis; discriminates venous vs arterial vs neuropathic |
| 2:00–3:00 | Red flags & systems review — claudication, rest pain, numbness, fever, weight loss, change in ulcer edge, lymph node swelling; DM/HT/smoking/PVD hx | 「行路行得耐隻腳會唔會痛？有冇覺得隻腳凍或者痺？有冇發燒？有冇瘦咗？你有冇糖尿、高血壓？食唔食煙？」 | Catches arterial disease, malignant transformation, diabetic foot; marks for red-flag screening |
| 3:00–3:45 | PMH, Drug Hx, Allergy, FHx, Social Hx — DM, varicose veins, DVT, occupation (prolonged standing), mobility, ADL impact | 「你有冇其他長期病？食緊咩藥？有冇藥物敏感？屋企人有冇糖尿或者血管問題？你做咩工作㗎？」 | Completeness of case report; identifies biopsychosocial issues |
| 3:45–4:30 | ICE — uncover hidden agenda | 「你自己覺得隻瘡點解唔好？最擔心咩嘢？今日嚟最想我幫你做啲咩？」(What do you think causes it? What worries you most? What were you hoping for today?) | Directly scores ICE marks; "Why today?" reveals hidden agenda (e.g. fear of cancer, amputation, wound worsening) |
| 4:30–5:15 | Summarise & check understanding | 「等我總結下：你隻腳嘅瘡已經XX耐，喺XX位置，你最擔心係……我講得啱唔啱？」 | Scores summarising + checking understanding |
| 5:15–6:00 | Explain plan, safety-net, close | 「我建議幫你檢查下隻腳嘅血液循環同埋驗下血糖，如果隻瘡突然變大、好痛、或者發燒就要即刻返嚟。你有冇嘢想問？」 | Safety-net scores marks; polite close |
Uncovering the hidden agenda: The patient may present with an ulcer but really came because they fear cancer (Marjolin's ulcer), amputation, or are struggling with wound care at home. Always ask: 「今日點解決定嚟睇醫生？」(Why did you decide to come today?)
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Site | Where exactly is the ulcer? | 「隻瘡喺邊度？腳眼附近定腳趾？」 | Gaiter area (medial malleolus) → venous; pressure areas/toes → arterial; sole → neuropathic [1][2] | Venous / Arterial / Neuropathic |
| Onset & Duration | When did it start? Any trauma? | 「幾時開始？有冇撞傷過？」 | Chronic non-healing > 3 months → consider malignancy | Marjolin's ulcer (SCC) |
| Pain | Is it painful? When is it worst? | 「痛唔痛？夜晚定企嘅時候痛啲？」 | Arterial: painful, worse at night/elevation; Venous: aching, worse standing; Neuropathic: painless [1][3] | Arterial (rest pain) vs Venous vs Neuropathic |
| Discharge | Any discharge or smell? | 「有冇嘢流出嚟？臭唔臭？」 | Purulent → infection; malodorous + enlarging → malignant change | Infected ulcer; Marjolin's |
| Claudication | Calf pain on walking? How far? | 「行路行幾遠隻腳會痛？」 | Claudication → PAD | Arterial ulcer |
| Rest pain | Pain in toes/foot at rest or in bed? | 「瞓覺嗰時腳趾會唔會好痛？要唔要放低隻腳先舒服啲？」 | Rest pain relieved by hanging foot down → critical limb ischaemia [4] | Urgent vascular referral |
| Numbness/tingling | Any numbness or pins-and-needles? | 「隻腳有冇痺或者針拮嘅感覺？」 | Neuropathy → diabetic foot | Neuropathic ulcer |
| DM History | Do you have diabetes? How is sugar control? | 「你有冇糖尿病？血糖控制得好唔好？」 | DM is a masquerade; drives neuropathic + arterial ulcers | Diabetic foot ulcer |
| Varicose veins/DVT | History of varicose veins or DVT? | 「你隻腳有冇靜脈曲張？之前有冇試過腳腫或者深層靜脈血栓？」 | Venous insufficiency → venous ulcer | Venous ulcer |
| Smoking | Do you smoke? How much? | 「你食唔食煙？食幾多？」 | Smoking: strongest RF for PAD [4] | Arterial ulcer |
| Medications | What medications are you taking? | 「你而家食緊咩藥？」 | Anticoagulants, steroids, hydroxyurea can affect healing/cause ulcers | Drug-related ulcer |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Completeness | — |
| FHx | Family history of DM, vascular disease? | 「屋企人有冇糖尿或者心血管病？」 | Risk factor assessment | — |
| Occupation & ADL | What is your job? Does the ulcer affect daily life? | 「你做咩工㗎？隻瘡影唔影響你日常生活？」 | Prolonged standing → venous; functional impact for biopsychosocial | Social/functional problem |
| Psychological | Are you worried/stressed about the ulcer? | 「隻瘡有冇令你擔心或者瞓唔到？」 | Anxiety, low mood from chronic wound | Psychological problem |
| Wound care | Who helps with dressing? Can you manage? | 「邊個幫你換紗布？你自己搞唔搞得掂？」 | Carer burden, social support | Social problem |
| Skin changes | Any change in ulcer edge (raised/hard)? | 「隻瘡嘅邊有冇變硬或者凸起嚟？」 | Raised/everted edge + enlarging → Marjolin's ulcer (SCC from chronic venous ulcer) [2][5] | Malignant transformation |
Case Report Form Answer Builder
- CC: Non-healing leg ulcer × [duration], [site]
- HPI must capture: Ulcer site (gaiter vs pressure area vs sole), onset (spontaneous vs post-trauma), duration, pain characteristics (↑standing vs ↑night vs painless), discharge, progression, associated symptoms (claudication, rest pain, numbness), prior episodes, current wound care
- Relevant PMH: DM, varicose veins, DVT, PVD, smoking
- Examples: "Ulcer not healing despite home wound care" / "Concerned about worsening wound" / "Pain from leg ulcer affecting sleep"
- Phrase as the single most important reason the patient came today
| Component | Likely Example | Exact Wording for Form |
|---|---|---|
| Ideas | "I think the wound is infected / not getting enough blood" | Patient thinks the ulcer is due to poor circulation / infection |
| Concerns | "I'm worried it might turn into cancer / I might lose my leg" | Patient is worried about the possibility of amputation or malignant change |
| Expectations | "I want the doctor to refer me to a specialist / give me antibiotics" | Patient expects specialist referral / effective wound treatment |
- Venous ulcer — if: gaiter area, shallow, sloping edge, surrounding CVI signs (hemosiderin staining, eczema, lipodermatosclerosis), intact peripheral pulses
- Arterial ulcer — if: toe/heel/lateral malleolus, deep, punched-out, cold limb, absent pulses, smoker
- Neuropathic ulcer — if: sole of foot, painless, DM, loss of sensation, callus
- Minimum evidence: ulcer location + surrounding skin findings + relevant history
| DDx | Key Discriminator |
|---|---|
| Arterial ulcer | Pressure area location, deep/punched-out, absent pulses, rest pain, claudication |
| Neuropathic (diabetic) ulcer | Plantar, painless, peripheral neuropathy, known/suspected DM |
| Malignant ulcer (Marjolin's / SCC / BCC) | Raised/everted edge, enlarging chronic ulcer, lymphadenopathy |
| Domain | Problem |
|---|---|
| Biological | Chronic venous insufficiency causing recurrent ulceration; or uncontrolled DM impairing wound healing |
| Psychological | Anxiety about amputation or cancer; low mood from chronic pain and restricted mobility |
| Social | Impaired mobility affecting work (especially if standing job); difficulty with wound care if lives alone; carer burden on family |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Venous ulcer | Hemosiderin pigmentation at gaiter area [2][5] | Inspect medial lower leg (distal 1/3) for brownish discolouration | Indicates chronic venous hypertension with RBC extravasation — hallmark of CVI |
| Arterial ulcer | Absent dorsalis pedis / posterior tibial pulse | Palpate dorsum of foot (lateral to EHL tendon) and behind medial malleolus | Absent pulse confirms arterial insufficiency as cause |
| Neuropathic ulcer | Loss of monofilament sensation on sole | Apply 10g monofilament to plantar surface of foot | Loss of protective sensation confirms peripheral neuropathy |
| Malignant (Marjolin's) | Everted/raised ulcer edge with inguinal lymphadenopathy | Inspect ulcer edge; palpate inguinal lymph nodes | Raised or everted edge + LN → malignant transformation of chronic ulcer (SCC) [2][5] |
| Pressure ulcer | Ulcer at bony prominence (heel/sacrum) in immobile patient | Inspect heel, sacrum; assess mobility | Location at pressure point + immobility confirms pressure aetiology |
Top Traps That Lose Marks
- Forgetting to ask about diabetes — DM is a masquerade that drives both neuropathic and arterial ulcers; a non-healing foot ulcer may be the first presentation of undiagnosed DM [6]
- Not differentiating venous vs arterial — Site is the fastest discriminator: gaiter area = venous; toes/heel = arterial; sole = neuropathic [1][2]
- Missing Marjolin's ulcer — Any long-standing venous ulcer that suddenly enlarges, becomes painful, has raised/everted edges → biopsy to rule out SCC (2% of chronic venous ulcers undergo malignant transformation) [2][5]
- Forgetting ABPI — ABPI must be checked before applying compression bandaging; ABPI < 0.8 → do NOT compress (will worsen arterial ischaemia) [2]
- Not asking ICE — The hidden agenda is often fear of amputation or cancer, not just wound treatment
- Writing "wound infection" as the main diagnosis — Infection is a complication, not the underlying cause of the ulcer
Must-Not-Miss Red Flags → Urgent Referral:
- Rest pain / gangrene / ABPI < 0.5 → urgent vascular surgery referral (critical limb ischaemia)
- Rapidly enlarging ulcer with raised edge → urgent biopsy (Marjolin's / skin cancer)
- Spreading cellulitis / systemic sepsis from infected ulcer → urgent admission
Safety-Net Closing Line: 「如果隻瘡突然變大、好痛、流膿、或者你發燒，就要即刻返嚟睇。」(If the ulcer suddenly enlarges, becomes very painful, has pus, or you develop fever, come back immediately.)
Key GC Lecture Slide Points (High-Yield):
- DDx of leg ulcers: venous, arterial, pressure, pyoderma gangrenosum, dysglobulinaemias, sickle cell/thalassaemia, BCC, SCC, panniculitis, vasculitis [3]
- Arterial leg ulcers: painful, worse at night; risk factors include smoking, diabetes, HT; other ischaemia symptoms common (claudication, coldness, numbness) [3]
- Vasculitic ulcers commonly found in lower limbs and pressure sites [7]
- Foot ulcers: common causes are arterial, venous, neuropathic, neoplastic [9]
- Marjolin's ulcer: SCC (rarely BCC) arising from long-standing venous ulcer; biopsy if suspicious [2][5]
High Yield Summary
What to ASK: Site of ulcer (gaiter vs toes vs sole), pain pattern (standing vs night vs painless), claudication, rest pain, numbness, DM/smoking/varicose veins/DVT history, wound care, ICE (fear of amputation/cancer)
What to WRITE: CC with site + duration; RFC = why today; ICE including fear of cancer/amputation; Most likely Dx based on site + skin signs + pulses; DDx = arterial, neuropathic, malignant; Biopsychosocial = underlying vascular/metabolic disease + anxiety + functional/social impact; Physical sign = hemosiderin staining (venous) or absent pulses (arterial) or monofilament loss (neuropathic)
What NOT to MISS: Undiagnosed DM, critical limb ischaemia (rest pain/gangrene → urgent referral), Marjolin's ulcer (enlarging chronic ulcer with raised edge → biopsy), ABPI before compression
Active Recall - Family Medicine Clinical Test
[1] Maksim Surgery Notes, p.176 (Lower extremity ulcers table) [2] Ryan Ho Cardiology, p.241 (Venous ulcers and Marjolin's ulcer) [3] GC 085. Skin rash_Doctor I have a rash.pdf, p.26 and p.34 (DDx of leg ulcers; arterial leg ulcers) [4] Ryan Ho Cardiology, p.206–207 (Claudication, rest pain, PAD risk factors) [5] Ryan Ho Cardiology, p.230 and p.233–236 (CVI examination, CEAP classification, venous skin changes) [6] Ryan Ho Endocrine, p.98 (Diabetic foot and peripheral neuropathy) [7] GC 053. Fingers turn white and blue.pdf, p.86 (Vasculitic ulcers) [8] Ryan Ho Haematology, p.9 (Leg ulcers in haematological disease, hydroxyurea) [9] GC 234. Common Foot and Ankle Conditions.pdf, p.5 and p.97 (Foot ulcers — arterial, venous, neuropathic, neoplastic)
Leg Pain
Leg pain is a symptom arising from musculoskeletal, vascular, neurological, or other causes, ranging from benign muscle cramps to limb-threatening conditions such as peripheral arterial disease or deep vein thrombosis.
LLQ Pain
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