Family medicine
Skin Ulcers
Skin ulcers are open lesions resulting from the loss of the epidermis and part or all of the dermis, often caused by vascular insufficiency, prolonged pressure, neuropathy, or infection, and characterized by impaired or delayed healing.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Venous ulcer | Gaiter area (medial malleolus), shallow, sloping edge, haemosiderin staining, leg oedema [1][2] | 「隻瘡係咪喺腳眼附近？隻腳有冇腫同埋皮膚變啡色？」 |
| Diabetic / neuropathic ulcer | Plantar foot, painless, punched-out, DM hx, loss of sensation [2][5] | 「你有冇糖尿？隻腳底有冇痺、冇感覺？」 | |
| Arterial ulcer | Toe tips / lateral malleolus, painful, punched-out, cold foot, absent pulses [2] | 「隻腳凍唔凍？行路會唔會腳痛要停低？」 | |
| Serious Not To Miss | Squamous cell carcinoma (SCC) / Marjolin ulcer | Non-healing ulcer > 3 wks, rolled/everted edge, arises in chronic scar/ulcer [1][2] | 「隻瘡有冇好耐都唔好？邊位有冇凸起嚟？」 |
| Basal cell carcinoma (BCC) | Rolled pearly edge, pigmented (common in HK), telangiectasia [4] | 「瘡邊有冇好似蠟咁嘅光滑凸起？有冇見到幼血管？」 | |
| Melanoma (ulcerated) | Asymmetry, border irregularity, colour variation, diameter > 6mm, evolution | 「隻瘡有冇唔對稱、顏色唔均勻、或者變咗形？」 | |
| Peripheral vascular disease (critical limb ischaemia) | Rest pain, gangrene, ABPI < 0.5 | 「瞓覺嗰陣隻腳痛唔痛？有冇腳趾變黑？」 | |
| Pitfalls | Pyoderma gangrenosum | Purple undermined edge, pathergy, associated IBD/haem malignancy [3] | 「隻瘡係咪喺整親嗰度開始？邊位係咪紫色同埋向內陷？」 |
| Vasculitic ulcer | Lower limbs and pressure sites, associated AI disease [6] | 「有冇其他關節痛或者出疹？」 | |
| Pressure ulcer | Bony prominences, immobility [2] | 「你有冇長期坐輪椅或者瞓床？」 | |
| Masquerades | Diabetes (undiagnosed) | Polyuria, polydipsia, weight loss, non-healing wound [5] | 「最近有冇飲多咗水、去多咗廁所、或者瘦咗？」 |
| Drug-related (steroid, immunosuppressant) | Chronic steroid use → poor healing, thin skin | 「有冇長期食類固醇或者其他壓免疫力嘅藥？」 | |
| Trying to Tell Me Something? | Cancer fear / Functional impairment / Work concerns | Hidden agenda | 「你最擔心嘅係咩？有冇影響返工或者日常生活？」 |
Skin Ulcers — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, build rapport | 「你好，我係X醫生，今日由我幫你睇症。可唔可以叫吓你個名同出生日期？」(Hello, I'm Dr X, I'll see you today. May I confirm your name and DOB?) | Interpersonal marks: greeting, ID confirmation |
| 0:30–1:30 | Open-ended exploration of CC + HPI | 「咩事嚟睇醫生呀？」→「隻瘡係幾時開始嘅？」→「你可唔可以形容吓隻瘡嘅情況？」(What brought you in? When did it start? Can you describe it?) | Elicit chief complaint; let patient talk first |
| 1:30–3:00 | Symptom analysis + red flags | 「痛唔痛？有冇流膿或者出血？」→「有冇大過或者細過？」→「有冇發燒或者周身唔舒服？」→「附近有冇腫起或者硬塊？」 | Scores HPI detail: site, size, progression, pain, discharge, systemic symptoms |
| 3:00–4:00 | Targeted PMHx / Drug Hx / Social Hx | 「你有冇糖尿病、血壓高、或者血管問題？」→「有冇食緊薄血丸或者其他藥？」→「你有冇食煙？行路行耐會唔會腳痛？」 | Uncovers DM, PVD, venous disease, smoking – essential for DDx |
| 4:00–4:45 | ICE + Hidden agenda | 「你自己覺得隻瘡係咩原因呢？」(Ideas) →「你最擔心嘅係咩？」(Concerns) →「你嚟今日係希望醫生幫你做啲咩？」(Expectations) | ICE marks; hidden agenda often = cancer fear or DM worry |
| 4:45–5:30 | Summarise + signpost | 「咁我總結吓，你隻腳嗰度有個瘡大概X個星期，愈嚟愈大，仲有啲痛，你擔心會唔會係嚴重嘅嘢，啱唔啱？」 | Summarising scores marks; check understanding |
| 5:30–6:00 | Closing + safety net | 「我哋會幫你檢查同安排跟進。如果隻瘡突然變大好多、出好多血、或者發燒，記住即刻返嚟睇。」→「仲有冇其他嘢想問？」 | Safety net + open close = high interpersonal marks |
Uncovering the hidden agenda: Ask 「今日點解特別嚟睇呢？係咪有啲嘢令你特別擔心？」— The patient may have come because a family member had skin cancer, or because the ulcer is affecting their work/daily function, not just the ulcer itself.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Where exactly is the ulcer? | 「隻瘡喺邊度？」 | Location is the single best discriminator [1]: medial malleolus = venous; tips of toes = arterial; plantar = neuropathic [2] | Venous / Arterial / Neuropathic ulcer |
| Onset & Duration | When did it start? | 「幾時開始有㗎？」 | Acute vs chronic; non-healing > 3 wks = red flag for malignancy | SCC (Marjolin ulcer) [2], BCC |
| Progression | Is it getting bigger? | 「有冇愈嚟愈大？」 | Rapidly enlarging = malignancy or pyoderma gangrenosum [3] | Malignancy, PG |
| Pain | Is it painful? | 「痛唔痛？」 | Arterial ulcers are painful; neuropathic ulcers are painless; venous ulcers ache when standing [2] | Arterial vs neuropathic vs venous |
| Discharge | Any pus, blood, or smell? | 「有冇流膿、出血或者臭味？」 | Infection superimposition; foul smell = anaerobic infection/necrosis | Infected ulcer, malignancy |
| Trauma / Pathergy | Any injury before it started? | 「之前隻腳有冇撞親或者整親？」 | Pathergy (ulcer at site of minor injury) = pyoderma gangrenosum [3] | PG |
| Edge / Colour changes | Have you noticed the edge colour? | 「瘡邊有冇變紫色或者捲起嚟？」 | Purple undermined edge = PG [3]; rolled pearly edge = BCC [4] | PG, BCC |
| Walking / Claudication | Pain in calves when walking? | 「行路行耐隻腳會唔會痛？要停低休息？」 | Intermittent claudication → PVD → arterial ulcer | Arterial ulcer, PVD |
| Leg swelling | Any leg swelling? | 「隻腳有冇腫？」 | Chronic venous insufficiency → venous ulcer | Venous ulcer, DVT history |
| Varicose veins | Do you have varicose veins? | 「你隻腳有冇靜脈曲張（青筋浮）？」 | Associated with venous ulcers [2] | Venous ulcer |
| Numbness / Sensation | Any numbness or tingling in feet? | 「隻腳有冇痺或者冇感覺？」 | Peripheral neuropathy → neuropathic ulcer (DM) [5] | Diabetic neuropathic ulcer |
| DM history | Do you have diabetes? | 「你有冇糖尿病？」 | DM = #1 cause of neuropathic ulcer + impaired wound healing [5] | Diabetic foot ulcer |
| PMHx – IBD | Any bowel problems? | 「你個肚有冇長期問題，例如肚痾或者肚痛？」 | PG associated with IBD [3] | Pyoderma gangrenosum |
| PMHx – Rheumatological | Any joint pain or autoimmune disease? | 「有冇關節痛或者免疫系統嘅病？」 | Vasculitic ulcers in RA, SLE, scleroderma [6]; digital tip ulcers in scleroderma | Vasculitic ulcer, scleroderma |
| Smoking | Do you smoke? | 「你有冇食煙？」 | Major RF for PVD → arterial ulcer; also SCC risk | Arterial ulcer, SCC |
| Drug Hx | What medications are you on? | 「而家食緊咩藥？」 | Steroids, immunosuppressants → impaired healing; anticoagulants → bleeding | Drug-related poor healing |
| Occupation | What do you do for work? | 「你做咩工作㗎？」 | Prolonged standing → venous; outdoor work → sun exposure → SCC; immobility → pressure ulcer | Venous ulcer, SCC |
| Functional impact | Does it affect your daily life? | 「隻瘡有冇影響你日常生活？」 | Psychosocial impact for biopsychosocial model | Social/functional problem |
| Family Hx | Any family history of DM or skin cancer? | 「屋企人有冇糖尿或者皮膚癌？」 | DM or skin cancer FHx | DM, melanoma/SCC |
| Sun exposure | Much sun exposure over the years? | 「你平時曬唔曬太陽？以前有冇做好多戶外嘢？」 | Chronic UV = RF for SCC and BCC [1] | Skin cancer |
| Immobility | Are you able to walk around? Bedridden? | 「你行唔行到？有冇長期瞓喺床？」 | Pressure ulcer at bony prominences [2] | Pressure ulcer |
Case Report Form Answer Builder
Format: "[Duration] [site] skin ulcer"
- Site, size, shape, edge, base, depth
- Onset and duration, precipitating event (trauma?)
- Progression (enlarging? stable?)
- Pain characteristics (constant/on walking/painless)
- Discharge (serous, purulent, blood)
- Associated symptoms: leg swelling, claudication, numbness, fever, weight loss
- Previous ulcers, treatments tried
- Relevant PMHx: DM, PVD, varicose veins, DVT, IBD, autoimmune disease
- Smoking, occupation, mobility status
| Likely RFC | How to Phrase |
|---|---|
| Non-healing ulcer causing concern about malignancy | "Patient presents for assessment of a non-healing leg ulcer of X weeks duration, concerned about possible serious cause" |
| Pain/functional impairment from ulcer | "Painful leg ulcer affecting mobility and daily function" |
| Worsening size despite home care | "Progressively enlarging skin ulcer not responding to self-care" |
Tip: The RFC is why they came today — often triggered by a new change (bigger, more painful, someone commented on it, or fear of cancer).
| Component | Likely Content | Exact Wording for CRF |
|---|---|---|
| Ideas | "Patient thinks the ulcer may be from poor circulation / diabetes / infection" | "Patient attributes ulcer to poor blood circulation in the legs" |
| Concerns | "Worried it might be skin cancer / will need amputation / won't heal" | "Patient is worried the non-healing ulcer could be cancerous" |
| Expectations | "Wants investigation / referral / wound care / reassurance" | "Patient expects further investigation and specialist referral if needed" |
Choose based on key stem features:
| Stem Clue | Most Likely Dx |
|---|---|
| Elderly + medial malleolus + shallow + leg oedema + haemosiderin | Venous ulcer |
| DM patient + plantar foot + painless + loss of sensation | Diabetic neuropathic ulcer |
| Smoker + toe tip + painful + cold foot + absent pulses | Arterial ulcer |
| Non-healing > 3 wks + raised/rolled edge + elderly + sun-exposed | SCC or BCC |
Minimum evidence: Location + edge characteristics + associated condition + supporting physical sign
| DDx | One Key Discriminator |
|---|---|
| Arterial ulcer | Painful, punched-out, at pressure points of foot, absent pedal pulses |
| Diabetic neuropathic ulcer | Painless, plantar aspect, loss of monofilament sensation, DM history |
| SCC (Marjolin ulcer) | Non-healing > 3 wks in chronic ulcer/scar, everted edge, needs biopsy |
(Swap in PG, BCC, pressure ulcer, or vasculitic ulcer depending on stem)
| Domain | Problem |
|---|---|
| Biological | Underlying poorly controlled diabetes / peripheral vascular disease contributing to non-healing ulcer |
| Psychological | Anxiety about possible malignancy / fear of amputation |
| Social/Functional | Impaired mobility affecting work capacity and ADLs; social isolation due to wound odour/appearance |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Venous ulcer | Haemosiderin staining and lipodermatosclerosis of gaiter area | Inspect lower leg around medial malleolus for brownish discolouration and skin thickening | Chronic venous hypertension causes RBC extravasation → haemosiderin deposition; pathognomonic for chronic venous insufficiency [1][2] |
| Arterial ulcer | Absent dorsalis pedis / posterior tibial pulse | Palpate dorsum of foot and behind medial malleolus | Absent pulses indicate PVD → arterial insufficiency causing ulceration [2] |
| Diabetic neuropathic ulcer | Loss of sensation to 10g monofilament | Apply monofilament to plantar surface of foot at standard points | Loss of protective sensation confirms neuropathy → neuropathic ulcer mechanism [5] |
| SCC / BCC | Rolled / everted edge of ulcer | Inspect and palpate ulcer edge | Rolled pearly edge = BCC; everted hard edge = SCC [1][4]; tissue biopsy is definitive |
| Pyoderma gangrenosum | Purple undermined edge [3] | Inspect ulcer edge — violaceous, overhanging | Characteristic; diagnosis of exclusion; pathergy test positive [3] |
| Vasculitic ulcer | Palpable purpura on lower limbs | Inspect both lower limbs for non-blanching purpuric lesions [6] | Small-vessel vasculitis → purpura + ulceration |
| Pressure ulcer | Located over bony prominence (sacrum, heel) in immobile patient | Inspect sacrum, heels, greater trochanters | Distribution matches pressure points in bedridden/immobile patients [2] |
Top Traps That Lose Marks
- Forgetting to ask about DM — undiagnosed diabetes is the classic masquerade for non-healing ulcers; always ask about polyuria/polydipsia/weight loss.
- Not differentiating ulcer types by location and edge — this is the #1 discriminator on the exam. Gaiter area = venous; toe tips = arterial; plantar = neuropathic; rolled edge = BCC; everted edge = SCC; purple undermined edge = PG [1][2][3][4].
- Missing malignancy in chronic ulcers — any ulcer > 3 weeks non-healing needs consideration of SCC (Marjolin ulcer) [2] or BCC; 4-quadrant biopsy recommended for non-healing venous ulcers [2].
- Confusing PG with infection — PG is commonly misdiagnosed as wound infection; surgical debridement worsens PG (pathergy) [3].
- Not asking ICE — always ask explicitly; the hidden concern is often cancer fear.
- Forgetting to check pulses — absent pedal pulses = arterial ulcer; this is the easiest physical sign to elicit and write.
- ABPI pitfall in DM — ABPI is unreliable in diabetic patients due to vessel calcification; use TcPO2 instead [2].
Must-Not-Miss Red Flags → Urgent Referral:
- Non-healing ulcer > 3 weeks → biopsy to exclude malignancy
- Critical limb ischaemia (rest pain, gangrene, ABPI < 0.5) → urgent vascular surgery referral
- Rapidly enlarging ulcer with purple edge → consider PG, do NOT debride
- Signs of systemic sepsis (fever, spreading cellulitis) → same-day hospital referral
Safety-Net Line for Closing: 「如果隻瘡突然變大好多、出好多血、發燒、或者隻腳變黑，記住即刻去急症室。我哋會安排跟進同埋可能要做組織化驗。」
High Yield Summary
What to ASK: Location, edge, pain, sensation, pulses, DM/PVD/varicose veins/IBD history, smoking, duration, progression, ICE.
What to WRITE:
- CC: "[Duration] [location] non-healing skin ulcer"
- Diagnosis: Match location + edge + associated condition → venous / arterial / neuropathic / malignant
- Physical sign: Haemosiderin staining (venous), absent pulses (arterial), monofilament loss (neuropathic), rolled edge (BCC/SCC), purple undermined edge (PG)
- Biopsychosocial: DM/PVD (bio), cancer fear (psych), impaired mobility/work (social)
What NOT to MISS:
- Undiagnosed DM (masquerade)
- Malignancy in chronic non-healing ulcer (Marjolin)
- PG misdiagnosed as infection — do NOT debride
- Always check and document pedal pulses
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 201. Skin ulcers skin and subcutaneous lesions; skin cancer.pdf [2] Senior notes: Maksim Surgery Notes.pdf (Section 7.4 Lower extremity ulcers; Section 8.5 Diabetic foot) [3] Lecture slides: CFB (MED09) Dermatology (II).pdf (Pyoderma gangrenosum slides) [4] Senior notes: Block A - Dermatology PBL 2.pdf (Case 24 - BCC) [5] Senior notes: Ryan Ho Endocrine.pdf (Diabetic Foot, Diabetic peripheral neuropathy) [6] Lecture slides: GC 053. Fingers turn white and blue.pdf (Vasculitic ulcers)
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