CLINICAL EXAMINATION OF VARICOSE VEINS:

CLINICAL EXAMINATION OF VARICOSE VEINS:


INSTRUCTION: EXAMINE THIS GENTLEMANS LEFT LEG.


TO PATIENT:

HELLO MR.JONES. MY NAME IS DR. SO N SO. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.

MAY I PLEASE EXAMINE YOU? THANK YOU.

LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.

COULD YOU PLEASE TAKE OFF YOUR TROUSERS AND KEEPING YOUR BRIEFS ON PLEASE STAND UP IN FRONT OF ME?

ARE YOU COMFORTABLE SIR?

DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG?

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.


ACT:
KNEEL DOWN AND LOOK AT BOTH THE LEGS SYSTEMATICALLY BUT BRISKLY.


TO EXAMINER:
THERE IS ON INSPECTON IN THIS MIDDLE AGED GENTLEMAN, VISIBLE DILATED VARICOSE VEINS ON RIGHT/ LEFT/ BOTH LEGS , IN THE DISTRIBUTION OF LSV (LONG SAPHENOUS VEIN)/ SSV (SHORT SAPHENOUS VEIN). THERE IS EVIDENCE OF VENOUS INSUFFICIENCY IN THE GAITER AREA (THAT IS SKIN OF LOWER THIRD OF MEDIAL SIDE OF CALF) WITH EDEMA, BROWN HEMOSIDERIN PIGMENT DEPOSITION, LIPODERMATOSCLEROSIS (SWOLLEN EDEMATOUS CALF WITH THIN ATROPHIED ANKLE) AND ECZEMA. ON THE RIGHT LOWER LEG THERE IS A LARGE VENOUS ULCER. VENOUS STARS (MINUTE INTRADERMAL VEINS) ARE NOT PRESENT AND THERE IS NO EVIDENCE OF ANY SCARS NOR ATROPHIE BLANCHE (WHITE SKIN SCARRING WITHOUT ULCERATION) OR REDNESS IN THE OVERLYING SKIN.

AND NOW THE OTHER LEG.

TO PATIENT:
SIR, CAN YOU PLEASE TURN AROUND. THANK YOU.

ACT:
LOOK AT THE BACK OF LEGS (OVER SSV).

MENTION THE INSPECTION FINDINGS IF PRESENT.

TO EXAMINER:
THERE IS NO EVIDENCE OF ANY VARICOSE VEINS, SIGNS OF VENOUS INSUFFICIENCY IN THE DISTRIBUTION OF SSV.


TO PATIENT:
I AM JUST GOING TO FEEL THE VEINS. PLEASE LET ME KNOW IF IT IS TENDER.

ACT:
FEEL TEMPERATURE OVER VARICOSITIES AND PALPATE ANY OBVIOUS VARICOSE VEINS.

TO EXAMINER:
ON PALPATION, SKIN OVER VARICOSITIES IS NOT WARM. VARICOSITIES ARE PALPABLE AND NON TENDER.


TO PATIENT:
I AM NOW GOING TO PRESS FOR A SECOND ON YOUR ANKLE.

ACT:
PRESS 5 CMS ABOVE MEDIAL MALLEOLUS FOR 3 SECONDS FOR PITTING EDEMA.

TO EXAMINER:
PITTING EDEMA IS PRESENT.

TO PATIENT:
COULD YOU PLEASE TURN BACK AROUND TO FACE ME?

ACT:
AGAIN CHECK TEMPERATURE, TENDERNESS OVER VEINS.

TO PATIENT:
I AM GOING TO FEEL ALONG THE LEG JUST BEHIND THE MEDIAL BORDER OF TIBIA FOR TENDER DEFECTS IN THE DEEP FASCIA (THAT IS ABOUT 5, 10 AND 15 CMS ABOVE THE MEDIAL MALLEOLUS)

TO PATIENT:
PLEASE LET ME KNOW IF IT IS TENDER ANYWHERE. I AM LOOKING FOR EVIDENCE OF PERFORATOR INCOMPETENCE.

TO EXAMINER:
PALPATION ALONG THE COURSE OF THE VEIN JUST BEHIND/ ALONG THE MEDIAL BORDER OF TIBIA DOES NOT REVEAL ANY TENDER DEFECTS IN THE DEEP FASCIA (WHERE THE COMMUNICATING VEINS PASS FROM THE SUPERFICIAL TO THE DEEP SYSTEM ….PHALENS TEST)


TO PATIENT:
DO YOU MIND IF I FEEL IN THE GROINS.

ACT:
FEEL ANATOMICAL LANDMARKS:
1. PUBIC TUBERCLE….FEEL IT AND ABOUT 3-4 CMS BELOW AND LATERAL TO IT LIES SFJ (SAPHENO FEMORAL JUNCTION).
2. OR FEEL ASIS AND PUBIC SYMPHYSIS, MID INGUINAL POINT…..THAT IS FEMORAL PULSE…PALPATE JUST MEDIAL TO FEMORAL PULSE FOR SFJ.


TO EXAMINER:
I AM PALPATING THE SFJ ABOUT 3.5 CMS BELOW AND LATERAL TO THE PUBIC TUBERCLE.

NOTE:
THE PUBIC TUBERCLE CAN BE DIFFICULT TO PALPATE BUT FORMS THE POINT OF INSERTION OF THE PROMINENT ADDUCTOR LONGUS TENDON WHICH RUNS MEDIALLY UP THE THIGH (TENDON CAN BE MADE MORE PROMINENT BY FLEXING, ABDUCTING AND EXTERNALLY ROTATING THE PATIENTS THIGH).

ACT:
FEEL FOR SAPHENA VARIX (PRESENTS AS A LUMP A LUMP IN GROIN AND IS A DILATATION OF LSV JUST BEFORE IT ENTERS FEMORAL VEIN. IT EMPTIES ON MINIMAL PRESSURE AND REFILLS ON RELEASE.

TO EXAMINER:
THERE IS A VARIX HERE ON THE RIGHT/ LEFT GROIN.


TO PATIENT:
COULD YOU PLEASE TURN YOUR HEAD TO THE OTHER SIDE AND COUGH PLEASE. (FOR EITHER VARIX OR SIMPLY SFJ)

TO EXAMINER:
I CAN FEEL A STRONG COUGH IMPUSLE SUGGESTING AN INCOMPETENT SFJ.

TO PATIENT:
I AM JUST GOING TO TAP IT (AT SFJ) AND FEEL LOWER DOWN.

ACT:
REST A HAND ON THE MEDIAL CALF JUST BELOW THE KNEE ALONG THE COURSE OF THE VARICOSE VEIN AND TAP THE SAPHENA VARIX/ SFJ/LSV FROM ABOVE DOWNWARDS.

TO EXAMINER:
PERCUSSION AT SFJ DEMONSTRATES TRANSMISSION OF WAVES DOWN THE VEIN (CRUVHEILLIERS SIGN) INDICATING A POSITIVE TAP TEST (INDICATES INCOMPETENT VALVES BELOW SFJ).

I WOULD NOW LIKE TO PERFORM THE TOURNIQUET TEST.

TO PATIENT:
COULD YOU LIE DOWN PLEASE? I AM GOING TO LIFT YOUR ANKLE GENTLY AND REST IT ON MY SHOULDER. KEEP YOR LEG STRAIGHT IF YOU CAN PLEASE.

ACT:
LIFT THE LEG, PUT THE ANKLE ON ONE SHOULDER AND STROKE THE LEG FIRMLY (WITH PALMAR SURFACE OF FINGERS).

TO PATIENT:
I AM JUST EMPTYING THE VEINS.

ACT:
PUT THE RUBBER TOURNIQUET TIGHTLY AROUND THE UPPER THIGH BELOW SFJ.

TO PATIENT:
STAND UP PLEASE.

ACT:
WATCH BELOW THE TOURNIQUET. DO THE VEINS FILL IMMEDIATELY?
1. IF YES……THE VARICOSITIES ARE NOT CONTROLLED AT THE LEVEL OF THE SFJ SUGGESTING INCOMPETENT PERFORATORS LOWER DOWN.
2. IF NOT….THE VARICOSITIES ARE CONTROLLED AT THE LEVEL OF SFJ.

NOTE:
IF ASKED THEN ONLY MENTION….

KEEP REPEATING THE PROCEDURE, MOVING THE TOURNIQUET PROGRESSIVELY DOWN THE LEG (JUST ABOVE KNEE, JUST BELOW KNEE) THAT IS BETWEEN THE SITES OF THE PERFORATOR VEINS. REPEAT UNTIL THE VEINS BELOW THE TOURNIQUET STAY COLLAPSED. IT DEFINES THE SEGMENT OF LEG CONTAINING INCOMPETENT PERFORATORS.

TO EXAMINER:
THE TOURNIQUET TEST REVEALS THAT THE VEINS ARE CONTROLLED AT THE SFJ.

NOTE:
ONLY DO THIS IF ASKED BY EXAMINER SPECIFICALLY OTHERWISE OMIT…
TRENDELENBURG TEST:
ASK PATIENT TO LIE FLAT. ELEVATE THE LEG UNTIL THE SUPERFICIAL VEINS ARE EMPTIED. ONLY PERFORM THE TEST IF THE TOURNIQUET TEST IS POSITIVE AT THE UPPER THIRD OF THIGH. PLACE TWO FINGERS AT THE SFJ. ASK PATIENT TO STAND UP, KEEPING YOUR FINGERS FIRMLY IN PLAE. WATCH LEG. NO FILLING OF SUPERFICIAL VEINS BELOW FINGERS, FILLING ON RELEASE OF FINGER PRESSURE INDICATES SFJ INCOMPETENCE.

TO EXAMINER:
I WOULD LIKE TO PERFORM PERTHES TEST.

TO PATIENT:
LEAVING THE TOURNIQUET ON COULD YOU PLEASE WALK AROUND/ STAND UP AND DOWN ON TIPTOES PLEASE.

ACT:
WATCH LEG.
IF VEIN GET BETTER.THE DEEP VENOUS SYSYTEM APPEARS TO BE FUNCTIONING.
IF VEINS GET WORSE AND PATIENT DEVELOPS SEVERE DISCOMFORT THERE MAY BE PROBLEMS WITH THE DEEP VENOUS SYSTEM THAT IS THERE IS OCCLUSION OF THE DEEP VEINS.

TO EXAMINER:
PERTHES TEST REVEALS THAT THE DEEP VENOUS SYSTEM IS FUNCTIONING.

TO PATIENT:
I AM JUST GOING TO FEEL IN YOUR GROINS SIR.

ACT:
PALPATE ALL PULSES INCLUDING FOOT PULSES.

TO EXAMINER:
ALL THE PULSES INCLUDING FOOT PULSES ARE PALPABLE AND PERFUSION IS GOOD.

TO PATIENT:
I AM JUST GOING TO LISTEN OVER VEINS.

ACT:
PLACE BELL OVER SITES OF MARKED VENOUS CLUSTERS.

TO EXAMINER:
AUSCULTATION OVER THE CLUSTER OF VEINS DOES NOT DETECT ANY CONTINUOUS MACHINERY MURMUR OF AV FISTULA.

TO PATIENT:
THANK YOU SIR. YOU MAY WEAR YOUR TROUSERS. LET ME HELP YOU WITH IT. THANK YOU AGAIN.


TO EXAMINER:
THE TOURNIQUET TEST CAN BE PERFORMED AT DIFFERENT LEVELS. A COMPLETE EXAMINATION WOULD INCLUDE:
1. LOOKING FOR SIGNS OF ARTERIAL INSUFFICIENCY AND PALPATION OF ALL PULSES INCLUDING FOOT PULSES.
2. ABDOMINAL EXAMINATION.
3. RECTAL EXAMINATION.
4. PELVIC EXAMINATION.
5. EXTERNAL GENITALIA EXAMINATION (TESTES IN MALES).MASSIVE ENLARGEMENT OF ABDOMINAL LYMPH NODES BY METASTASES FROM SMALL TESTICULAR TUMORS CAN CAUSE IVC OBSTRUCTION.
6. DOPPLER ULTRASOUND ASSESSMENT OVER SFJ OR SPJ (SAPHENO POPLITEAL JUNCTION).


TO EXAMINER:
THIS PATIENT HAS VARICOSE VEINS WITH SIGNS OF VENOUS INSUFFICIENCY.


I WOULD LIKE TO WASH MY HANDS.