Examination Of Lower Limb For Varicose Veins And Venous Insufficiency

Question 1

What are the steps of this examination?

Answer 1

Inspect the legs, identify the saphenofemoral junction, cough test, tap test, trendelenburg test, perthe’s test, auscultation, abdominal examination

Question 2

What are you inspecting the legs for?

Answer 2

Varicosities, venous eczema, hair loss, oedema, lipdermatosclerosis, haemosiderin deposition, genius ulceration, scars

Question 3

Where are varicosities likely?

Answer 3

Particularly in the distribution of the long saphenous vein (medial though and leg) and short saphenous vein (lateral leg)

Question 4

Why would you get oedema?

Answer 4

Due to venous stasis

Question 5

What is lipodermatosclerosis?

Answer 5

Scarring of the skin and fat

Question 6

Where is the saphenofemoral junction?

Answer 6

4cm lateral and 4cm inferior to the pubic tubercle

Question 7

Why do we identify the saphenofemoral junction?

Answer 7

To inspect for a saphenovarix (varicosities at the SFJ)

Question 8

How do you perform the cough test?

Answer 8

Putting your finger on the SFJ and asking the patient to cough. Palpate for thrills at the SFJ.

Question 9

How do you perform the tap test?

Answer 9

Put your finger on the SFJ and putting a finger of your other hand on any varicosities in the long saphenous vein distribution. Tap on the SFJ.

Question 10

What would you find on the tap test?

Answer 10

If the SFJ is incompetent, you will feel the transmitted percussion wave in the varicosities further down the leg

Question 11

What is the trendelenburg test?

Answer 11

Ask the patient to lie flat. Raise the leg and keep it raised for a few minutes to exsanguinate as much blood as possible. Apply a torniquet high around the thigh. Ask the patient to stand up and inspect to see whether the varicose veins refill, repeat the test at the mid-thigh perforators, the saphenopopliteal junction and the mid-calf perforators

Question 12

What is the purpose of Perthe’s test?

Answer 12

To assess the patency of the deep veins

Question 13

How do you perform the Perthe’s test?

Answer 13

Ask the patient to lie down. Without exsanguinating the leg, apply a tourniquet around the thigh. Ask the patient to stand and rock up and down onto their tiptoes ten times.

Question 14

What are the results of the Perthe’s test?

Answer 14

If the superficial veins empty, the deep veins must be patent.

Question 15

How do you perform auscultation ?

Answer 15

Using a doppler probe on the SFJ. Squeeze the thigh.

Question 16

What are normal results of the Doppler?

Answer 16

You should hear a single ‘whoosh’ as the blood is squeezed from the long saphenous vein into the femoral vein.

Question 17

What are abnormal results of a Doppler?

Answer 17

A second ‘whoosh’ indicates incompetence of the SFJ as the blood falls back into the long saphenous vein past the incompetent valve

Question 18

Why do you examine the abdomen?

Answer 18

To exclude an abdominal or pelvis cause of raised venous pressure.

Question 19

What are the stages of a peripheral vascular examination?

Answer 19

Inspection, pulses, eyes, tongues, abdomen, light-touch sensation, capillary refill, auscultation, buerger’s test, ABPI

Question 20

What are you inspecting on general inspection?

Answer 20

Colour, build, comfort, position

Question 21

What are you inspecting the hands for?

Answer 21

Colour, capillary refill, nicotine staining

Question 22

What are you checking and comparing the radial pulses?

Answer 22

Rate, rhythm, volume, radioradial delay

Question 23

What are you looking for in the eyes?

Answer 23

Subconjunctival pallor (anaemia) and corneal arcus (hyperlipidaemia)

Question 24

What are you looking for in the lips and tongue?

Answer 24

Dehydration and central cyanosis

Question 25

What are you looking for in the abdomen?

Answer 25

Scars, visible masses and visible pulsations

Question 26

What are you inspecting in the legs, feet and toes?

Answer 26

Symmetry, colour, temperature, oedema, trophic changes, varicose eczema, lipodermatosclerosis, venous guttering, ulceration

Question 27

What trophic changes are you looking at?

Answer 27

Loss of hair, shiny skin, wasting of subcutaneous tissues

Question 28

What are you looking for in ulceration?

Answer 28

Site, shape, size, margins, colour, exudate, odour

Question 29

What pulses do you palpate?

Answer 29

Radial, ulnar, brachial, carotids, aorta, femoral, popliteal, dorsalis pedis, posterior tibial

Question 30

What do you check in the toes?

Answer 30

Light touch sensation and capillary refill

Question 31

What pulses do you auscultate?

Answer 31

Carotids, subclavian, aorta and femoral arteries

Question 32

How do you perform buerger’s test?

Answer 32

Elevate both legs to 45 degrees, sit the patient up and ask them to hang their legs down over the side of the bed

Question 33

What does pallor of the feet when elevate indicate?

Answer 33

Ischaemia

Question 34

What affects the angle to which the legs have to be lifted in Buerger’s test?

Answer 34

The poorer the arterial supply, the less the angle to which the legs have to be raised for them to become pale

Question 35

What colour do the ischaemia legs go?

Answer 35

The skin at first becomes blue, then red.

Question 36

Why does the skin go blue?

Answer 36

Blood is deoxygenated in its passage through the ischaemic tissue

Question 37

Why do the legs go red?

Answer 37

Due to reactive hyperaemia from post-hypoxic vasodilation

Question 38

Do you do Bueger’s test with one leg or both legs ?

Answer 38

Both legs at the same time

Question 39

How do you measure the ABPI?

Answer 39

Dividing the highest systolic blood pressure in the arteries at the ankle by the higher of the two systolic blood pressures in the arm

Question 40

What ABPI indicates significant arterial disease

Answer 40

Less than 0.8