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Friday, June 3, 2011

Examination of Varicose Veins(WITH VIDEOS)

Varicose Veins:
Elongated, dilated and tortuous veins are known as varicose veins. Veins of lower limb, spermatic veins, oesophgeal veins and haemorrhoidal veins have tendency towards varicosity. Most commonly varicose veins of lowe limb are involved and so we will consider the varicosities of the lower limbs.






Examination:
Follow the right side of the patient
Introduce yourself to the patient
Ask for the consent
Expose properly (Both lower limbs and abdomen up to the umblicus)

Inspection:
Following points should be in mind during inspection:
1- Whether varicose veins are present or not
2- Which leg side is involved
3- Which system of veins is involved( short or long saphenous system or both)
4- Colour of the limb  
   (i) Locally red --- Superficial thrombophlebitis   
   (ii) Generalized white colour --- Phlegmasia alba dolens ( swollen leg due to oedema or lymphatic obstruction)   
   (iii) Blue leg --- Phlegmasia cerulea dolens ( it confirms DVT )
5- Look for the skin changes ( shiny and stretched due to oedema, eczema, pigmentations, ulceration, lipodermatosclerosis, scar marks )
6- look for the cough impulse at saphenous opening (saphena varix)

Palpation:
1- Temperature
2- Tenderness
3- Palpation of ulcer or any other skin changes
4- Brodie-Trendelenburg test
5- Tourniquet test
6- Morrissey's cough impulse test
7- Perthes' test
8- Schwartz test

Persussion:
Scwartz test

Auscultation:
Continuous machinery murmur may be heard where arterio-venous fistula is present

Regional lymph nodes:
Inguinal lymph nodes may be enlarged if venous ulcer is present

Other limb:
Also examine the normal leg for varicose veins.

Brodie-Trendelenburg test:
This test is performed to determine the incompetency of the sapheno-femoral valve and other communicating system and can be performed in two ways. In both ways, patient is placed in recumbent/supine position, leg is raised and veins are emptied.The sapheno-femoral junction is pressed with thumb or tourniquet is applied just below the sapheno-femoral junction and patient is made to stand quickly. In first method, pressure is released, if the varices fill quickly from above in a column it indicates sapheno-femoral valve incompetency. In second method, the pressure is not released for a minute and leg is observed, the gradual filling of vein indicates incompetency of communicating veins. Positive Trendelenburg test is an indication for operation.

Tourniquet Test:
Tourniquets are tried around thigh and leg at different levels. Superficial veins are made empty by raising the leg in recumbent position. Now, the patient is made to stand. If the veins above the tourniquet fill quickly and below it remains collapsed, it indicates presence of incompetent vein above the tourniquet and vice-versa. Thus moving the tourniquet down the leg in steps one can determine the position of incompetent veins.

Perthes' Test:
It is done to know whether the deep veins are normal or not. A tourniquet is tied around the upper thigh tight enough to prevent the reflex down the vein. The patient is asked to walk quickly. If the communicating and deep veins are normal the varicose veins become shrunken. If communicating and deep veins are abnormal the varicose veins will be more distended.

Schwartz Test:
It is done in long standing varicose vein. A tap is made on the long saphenous varicose vein in the lower leg, an impulse is felt at saphenous opening.



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