Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain 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)

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

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