15 Vascular (venous)

Lower limb
Checklist P MP F

Checklist P MP F • Oedema

HELP Auscultates:

H: ‘Hello’ (introduction and gains consent) • Bruits (listen over any varicose veins – bruit
may signify a vascular malformation)
E: Exposure (expose legs up to groins)
Special tests:
L: Lighting
• Trendelenburg test:
P: Positions correctly (supine), asks if the patient
• Lay patient flat
is in any pain
• Empty varicose veins by lifting leg
Washes hands • Place your fingers at SFJ
Inspection from end of bed: • Ask patient to stand up and look for refilling
• Comfortable of the veins
• If veins refill, incompetence is below the SFJ
• Varicose veins – note which vein
• Tourniquet test:
• Coexistent arterial pathology (amputation,
• Lay patient flat
pallor)
• Empty varicose veins by lifting leg
• Relevant paraphernalia (walking aids) • Apply a tourniquet at level of the SFJ and
Inspection of legs: front, side and behind: tighten it (this acts as an artificial valve)
• Ask patient to stand up and look for refilling
• Trophic changes (venous eczema, haemosiderin
of the veins
deposition, lipodermatosclerosis,
• If they do not refill, incompetence is at the
thrombophlebitis, atrophie blanche)
level of the SFJ
• Scars (e.g. vein harvesting, healed ulcer) • If they do refill, incompetence is below the
• Ulceration (gaiter area – medial malleolus) SFJ
• Oedema (around ankles) • If they refill, work your way down leg by
applying tourniquet just above knee, then
• Dressings (states would ideally examine
below it, then at mid-calf region, and look
underneath)
for refilling of vein
Palpation:
• Perthes test:
• Skin temperature with back of hands, moving • Lay patient flat
up leg from feet in distribution of the long and • Empty varicose veins by lifting leg
short saphenous veins • Apply a tourniquet around mid-thigh area
• Skin thickening (lipodermatosclerosis) (4–5 cm above knee)
• Ensure this is not very tight (so that it
• Thrombophlebitis (warmth and tenderness over
compresses only the superficial veins and
a vein)
not the deep veins)
• Locate saphenofemoral junction (SFJ) (4 cm • Ask patient to stand up and tiptoe up and
below and lateral to pubic tubercle): down about 10 times (so that calf muscles
• Feel for saphena varix contract)
• Assess for cough impulse • If varicose veins remain full of blood, may
• Tap test: be a deep vein obstruction (e.g. thrombosis)
• Place your hand over varicose vein and tap • If varicose veins empty, there is no deep
proximally. Test is positive if pulsation is felt vein obstruction
over the varicose vein

73
74 Examinations: 15 Vascular (venous)

Checklist P MP F Checklist P MP F
• Doppler test: • Carry out brief local neurological examination
• Place Doppler probe over varicose vein. Thanks patient
Squeeze distal to vein and listen for double
Offers to help patient get dressed
‘whoosh.’ This indicates an incompetent
valve Washes hands

States intent to complete the examination with Presents findings

the following: Offers appropriate differential diagnosis
• Examine remainder of the peripheral vascular Suggests appropriate further investigations and
system management
• Examine abdomen for masses OVERALL IMPRESSION:
• Do a rectal examination for masses
• Examine external genitalia

you can try to perform a functional assessment to show

the examiner you are trying to clarify the level of dis-
Summary of common conditions seen ability caused by the disease. This can also guide man-
in OSCEs agement as painful varicose veins are an indication for
surgical treatment.
Figure 15.1 illustrates various features of chronic
Pathology Notes venous disease, including thread veins, lipodermato-
Varicose veins Abnormal dilatation and tortuosity of superficial sclerosis and haemosiderin deposition.
venous circulation due to incompetent valves
and resulting venous hypertension Examine a varicose as an
Saphena varix Dilatation of saphenous vein at the SFJ autonomous entity
May have a cough impulse and can be If you see a varicose vein, examine it as you would any
differentiated from a femoral hernia by its lump or skin lesion. Do this before proceeding with the
blue colour and the fact that it disappears rest of the examination. Look carefully for scars from
when the patient lies flat previous vascular surgery as these can often be hard to
Chronic venous Presence of valvular dysfunction and chronic spot.
insufficiency venous hypertension will cause a number of
trophic changes to occur
Remember that a large proportion
See the above checklist for features of trophic
of venous pathology coexists with
disease
arterial pathology
Venous ulcers See Chapter 14 for notes on arterial
Mention this in your closing statement. It is an impor-
examination
tant safety issue as the compression bandaging used to
treat venous disease is contraindicated in those with
severe arterial disease. Hence an ABPI should be under-
taken before compression bandaging is issued.
Hints and tips for the exam
Venous examination of the lower limb is fairly straight-
Questions you could be asked
forward and is likely to appear as these patients have a
chronic illness and are plentiful in number. To do well Q. What are varicose veins?
at this station, you must first have a sound understand- Q. How are they treated?
ing of the venous anatomy of the legs, and then dem- Q. What are the trophic skin changes of chronic
onstrate it during the examination. For example, when venous insufficiency?
palpating the vasculature, remember to go from the feet Q. How do you treat a venous ulcer?
upwards (as the veins take blood towards the heart!). Q. What investigations would you perform for an
ulcer?
Inspect thoroughly Q. What is the management of an ulcer?
Inspect the room carefully for any walking aids. If you A. Answers to all these questions can be found in the
manage to complete your examination in good time, text above.