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Varicose veins focussed examination

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Expose patient’s legs and feet
  • Check for any pain in legs

General inspection

  • Patient: well/unwell, breathless, pain/discomfort

Leg inspection

  • Observe gait
  • Inspection: ask patient to stand and inspect carefully from all angles, then inspect again with patient lying supine
    • Skin: colour changes
    • Ankle/leg swelling (DVT, heart failure)
    • Venous insufficiency (describe)
    • Venous eczema and haemosiderin deposits (damaged capillaries leak blood → red-brown patches)
    • Lipodermatosclerosis (inflammation of subcutaneous fat → woody hard skin, pigmentation, swelling, redness, ‘inverted champagne bottle leg’)
    • Venous ulcers/atrophie blanche
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Stages of venous insufficiency
  • Venous dilatation and tortuosity (varicose veins)
    • Distribution (long saphenous vein is all the way up the medial part of the leg; short saphenous vein is up the posterolateral part of the lower leg)
    • Colour 
    • Prominence
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Long saphenous vein anatomy

Palpation

  • Varicosities: palpate all the way along varicosities for tenderness and hardness (phlebitis)
  • Saphenofemoral junction: 2.5cm below and 2.5cm lateral to pubic tubercle 
    • Feel for a saphena varix (large varicosity at saphenofemoral junction) 
    • Ask patient to cough and feel for thrills/dilatations (suggest saphena varix)
  • Elevate limb to 15˚ and note rate of venous emptying
  • Trendelenburg (/tourniquet) test: if varicosities present, this can determine the location of venous regurgitation
    • Lift patient’s leg as high as comfortable and milk leg to empty veins
    • While leg is elevated, apply tourniquet or press your thumb over saphenofemoral junction 
    • Ask patient to stand while you maintain pressure over the saphenofemoral junction
    • Rapid filling of the varicosities with the tourniquet still on suggests incompetent perforator veins lie below the level of the saphenofemoral junction
    • Now repeat the test, moving the tourniquet down 3cm each time. When varicosities do not refill, the incompetent perforator is above the tourniquet but below where it was previously applied.
  • Calf tenderness (DVT)

Percussion and Auscultation

  • Percussion wave of varicosities: tap distally and feel impulse proximally (normal); tap proximally and feel impulse distally (incompetent valves)
  • Auscultate varicosities for a machinery–like rumbling sound if you suspect an arteriovenous fistula

Finally

  • Pitting oedema: if present, establish how far oedema extends and also check JVP at 45˚ 
  • Palpate arterial pulses 

To Complete

  • Thank patient and restore clothing
  • ‘To complete my examination, I would perform full abdominal and pelvic examinations (for masses causing venous obstruction).’
  • Summarise and suggest further investigations you would do after a full history (e.g. duplex USS)

Time to test your knowledge!

What is the definition of a varicose vein?

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List three risk factors for varicose veins

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What are the associated skin changes?

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What is the gold standard for diagnosing varicose veins?

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Discuss the management options for varicose veins

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Learn more here…

There’s more learning on varicose veins here!

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