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Varicose Vein Examination for Medical Student OSCE

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1. Introduce, identify, explain, consent

2. Inspection: pt standing

   1. Shape – beer bottle shape (oedema + venous compromise)

   2. Varicose veins – location and distribution. Especially inspect along long and short saphenous (medial malleolus to groin / lateral malleolus to popliteal fossa)

   3. Gaiter area – above medial malleolus – skin changes

      1. Venous stars – fan-shaped dilatation of superficial venules, spreading from the ankle

      2. Eczma – above medial malleolus

      3. Ulcers – over medial malleolus

      4. Ankle swelling – observe for oedema

      5. Pigmentation – brown haemosiderin

      6. Thrombophlebitis – hard, inflamed, tender veins – like thick cords

      7. Lipodermatosclerosis – fibrosis of skin and subcutaneous fat

      8. Scars – previous vascular surgery

3. Palpation

   1. Temperature – bimanual, soles and legs. Medial legs for warmth (around varicose veins) or tenderness (incompetent perforators)

   2. Pitting oedema

   3. Veins – for tenderness (phlebitis) or hardness (thrombosis)

      1. Long saphenous – anterior to medial malleolus ? medial knee ? saphenofemoral opening, 4cm below and lateral to pubic tubercle

      2. Short saphenous – behind lateral malleolus ? midline of posterior calf ? popliteal vein

   4. Junctions – saphenofemoral and saphenopopliteal – ask pt to cough, palpate for impulse – indicates incompetence of junction

4. Auscultation – over venous cluster, for bruits (ateriovenous fistula)

5. Special tests – first examine peripheral pulses

   1. Tap test – place finger at bottom of a long varicose vein; tap above this site with other hand. Impulse indicates superficial vein incompetence

   2. Trendelenburg’s test – pt supine; elevate leg to collapse superficial veins. Occlude saphenofemoral junction with two fingers, ask pt to stand. Remove fingers: superficial veins refill in saphenofemoral incompetence

   3. Tourniquet test – pt supine; elevate leg to collapse superficial veins. Place tourniquet around upper thigh, ask pt to stand. Superficial vein filling indicates incompetent perforators. Repeat test working down leg, until veins below tourniquet remain collapsed: incompetent perforators are above this point.

6. Request abdo and pelvic examination – masses obstructing IVC. Doppler USS to examine flow in incompetent valves

7. DD

   1. Varicose veins – swollen, dilated, tortuous, irregularly shaped veins, occurring due to incompetent venous system valves. 1? - hereditary weakness in vein walls causing dilatation + valvular incompetence. 2? - due to DVT destroying deep valves ? reflux and greater pressures in deep system; venous flow obstruction – pregnancy, fibroids, ovarian cysts; high-pressure flow e.g. AV fistula.

Chronic varicose veins can cause venous eczma, skin pigmentation, leg ulcers, haemorrhage, phlebitis and vein calcification

1.  

   1. DVT – usually due to immobility. Unilateral acutely painful swollen and hot leg

 

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by: Admin
Total views: 0
Word Count: 688
Date: Fri, 22 Jan 2010 Time: 4:05 PM
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