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, look for:
  • Skin: colour changesAnkle/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

• 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

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

How to perform Trendelenburg test

• 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 the varicosities are caused by venous regurgitation from perforator veins below the level of the saphenofemoral junction
• Now repeat the test, moving the tourniquet down 3cm each time. When varicosities do not refill, the affected perforator vein is between the current tourniquet position and where it was previously.

• 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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