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 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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