Renal Exam

Lower Limb Ulceration



  • Ulcers, or non-healing open wounds, may occur in the lower limb in the context of arterial disease, venous disease or peripheral neuropathy.

Arterial Ulcers

  • The presence of white, painful ulcers suggests a partial or complete arterial occlusion.
    • Look For

    • Deep, painful white ulcers with blanched surrounding tissue, affecting the toes, heels and bony prominences. These ulcers may become black with necrosis.
    • Causes of Arterial Ulcers

    • Atherosclerosis
    • Diabetes
    • Thromboangiitis
    • Vasculitis

Venous Ulcers

  • Red, painless ulcers are suggestive of venous insufficiency.
    • Look For

    • Superficial painless red ulcers with moderate exudate, most commonly over the gaiter area (from mid-calf to 1cm below the malleoli)
    • Causes of Venous Ulcers

    • Venous hypertension due to incompetent valves
    • Venous outflow obstruction
    • Calf-muscle pump failure - obesity, immobility

Neuropathic Ulcers

  • Neuropathic ulcers occur due any cause of sensory loss to the foot, resulting in greater likelihood of damage and unawareness of injury.
    • Look For

    • Deep ulcers surrounded by callus, most commonly on weight bearing areas such as the sole of the foot. Associated with diminished sensation of the foot and normal pedal pulses.
Last updated on November 28th, 2019
Want more info like this?
  • Your electronic clinical medicine handbook
  • Guides to help pass your exams
  • Tools every medical student needs
  • Quick diagrams to have the answers, fast
  • Quizzes to test your knowledge


 Asif A, Leon C, Orozco-Vargas LC, et al. Accuracy of Physical Examination in the Detection of Arteriovenous Fistula Stenosis. Clinical Journal of the American Society of Nephrology. 2007;2:1191-1194. Aydin M, Harvey-Woodworth CN. Halitosis: a new definition and classification. British dental journal. 2014;217:E1-E1. Azad K, Hajirnis K, Sawant S, Sabnis V. Kyrle's disease. Indian dermatology online journal. 2013;4:378. Ballas M. Bleeding and bruising: a diagnostic work-up. Am Fam Physician. 2008;77:1117. Barkun AN, Camus M, Green L, Meagher T, Coupal L, De Stempel J, Grover SA. The Bedside Assessment of Splenic Enlargement. The American Journal of Medicine. 1991 Nov; 91: 512-518. Barron M. Importance of Hepatomegaly and Splenomegaly in Differential Diagnosis. Arch Intern Med (Chic). 1932; 50(2): 240-256. Beathard GA. Physical examination of the dialysis vascular access. Semin Dial. 1998; 11:231. Bernhard JD, Yosipovitch G. Chronic pruritis. The New England Journal of Medicine. 2013;368:1625. Blackard EH. Pulse Characteristics of Abdominal Aortic Aneurysm and of the Femoral Artery Distal to It. Circulation. 1958 Dec; 18: 1135-1138. Bohadana A. Fundamentals of Lung Auscultation. The New England Journal of Medicine. 2014 May; 370(21): 2053. Cabot RC. The Causes of Ascites: A Study of Five Thousand Cases. The American Journal of the Medical Sciences. 1912 Jan; 143(1): 1-14. Callender VD, St Surin-Lord S, Davis EC, Maclin M. Postinflammatory hyperpigmentation. American Journal of Clinical Dermatology. 2011;12:87. Carmant L. Assessing ketosis: Approaches and pitfalls. Epilepsia. 2008;49:20-22. Cartwright MM, Hajja W, Al-Khatib S, et al. Toxigenic and metabolic causes of ketosis and ketoacidotic syndromes. Critical care clinics. 2012;28:601-631. Cestari TF, Dantas LP, Boza JC. Acquired hyperpigmentations. Anais Brasileiros de Dermatologia. 2014;89:11-25. Challenger F, Walshe JM. Foetor hepaticus. Lancet. 1955;268:1239.2007;13:71-76. Choi P, Nemati E, Banerjee A, Preston E, Levy J, Brown E. Peritoneal dialysis catheter removal for acute peritonitis: a retrospective analysis of factors associated with catheter removal and prolonged postoperative hospitalization. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2004;43:103.
Choong S, Emberton M. Acute urinary retention. BJU International. 2000;85:186-201.
 Chua Chiaco JM, Parikh NI, Fergusson DJ. The Jugular Venous Pressure Revisited. Cleveland Clinic Journal of Medicine. 2013 Oct; 80(10): 638-644. Crighton Bramwell, The Arterial Pulse in Heath and Disease, The Lancet, Volume 230, Issue 5944, 31 July 1937 Davies S, Spanel P, Smith D. Quantitative analysis of ammonia on the breath of patients in end-stage renal failure. Kidney International. 1997;52:223-228. Dorrington KL. Skin Turgor: Do We Understand the Clinical Sign? Lancet. 1981 Jan; 317(8214): 264-266. Douglas VC, Josephson SA. Delirium. Continuum: Lifelong Learning in Neurology. 2010 April; 16(2): 120-134. Eipper DF, Gifford RW, Stewart BH, Alfidi RJ, McCormack LJ, Vidt DG. Abdominal Bruits in Renovascular Hypertension. The American Journal of Cardiology. 1976 Jan; 37: 48-52. Fokou M, Teyang A, Ashuntantang G, et al. Complications of arteriovenous fistula for hemodialysis: an 8-year study. Annals of vascular surgery. 2012;26:680. Fostini AC, Girolomoni G, Tessari G. Prurigo nodularis: an update on etiopathogenesis and therapy. Journal of Dermatological Treatment. 2013;24:458-462. Franks AG. Skin Manifestations of Internal Disease. Medical Clinics of North America. 2009;93:1265-1282. Gokdogan O, Catli T, Ileri F. Halitosis in otorhinolaryngology practice. Iranian journal of otorhinolaryngology. 2015;27:145-153. Guevara M, Sanchez-Fueyo A, Rodes J. Ascites. Medicine. 2002; 30(12): 73-74. Gupta K, Dhawan A, Abel C, Talley N, Attia J. A Re-evaluation of the scratch test for locating the liver edge. BMC Gastroenterology. 2013; 13: 35. Hall GW, Hann IM. Investigating Splenomegaly. Current Paediatrics. 1998; 8: 220-224. Henker R, Kramer D, Rogers S. Fever. AACN Clin Issues. 1997;8:351-367. Hillman K. Respiratory rate: the neglected vital sign. Medical journal of Australia. 2008; 188(11): 657. Hillman, K (2008). Respiratory rate: the neglected vital sign. Medical journal of Australia (0025-729X), 188 (11), p. 657. Howard RS. Coma and Stupor. Handbook of Clinical Neurology. 2008; 90: 57-78. Howard SR, Siegfried EC. A case of leukonychia. The Journal of pediatrics. 2013;163:914-915. Huang C. ED presentations of acute renal infarction. Am J Emerg Med. 2007;25:164-169. Jacoby E, Barzilai A, Laufer J, et al. Neonatal Hyperpigmentation: Diagnosis of Familial Glucocorticoid Deficiency with a Novel Mutation in the Melanocortin?2 Receptor Gene. Pediatric Dermatology. 2014;31:e13-e17. Kavouras SA. Assessing Hydration Status. Current Opinion in Clinical Nutrition & Metabolic Care. 2002 Sept; 5(5): 519-524. Kennedy C, McCarthy C, Alken S, et al. Pleuroperitoneal leak complicating peritoneal dialysis: a case series. International journal of nephrology. 2011;2011:526753-4. Kingery FA. Xanthelasma: Curbstone Recognition of Dyslipidosis. JAMA. 1965; 193(6): 439. Kumar V, Aggarwal S, Sharma A, Sharma V. Nailing the diagnosis: koilonychia. The Permanente journal. 2012;16:65-65. Kuypers DR. Skin problems in chronic kidney disease. Nature Clinical Practice Nephrology. 2009;5:157-170.
Leung AK, Chan KW. Evaluating the child with purpura. American family physician. 2001;64:419.
 Lewin J, Maconochie I. Capillary Refill Time in Adults. Emerg Med J. 2008; 25: 325-326. Ludbrook J, Clarke AM, McKenzie JK. Significance of Absent Ankle Pulse. British Medical Journal. 1962; 1(5294): 1724-1725. Mak V, Melchor R, Spiro S. Easy bruising as a side-effect of inhaled corticosteroids. European Respiratory Journal. 1992;5:1068. MArx HT, Yu PN. Clinical examination of the arterial pulse. Progress in Cardiovascular Diseases. 1967 Nov; 10(3): 207-235. McKnight JT, Adcock BB. Paresthesias: a practical diagnostic approach. Am Fam Physician. 1997;56:2253. Meidl EJ, Ende J. Evaluation of liver size by physical examination. Journal of General Internal Medicine. 1993 Nov; 8(11): 635-637. Minford AMB, Richards EM. Excluding medical and haematological conditions as a cause of bruising in suspected non-accidental injury. Archives of disease in childhood. Education and practice edition. 2010;95:2-8. Mittal T, Kumar V, Khullar R, et al. Diagnosis and management of Spigelian hernia: A review of literature and our experience. Journal of Minimal Access Surgery. 2009;4. Mortimer PS. Levick JR. Chronic Peripheral Oedema: the Critical Role of the Lymphatic System. Clinical Medicine. 2004; 4(5): 448-453. Moses WR. Shifting Dullness in the Abdomen. Southern Medical Journal. 1946; 39(12): 985. Murphy RL. Auscultation of the Lung: Past Lessons, Future Possibilities. Thorax. 1981; 36: 99-107. Musa-Veloso K, Likhodii SS, Cunnane SC. Breath acetone is a reliable indicator of ketosis in adults consuming ketogenic meals. The American journal of clinical nutrition. 2002;76:65. Naylor C. Physical Examination of the Liver. JAMA. 1994; 271(23): 1859-1865. Orszagh J, Kodlova E. Cesk. Asterixis as a nonspecific sign of respiratory encephalopathy. Neurol Neurochir. 1977 Sep;40(5):354-5. Pal G, Lin MM, Laureno R. Asterixis: a study of 103 patients. Metabolic Brain Disease. 2014;29:813-824. Patel LM, Lambert WC, Lambert PJ, Gagna CE, Maghari A. Cutaneous signs of systemic disease. Clinics in Dermatology. 2011;29:511-522.
Sahoo AK, Rauta S. Kyrle's Disease: A Rare Skin Manifestation of Systemic Diseases. Journal of Medicine. 2014;15:144.
 Schroth BE. Evaluation and Management of Peripheral Oedema. JAAPA. 2005 Nov; 18(11): 29-34. Smith MD, Seth JH, Fowler CJ, Miller RF, Panicker JN. Urinary retention for the neurologist. Practical neurology. 2013;13:288. Soder B, Johansson B, Soder PO. The relation between foetor ex ore, oral hygiene and periodontal disease. Swedish dental journal. 2000;24:73. Sousa CN, Apóstolo JL, Figueiredo MH, Martins MM, Dias VF. Physical examination: How to examine the arm with arteriovenous fistula. Hemodialysis International. 2013;17:300-306. Specchio F, Carboni I, Chimenti S, Tamburi F, Nistico' S. Cutaneous manifestations in patients with chronic renal failure on hemodialysis. International journal of immunopathology and pharmacology. 2014;27:1. Speeckaert R, Van Gele M, Speeckaert MM, Lambert J, Geel N. The biology of hyperpigmentation syndromes. Pigment Cell & Melanoma Research. 2014;27:512-524. Taguchi Y, Takashima S, Tanaka K. Koilonychia in a patient with subacute iron-deficiency anemia. Internal medicine (Tokyo, Japan). 2013;52:2379. Tangerman A, Meuwese-Arends M, Jansen JMJ. Foetor hepaticus. The Lancet. 1994;343:1569-1569. Vora A, Makris M. An approach to investigation of easy bruising. Archives of Disease in Childhood. 2001;84:488-491. Young RR, Shahani BT. Asterixis: one type of negative myoclonus. Adv Neurol 1986; 43: 137-156. Zalewska A, Zato?ski M, Jab?onka-Strom A, Paradowska A, Kawala B, Litwin A. Halitosis--a common medical and social problem. A review on pathology, diagnosis and treatment. Acta gastro-enterologica Belgica. 2012;75:300.