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Lower limb vascular (venous system) examination

Lower limb venous system examination and questions for medical student exams, finals, OSCEs and MRCP PACES

 

Intro (WIIPPPPE)

  • Wash your hands
  • Introduce yourself
  • Identity of patient – confirm
  • Permission (consent and explain examination)
  • Pain?
  • Position – initially standing
  • Privacy
  • Exposure – trousers/skirt removed

 

General Inspection

  • Surroundings
    • Monitoring and treatments
    • Paraphernalia – especially walking aids
  • Patient
    • Well or unwell?
    • Comfortable or in pain?
    • Body habitus

 

Systemic examination

  • Inspect (standing)
    • Ask patient to externally rotate each leg. Inspect long saphenous vein and perforator veins of the superficial system (2, 3 and 5cm above medial malleolus).
      • Pay close attention to the saphenofemoral junction (SFJ) for a saphena varix (2.5cm lateral and below the pubic tubercle).
    • Ask patient to turn away from you to inspect the short saphenous vein and sapheno-popliteal junction.
  • Inspect (supine at 45 degrees)
    • Signs of venous insufficiency – entire leg and foot but especially gaiter area:
      • Venous ulcers
      • Scars from healed venous ulcers
      • Haemosiderin deposit
      • Venous eczema
      • Lipodermatosclerosis and inverted champagne bottle shaped legs
      • Atrophie blanche
      • Venulectasias (thread veins)
    • Signs of thrombophlebitis
      • Swollen, red, tender vein
      • Hardened thrombus within vein
    • Signs of DVT
      • Swollen, red, painful calf often with dilated superficial veins

 

Vascular examination video

 

  • Palpate
    • Temperature
    • Calf tenderness (DVT)
    • Pitting oedema
    • Palpate over course of long saphenous, perforators and short saphenous vein (varicosities, thrombophlebitis)
    • If there is a saphena varix:
      • Ask the patient to cough to emphasise it
      • Palpate for a thrill over varix
    • Tap test:
      • Tap long saphenous vein (medial) at knee and palpate SFJ simultaneously. A palpable impulse at the SFJ indicates venous insufficiency in the long saphenous vein.
  • Auscultate
    • Any large clusters of veins (continuous ‘machinery’ murmur suggests AV fistula)

 

Closure

  • Thank patient
  • Ensure patient is comfortable
  • Check if they need any help getting dressed
  • Wash hands
  • Turn to examiner, hands behind back, holding stethoscope before saying: “To complete my examination, I would like to…”
    • Further examinations:
      • Perform a peripheral arterial examination (mixed vessel disease may contraindicate venous compression stockings)
      • Perform an abdominal examination (to exclude abdominal cause of varicose veins)
    • Bedside investigations:
      • Confirm site of venous incompetence with hand-held Doppler probe
    • Further investigations
      • Colour flow venous duplex of superficial and deep system
      • Colour flow arterial duplex if mixed vessel disease suspected
      • Consider venography in complicated cases
    • For further information on special tests in the venous exam (Trendelenberg’s, Pethes’ and the tourniquet test) please see the questions section.

 

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Common Lower limb venous system examination exam questions for medical students, finals, OSCEs and MRCP PACES

 

Click here to download free teaching notes on Lower limb venous system examination: Lower limb venous system examination

Perfect revision for medical students, finals, OSCEs and MRCP PACES