Lower limb chronic venous insufficiency and varicose vein examination

Question 1

What is the first thing to do in this exam?

Answer 1

Wash hands

Question 2

Introduce yourself :

Answer 2

Hello, my name is Beth Smith and I’m one of the third year medical students.

Question 3

What patient details do you confirm?

Answer 3

Name
DOB (+ Age)
check band if one present

Question 4

Explain the LLCVI / VV exam to a patient

Answer 4

I’ve been asked to examine the veins in your legs today, it’s going to involve me having a look, a feel and a listen to any veins that bulge out. is that okay?

Question 5

What are the last steps of the introduction?

Answer 5

GAIN CONSENT

Ask them to appropriately undress (pants off)
- ask if that is okay

Do they want a chaperone?

Ask if they are in any pain

Question 6

On inspection what are we looking for?

Answer 6

Varicosities;

Venous eczema;

Venous ulceration;

Scars;

Identify the saphenofemoral junction (SFJ)

Question 7

Where in particular do you want to look for varicosities?

Answer 7

The distribution of the long saphenous vein (medial thigh + leg) and short saphenous vein (back of leg).

Question 8

Describe the appearance of venous eczema

Answer 8

An oedematous area of
hardened skin that is hyperpigmented and erythermatous

Question 9

Explain why varicose ezcema occurs

Answer 9

Occurs due to venous HTN -> fluid collection in tissues -> fluid stasis -> activation of the innate immune response -> inflammation.

Question 10

why does the oedema occur?

Answer 10

Venous stasis

Question 11

What else causes the appearance of the ezcema?

Answer 11

Lipodermatosclerosis (scarring of the skin + fat)

Haemosiderin deposition (orange-brown patches).

Question 12

Describe the appearance of a venous ulcer

Are they painful?

Where are they usually located?

Answer 12

Large, irregular border with sloping edges.

Shallow in depth, mildly painful.

Usually in the gaiter area above the medial malleolus.

Question 13

What is the gaiter area?

Answer 13

below the knee and above the ankle

Question 14

Why might scars be present?

Answer 14

Previous surgery
Healed ulceration.

Question 15

Where is the SFJ?

Answer 15

4 cm lateral and 4 cm inferior to the pubic tubercle

Question 16

What should we do / cover when palpating?

Answer 16

Temperature

Visible varicosities

Cough test

Tap test

Question 17

How and where do we feel for temperature?

Answer 17

Place back of hand on varicosities

Question 18

What might increased temperature of a varicosity indicate?

Answer 18

Phlebitis

Question 19

When palpating visible varicosities what would indicate thrombophlebitis?

Answer 19

If vessel feels hard, ‘cord-like’ + there’s pain it’s strongly suggestive of thrombophlebitis.

Question 20

How do you perform a cough test?

Answer 20

Put finger on the SFJ + ask patient to cough.

Palpate for thrills at the SFJ.

Question 21

How do you perform a tap test?

Answer 21

Put finger on the SFJ
Put other finger on any varicosity in the long saphenous vein distribution.

Tap on the varicose vein being assessed

Question 22

If there is a thrill felt in the SFJ upon tapping a varicosity what does that indicate?

Answer 22

That there is continuity of the vein secondary to incompetent valves as venous valves should prevent the thrill transmitting along the entirety of the vessel.

Question 23

What do we auscultate?

What part of the stethoscope do we use?

Answer 23

Any varicosities

The bell

Question 24

If a bruit is heard what do this indicate?

Answer 24

turbulent blood flow

?underlying AV malformation.

Question 25

As soon as the exam has finished what should you do?

(LLCVI/ VV)

Answer 25

Thank the patient

Wash hands

Offer to help them dress

Explain that you are going to talk to the examiner now.

Question 26

To complete the examination….

(LLCVI/ VV)

Answer 26

I’d like to perform an abdominal + peripheral arterial examination and Doppler ultrasound of any varicosities”.

Question 27

Summarise a normal LLCVI / VV exam

Answer 27

“Today I performed a varicose vein examination on [name] a [age] year old [gender].”

On general inspection, [name] appeared comfortable at rest.

There was no peripheral signs of venous insufficiency in the legs.

Both the cough test and tap test were negative.

To conclude, this is consistent with a normal varicose vein examination.