Introduction
W ash hands
I ntroduce self
Ask P atient’s name, DOB and what they like to be called
E xplain examination and obtain consent
Expose the patient’s legs . Check for any pain in legs.
General inspection
Look at the patient from the end of the bed
Are they well/unwell?
Any breathlessness?
Are they in pain/discomfort?
Consider DVT risks
Signs of malignancy (e.g. cachexia)
Signs of immobility (e.g. walking aids)
Signs of recent surgery or trauma, pregnancy
Look around the bed: medicines etc.
Leg inspection
Inspect with the patient standing:
Look at the patient’s skin: are there any colour changes?
Ankle/leg swelling (unilateral may indicate DVT; bilateral may indicate oedema, e.g. in heart failure )
Venous insufficiency signs
Venous eczema and haemosiderin deposits (red-brown patches)
Lipodermatosclerosis (‘inverted champagne bottle leg’; increased venous pressure causes inflammatory cells to fibrose subcutaneous tissue)
Venous ulcers
Note any venous dilatation and tortuosity (varicose veins )
Stages of venous insufficiency
A patient presents to ED with chest pain and this trace. What would you do?
Interpretation management
Covered in OSCE Stations
Palpation
Palpate with the patient supine:
Temperature: feel for temperature differences between legs using the back of your hand (minimum three places each side)
Tenderness: palpate for calf tenderness with knee slightly flexed (squeeze near ankle and then up calves while watching face)
Pitting oedema: if present, establish how far oedema extends (and also check JVP)
Calf diameters: measure circumference 10 cm below tibial tuberosity (>3cm difference = significant)
Palpate pulses
To complete
Thank patient and restore clothing
‘To complete my examination, I would perform full cardiovascular and respiratory examinations. I would review the patient’s observations, including oxygen saturations and respiratory rate. If these are abnormal, I would consider the possibility of a pulmonary embolism.’
Summarise and suggest further investigations you would consider after a full history
Why don’t you test your knowledge?
How would you investigate a patient with a suspected DVT? Consider the Wells score in your answer.
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Name five risk factors for venous thromboembolism
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