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 region
4. SKIN any surgical scars EXAMINE GROIN CREASES and INNER THIGHS
5. 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 shape
b) Stasis eczema red brown patches due to deposition of hemosiderin
c) Ulcerations (active)
d) Ulcerations (passive/healed) atrophic blanch
e) Pedal edema due to pooling of venous blood
PALPATION
1. 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 veins
2. 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 test
b) TRENDELENBURG TEST
Step 1: Tell patient to lie down on bed
Step 2: Elevate the patients leg to empty the veins
Step 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 TEST
Step 1: Tell patient to lie down
Step 2: Empty veins by raising leg
Step 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) Homans Test for DVT
- Hold the foot in forced dorsiflex and the other hand over the calf
- Tenderness indicates suspected DVT
f) Hand-held Doppler
Purpose: To identify SFJ/popliteal fossa reflux
Method: Squeeze muscles of thigh/calves, place Doppler proximal to
the point of pressure
Normal: 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/TAPPING
1. Chevriers 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
AUSCULTATION
1. Auscultate for bruits over varicosities if there is a bruit, this could imply
an arterio-venous fistula
Others:
COMPELTE ABDOMINAL EXAMINATION WITH DRE
