VARICOSE VEINS CASE PROFORMA After taking informed consent, patient is examined in

standing
Name: Age: Sex: Occupation: Address: INSPECTION:
HISTORY -Assess Great (medial) and Short saphenous (lateral) veins,
popliteal swellings
Chief Complaints: -Look for (redness)superficial thrombophlebitis/generalized
Swelling along veins in Rt/Lt leg since swelling of DVT
Pain in Rt/Lf/both limbs since -Skin of Limb: 1. Colour, 2. Texture: Stretched/shiny due to
Pigmentation of skin of leg since edema, eczema/pigmentation (Gaiter area), ulceration
Ulcer in the leg since (examine like ulcer), scar of operations of varicose or healed
venous ulcer, toes-loss of hair/increased brittleness
History of Present Illness: -Cough Impulse (Saphenavarix)
Patient was apparently asymptomatic __ days back when he -Any ankle flares/venous stars
developed PALPITATION:
1. Swelling- site[Greater saphenous/Short saphenous], onset, Confirm inspection findings
duration, progression, relation to standing/walking, reduces on 1. Skin Temperature
lying down, any pain or color change along vein course 2. Skin tenderness (local tenderness)
2. Pain: onset, character, severity, time of occurrence (towards 3. Brodie Trendelenberg Test 1 and 2
end of day), Aggravating and relieving factors, any night cramps 4. Multiple Tourniquet test [Oschner Mahoner Test]=
3. Ulceration: Site, onset (traumatic, spontaneous), pain in ulcer, 5. Modified Perthes Test= to find deep vein thrombosis
discharge/bleeding, progression. • Important preliminary to do this test is that there should not be any
H/O itching, change in colour of limb perforator incompetence to do this test. Tourniquet is applied below
H/O constipation the saphenofemoral junction (no need to milk the veins before
applying tourniquet). • Ask the patient to walk with tourniquet
H/O lump abdomen
Observation:
H/O trauma
• Shrinking of varicose veins: Indicates that there is normal deep
H/O bladder symptoms (BPH) veins and perforators.
(Note: If there is perforator incompetence there will not be shrinking
of veins, hence cannot be done in cases of perforator incompetence)
PAST HISTORY: • More prominence of varicose veins associated with severe cramp
H/O similar complaints in the past like pain: Indicates there is deep vein thrombosis.
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ Note: Advantage over Perthes is that here the result is objective
Asthma/COPD/ / Blood transfusions (veins becoming prominent) as well as subjective (cramp like pain).
Any H/O of prolonged immobilisation 6. Schwartze Test= Ask the patient to stand and keep thumb of one hand at
Drug and Treatment History: Previous surgeries, stockings use the saphenous opening. Tap with other hand along the course of long
saphenous vein in the lower part of leg. Impulse is felt in the thumb at
FAMILY HISTORY: saphenous opening. This test implies the valves along the GSV are
None of the patient’s parents, siblings or first degree relatives have or incompetent.
have had similar complaints or any significant co morbidities 7. Pratt’s Test= To mark the position of weak perforators. Steps:
• Apply Esmarch elastic bandage from toes to groin to empty the
superficial veins. • Apply tourniquet at groin (below SF junction). •
Obstetric and Menstrual History= H/O recurrent abortions
With tourniquet in position remove bandage gradually from above
PERSONAL HISTORY: below and simultaneously apply another elastic bandage from groin
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and to toes in reverse direction. Inference: At the position of weak
perforators blow outs can be seen. Mark these blow outs with skin
Smoking), OCP use. In pregnancy- White leg
pencil.
Any Allergies
8. Morrisey’s Test= Limb is elevated to empty the veins and the limb is then
put to bed and the patient is asked to cough forcible. An expansile impulse is
PHYSICAL EXAMINATION
felt at the saphenofemoral junction in cases of sapheno-femoral
1. GENERAL SURVEY incompetence. Bruit can be heard on auscultation
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky 9. Fegan’s Test= after marking the blow outs make the patient lie
score) down to empty the veins. You can palpate the defect in deep fascia at
-Mental state and intelligence (CCC) these spots
-Build, state of nutrition 10. Oedema/Thickening/Redness (Periostitis)/ Lipodermatosclerosis
-Decubitus and Attitude, Any facies 11. Pulses-Arterial
12. Ian Aird Test= empty the proximal segment of the GSV with two fingers.
Release the proximal finger. If the vein fills up, it indicates SFJ incompetence.
A __ year old patient, supine decubitus who is __ built __
13. Homan’s Test = Forcible dorsiflexion of foot with knee extension causes
nourished is conscious, coherent, cooperative, and comfortably
pain in the calf.
seated/lying on the bed, well oriented to time, place and 14. Moses Test= Squeezing the calf muscles from side-to-side results in
person. severe pain at the calf.

PERCUSSION: Schwartz test

Check Pallor, Icterus, cyanosis, koilonychias, generalised
lymphadenopathy and pedal edema. AUSCULTATION: Along major arteries (Any bruit, systolic murmur,
VITALS: Temperature, Pulse, RR, BP. machinery murmur
Regional Lymph nodes: Inguinal (enlarged in venous ulcer)
LOCAL EXAMINATION-Varicose
 OTHER LIMB: Saphenous opening:
•• Just 4 cm below and lateral to the public tubercle
OTHER SYSTEMS: •• Closed by cribriform fascia and forms the lower boundary
CVS- Normal S1 S2 heard, No murmurs. of femoral canal
Respiratory: Normal vesicular breath sounds, No adventitious •• Saphenofemoral junction is seen just above the saphenous
sounds GIT: Per Abdomen Soft. opening
CNS- No Facial asymmetry, all reflexes are normal
II. Multiple tourniquets test
PROVISIONAL DIAGNOSIS: Step 1: Patient in recumbent position Milk all the veins. Three
This is a case of varicose vein affecting GSV of Rt lower limb with tourniquets are applied:
perforator incompetence of SFJ, below knee perforator and 5cm 1. Just below saphenofemoral junction 2. Just below mid-thigh
ankle perforator without any clinical evidence of DVT. 3. Just below knee
As per CEAP- C4as, Ep, Asp, Pr • Tourniquets are applied below each perforator.• Ask the patient
to stand.
NOTES Inference
CEAP Classification • Appearance of veins between tourniquet 1 and 2 is seen in
Clinical [S=Symptomatic pain, tightness, skin irritation, heaviness, adductor canal perforator incompetence • Appearance of veins
and muscle cramps, and other complaints attributable to venous between tourniquet 2 and 3 is seen in below knee perforator
dysfunction, A=Asymptomatic] incompetence • Appearance of veins below the 3rd tourniquet is
seen in lower leg perforators incompetent.
C0 No visible or palpable signs of venous disease If the veins above the tourniquet fills up and those below it remain
C1 Telangiectasies or reticular veins collapsed, it indicates presence of incompetent communicating
C2 Varicose veins vein above the tourniquet. Similarly if the veins below the
C3 Edema
tourniquet fill rapidly whereas the veins above the tourniquet
C4A Pigmentation or eczema
remain empty, the incompetent communicating veins must be
C4B Lipodermatosclerosis or athrophie blanche
below the tourniquet
C5 Healed venous ulcer
•• On releasing the tourniquet one by one from below upwards,
C6 Active venous ulcer
sudden retrograde filling of veins occurs. •• Some of them use a
.
fourth tourniquet palm breath above medial malleolus; appearance
Etiological Anatomical Pathophysiology of veins below 4th tourniquet implies lower leg perforator
incompetence
Ec: congenital As: superficial veins Pr: reflux Syndromes associated with varicose veins:
Ep: primary Ap: perforating veins Po: obstruction 1. Klippel-Trenaunay syndrome:
• Abnormal lateral venous complex (short saphenous)
Es: secondary Ad: deep veins Pr,o: reflux and obstruction • Capillary nevus• Bony abnormalities • Aplasia of deep veins •
Limb lengthening
En: no venous cause An: no venous location Pn: no venous pathophysiology
identified identified identifiable 2. Kasabach-Merritt syndrome: ‘Platelet trapping within
hemangiomas’
Signs of Gangrene: • Multiple cutaneous and large visceral hemangiomas
Change of colour(pale-bluish purple-black), Loss of temperature, Loss • Arteriovenous shunt • Congestive cardiac failure • Skeletal
of sensation, Loss of pulsation, Loss of function distortion and contour abnormalities • Hypopigmentation
Complications of Varicose Veins:
Perthes test Marjolin Ulcer, Periostitis tibia, Equinus deformity (Due to ulcer)
– Wrap the whole lower limb with elastic bandage Hemorrhage, Phlebitis, Calcification (Due to varicosity)
– Ask the patient to walk or exercise. Eczema, Pigmentation, Lipodermatsclerosis (Skin)
Result: If there is deep vein thrombosis, all the blood on getting diverted
into the deep venous system due to collapse of superficial venous system Varicose ulcers are treated by ‘Bissgard’s method: 4E’s=
by elastic bandage causes the deep venous system to dilate and results in Education, Elevation, Elastic Stockings, Exercise
severe cramps. Phlegmasia alba dolens (white leg)
The result is patient dependent and it is hence subjective Phlegmasia cerulea dolens (cyanotic mottled skin)
(Pregangrenous)
Brodie Trendelenburg test: Primary Varicose Veins= Idiopathic
Test 1. For saphenofemoral incompetence, Test 2. For perforator Secondary= 1. Obstruction to venous flow= Pregnancy,
incompetence Ovarioan mass, Pelvic organ cancer, Abdominal
Patient in recumbent position legs raised to empty the vein, may be lymphadenopathy, Ascites, Iliac vein thrombosis,
hastened by milking the veins. Tourniquet is applied below Retroperitoneal Fibrosis
saphenofemoral (SF) junction (Thumb may be used to occlude the SF 2. Destruction of Valve: DVT, OCP 3. High Pressure flow: AV
junction). fistula
Test 1: • Pressure released at the SF junction.• Varices fill very quickly from
above• Test 1 is positive, i.e. saphenofemoral incompetence is present.

Test 2: • Do not release the pressure for one minute • Gradual filling of
veins occur in the lower limb. • Test 2 is positive, i.e.
perforator incompetence is present.