15 Vascular (Venous)

15 Vascular (venous)

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

OSCEs for Medical Finals, First Edition. Hamed Khan, Iqbal Khan, Akhil Gupta, Nazmul Hussain, and Sathiji Nageshwaran.