DOCTOR INFORMATION

Varicose Vein Examination (OSCE)


Introduction

  1. Greet the patient and introduce yourself
  2. Confirm patient details โœ
  3. Explain the procedure in a patient friendly manner ๐Ÿ‘จ
  4. Explain that a member of staff from the ward will be present throughout the procedure as a chaperone
  5. Get patient consent โœ…
  6. Wash hands โœ‹
  7. Ensure the patient is standing with their lower limbs exposed
  8. Check the patient is not in any pain

 

General Inspection of the patient


Identify any clinically relevant signs:

โž– Ulcers: can indicate diseased veins/arteries

โž– Scars: can indicate that the patient has had previous ulcers which are now healed, or previous surgery


Identify and objects or equipment that may provide an insight into their medical status:

โž– Mobility aids: indicates their current mobility โ™ฟ

โž– Vital signs: indicates their current clinical status 

โž– Prescriptions: indicates any relevant medications they are on ๐Ÿ’Š

โž– Medical Equipment: for example, dressings on wounds or compression stockings 

 

Inspection of patientโ€™s legs


Surgical scars: clarify the surgery with patient, for example, a low groin scar can indicate venous treatment (remember venous treatment is minimally invasive nowadays and so you wonโ€™t see any scars)

Venous eczema: inflammation caused by fluid in the tissues due to venous hypertension (you can ask โ€œis it itchyโ€ to help identify it!)

โž– Lipodermatosclerosis

โž– Atrophie-blanche (white atrophy): depressed atrophic plaques which are star shaped and ivory-white with red dots and surrounding hyperpigmentation

โž– Crusty plaques which are blistered and itchy or dry and scaly plaques

โž– Orange-brown pigmentation patches

Lipodermatosclerosis: a form of panniculitis caused when the innate immune system is activated in soft tissues for a prolonged period. It often occurs in individuals with chronic venous insufficiency (CVI) which is often caused by varicose veins.

โž– Clinical features of Lipodermatosclerosis:

โž– Swelling

โž– Hyperpigmentation

โž– Skin hardening or thickening

โž– Erythema

โž– โ€˜Taperedโ€™ appearance of legs above the ankles

Venous ulcers: believed to be caused when the venous valves do not function properly

โž– Mild pain

โž– Shallow depth

โž– Large, irregularly shaped border

โž– Commonly located at the ankleโ€™s medial aspect

Saphena varix: when the saphenous vein is dilated in the groin where it meets the femoral vein

โž– Lump (2-4cm inferior lateral to pubic tubercle)

โž– Bluish colouration of lump

โž– Lump is soft to palpate

โž– Lump disappears when patient is lying down

Arterial disease: it is important to assess for this when treating issues of the venous system as it may mean the patient is unsuitable for the standard varicose vein treatment of compression therapy as it may put them at risk of secondary ishcaemia. Similarly, if the patient suffers from venous ulcers, it is important to ensure their arterial supply is adequate before you treat it

โž– Grangrene

โž– Hair loss 

โž– Arterial ulcers

โž– Peripheral cyanosis

โž– Lower temperature โ„

โž– Peripheral pallor

Varicose veins: dilated superficial veins, commonly seen on the legs, however when found on the genitals or buttocks, it can indicate pathology of the venous system within the pelvis   


Great saphenous vein: this is the largest vein in the human body, it runs the entirety of the way up the medial side of the leg

  1. It originates where the big toeโ€™s dorsal vein meets the dorsal venous arch of the foot ?
  2. It then passes in front of the medial malleolus before running up the leg on the medial side
  3. When it reaches the knee, it passes over the posterior border of the femur boneโ€™s medial epicondyle
  4. Finally, after passing through the proximal anterior thigh, it joins the femoral vein

Small saphenous vein: it drains the lateral side of the lower leg

  1. It originates where the dorsal vein of the fifth digit meets the dorsal venous arch of the foot ๐Ÿ‘ฃ
  2. It runs along the lateral aspect of the foot followed by the posterior aspect of the legs
  3. It drains into the popliteal vein at or above knee joint level (the saphenopopliteal junction)

 



Assess varicosities


Assess the temperature of varicosities: using the back of your hand

โž– Higher temperature ๐ŸŒก indicates inflammation

Palpate varicosities: palpate the entire length, asking the patient when they feel pain

โž– Tenderness and redness indicate phlebitis

โž– Tenderness and hardness indicate thrombophlebitis

 

Additional lower limb assessment


โž– Assess the limb for pitting oedema: moving up the leg, use your fingertis to apply pressure for a few seconds above the medial malleolus, then observe whether an indentation is formed

โž– Cause: heart failure ๐Ÿ’” (its presence can also impact the integrity of the skin)

โž– Palpate lower limb pulses to assess the arterial blood supply of each leg: moving in a proximal to distal direction (use a Doppler if not palpable)

โž– Femoral pulse ๐Ÿ’“: palpated at the mid-inguinal point to check pulse is present and check the volume

โž– Popliteal pulse ๐Ÿ’“: palpate in the inferior region of the popliteal fossa

  1. When the patientโ€™s legs are relaxed, place your thumbs on the tibial tuberosity
  2. Flex the knew to 30ยฐ as you place your fingers in the popliteal fossa to feel the pulse

โž– Posterior tibial pulse ๐Ÿ’“: palpated posterior to the tibiaโ€™s medial malleolus, compare strength of pulse between the two feet

โž– Dorsalis pedis pulse ๐Ÿ’“: palpated over the dorsum of the foot, lateral to the extensor hallucis longus tendon, or over the 2nd and 3rd cuneiform bones. Comparison of the strength of this pulse between the two feet should be made

 

Percussion โ€˜tap testโ€™:

โž– A rarely used method to assess the venous valve competency of lower limbs

  1. Apply a small amount of pressure onto the saphenofemoral junction with one finger ๐Ÿ‘‰
  2. Tap the varicose vein (lower down the leg) being assessed
  3. If you detect a โ€˜thrillโ€™ with your finger, it indicates that the venous valves are incompetent causing vein continuity, as the valves did not prevent the thrill

 

Auscultation:

โž– Another rarely used procedure which involves placing your stethoscopeโ€™s bell over the varicosity, listening for a bruit which indicates turbulent blood flow which can suggest arteriovenous malformation

 

Additional tests


Venous duplex scanning: 

โž– Today, all patients being considered for varicose vein treatment should undergo venous duplex scan of the whole superficial venous system for the following reasons:

โž– To confirm where the incompetence originated (e.g. saphenofemoral or saphenopopliteal junction)

โž– To assess whether the veins are straight enough to undergo endovenous treatment

โž– To establish the role the deep venous system is playing (e.g. the patient may be at risk of chronic limb swelling if the superficial venous system is treated when it is returning venous blood because the deep veins are incompetent)


Handheld Doppler: 

โž– A traditional test rarely performed since the advent of venous duplex scanning


Trendelenburg test/ Tourniquet test: 

โž– To locate the incompetent venous valves

  1. Lift leg upwards as patient lays flat and milk the leg towards the groin area to empty the superficial veins
  2. Place tourniquet over the saphenofemoral junction
  3. Observe the veins filling as the patient stands
  4. No filling and veins remain collapsed: incompetent venous valves
  5. Veins fill: incompetent valve is inferior to the saphenofemoral junction
  6. Repeat steps 1-4 but this time place tourniquet 3cm lower than the first time
  7. Repeat until you have identified the location of the incompetent valves, visualised by observing where filling stops


Cough impulse test:

  1. Ask patient to cough with your hand over the saphenofemoral junction
  2. If you feel an impulse, this is indicative of a saphena varix


Pertheโ€™s test: 

Allows you to distinguish between venous valvular insufficiency in the deep perforator and superficial venous system

  1. With the patient standing, apply tourniquet at mid-thigh level
  2. Ask patient to walk around for 5 minutes
  3. If the varicose vein is less distended after 5 minutes, it indicates that the deep venous valvular system is sufficient, suggesting the problem is with the superficial veins
  4. If the varicose veins remain distended after 5 minutes, it indicates there is a problem with the deep venous system, potentially caused by deep vein thrombosis

                           

Completion of the Examination

  1. Explain to the patient that the examination is complete, and thank them
  2. Wash hands โœ‹
  3. Summarise what the examination revealed


Summary:

  1. Greet the patient, introduce the chaperone and briefly explain the procedure
  2. Inspect the patient for any clinically relevant signs
  3. Inspect the patient's legs for any clinically relevant signs
  4. Assess varicosities
  5. Assess lower limbs e.g. measure pulses, perform percussion tap test and auscultation
  6. Perform additional tests: Venous duplex scanning, Handheld Doppler, Trendelenburg test, Cough impulse test and Perthe's test
  7. Complete the examination by thanking the patient


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