Instruction: Examine the legs of this patient

ITEM: VARICOSE VEINS

INTRODUCTION: I will be examining your legs, and hence, could you please pull your pants higher up your waist so I can have a better view of your thighs and calves. If there is any pain on your legs inform me.

At this point: The patient is still sitting

Instruction: Could you please stand up for me?

Your position: Kneeling or bending down to the same level as the knees.INSPECTION: [FRONT and BACK]; front is LSV, back is SSV

1. SITE – which veins are affected – LSV, SSV, superficial circumflexiliac, femoral vein, superficial epigastric, superficial external pudendal, dorsal venous arch- LSV – medial part of the leg all the way up until saphenofemoral junction- SSV – only lateral and posterior calves

2. SIZE – are these true varicosities or physiological dilations? 3. Saphena varix at the saphenofemoral junction in groin region4. SKIN – any surgical scars – EXAMINE GROIN CREASES and INNER THIGHS5. Signs of chronic venous insufficiency: [Begin with entire leg, thighs downwards, then focus

on Gaiter area]a) Lipodermoatosclerosis – pigmentation, swelling, redness, heat, inverted champagne

bottle shapeb) Stasis eczema – red brown patches due to deposition of hemosiderinc) Ulcerations (active)d) Ulcerations (passive/healed) – atrophic blanché e) Pedal edema due to pooling of venous blood

PALPATION1. State of skin

a) Pitting edema b) Trace fingers along course of the major superficial veins – INDURATION/ TENDERNESS- Induration and tenderness of dilated and tortuous veins indicates that there is phlebitis

of the varicose veins2. Sites of fascial defects

- Palpate medial aspect of leg – is there a defect in the compartmental fascia through which perforater veins pass through?

3. Sites of venous incompetence a) Palpate saphenofemoral junction [location: 3.5 cm below and lateral pubic tubercle]- Is there a thrill? - Tell patient to cough – if the thrill is accentuated [jet-like] – positivie Cruveilher testb) TRENDELENBURG TEST

Step 1: Tell patient to lie down on bedStep 2: Elevate the patient’s leg – to empty the veinsStep 3: Place one finger and press hard on the SFJ [occlude SFJ]Step 4: Tell patient to slowly stand up (maintain pressure on SFJ) Step 5: Observe if veins refill. If there is no refilling, the problem is with an incompetent SFJ. If there is still refilling, the distal perforators are incompetent [but does not rule out a problematic SFJ]

c) TOURNIQUET TESTStep 1: Tell patient to lie downStep 2: Empty veins by raising legStep 3: Use a tourniquet to occlude the SFJ [alternatives: gloves/ tight bandage]Step 4: Tell patient to stand up.

Step 5: Does it refill? If not, the problem is with the SFJ. If yes, most probably the problem is with a perforator valve lower down the leg.Step 6: Repeat steps 1 to 4, but this time place tourniquet at mid-thigh and below knee respectively.

d) Perthes Test of the Deep veins- Determines if the deep femoral veins are competent or not- Empty the veins and then apply a tourniquet at the mid thigh level. Tell the patient to

stand.- Ask the patient to either:

a) walk around the room for 5 minutes, or b) repeatedly alternate between standing on tip-toes to standing on flat feet for 5 minutes

Results:If deep system is competent, the blood will go through and back to the heart, and the patient will have no symptoms. If the deep system is incompetent, the patient will feel pain in the leg and the varicosities will increase in size

e) Homan’s Test for DVT- Hold the foot in forced dorsiflex and the other hand over the calf- Tenderness indicates suspected DVT

f) Hand-held DopplerPurpose: To identify SFJ/popliteal fossa refluxMethod: Squeeze muscles of thigh/calves, place Doppler proximal to the point of pressureNormal: A single wave [bi or triphasic]Abnormal: A turbulent regurgitant sound due to reflux

g) Indications for Duplex US scanning:- Previous DVT- SIGNS OF CHRONIC VENOUS INSUFFICIENCY - Recurrent varicosities - Ambiguity in determining vein at fault

PERCUSSION/TAPPING1. Chevrier’s TAP SIGN

- Tap proximal part of varicose vein – if you can feel the vibration downstream, this is abnormal

- Tapping distally and feeling the wave proximally is normal physics

AUSCULTATION1. Auscultate for bruits over varicosities – if there is a bruit, this could imply an arterio-venous

fistula

Others:COMPELTE ABDOMINAL EXAMINATION WITH DRE