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The Peripheral V enous Disease Examination DR AMY ROSS (FY2)OSCE EXAMINATION– what is expected Important aspects from history Recap on upper & lower limb anatomy GENERAL INSPECTION Recap of upper and lower limb anatomy Varicose veins Lipodermatosclerosis PALPATION Trendelenburg testlimb venous systemsof upper and lower Different types of varicose veins OSCE: hints Observe Gait. Inspect from front/side and and tips back. Understand treatment optionsOSCE CHECK LIST - https://geekymedics.com/wp-content/uploads/2020/09/OSCE-Checklist- VaricoseVein-Examination.pdfIntroduction 1. Wash hands 2. Introduce yourself to the patient 3. Confirm the patient’s name and date of birth. 4. Briefly explainwhat the examination will involve 5. Gain consent 6. Position the patient on the bed, with the head of the bed at45°. Important - ** ask patient if they are in any pain prior to examining **General Inspection End of the bed: ?Comfortable at rest ?Breathless ?Appear to be in any pain or discomfort Observe Gait - ?antalgic gait Inspect legs – from front then side then back! 7% of people with varicose veins develop 1-2% of people with skin changes related lower leg skin changes (such as to varicose veins develop lower limb haemosiderin deposition and/or ulceration each year. ¹ lipodermatosclerosis). ¹General InspectionImages taken from BMJ ³Images taken from DermNetNZ.org ² Haemosiderin deposits Varicose veins Oedema Venous eczema ( damaged capillaries Lipodermatosclerosis Atrophe blanche Venous ulcers leak blood à red brown patches) General Inspection– Peripheral Venous oedema/unilateral eczema/haemosiderin ankle swelling deposits Is there any mobility aids? Is the foot cyanotic or well Medications/ compression perfused? Cold/Warm to touch? stockings/wound dressings Any previous scarring from previous surgery? ? Any ulcers – check Lipodermatosclerosis in between toes!If a patient has a varicocele what can this be a presenting feature of? Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller Bilateral varicoceles may affect fertility Usually managed conservatively. If concerns about testicular function or fertility, then surgery or radiological management can be considered.What is the name of a large varicosity found at thesapheno-femoral junction?Varicose Vein – venous dilatation & tortuosity Engorged peripheral veins à damaged or incompetent valves à turbulent blood flow or reflux à great saphenous vein/ small saphenous vein/ deep veins. Incompetent valves are described as “insufficient” à do not return venous blood towards the heart effectively (venous insufficiency). COMMENT on distribution/colour/prominence… TYPES – PRIMARY (due to venous wall weakness) VS SECONDARY (deep vein thrombosis or leg injury)Lipodermatosclerosis– What is it? Another name for it…Inflammation of subcutaneous fat à woody and hard skin/pigmentation/swelling/redness “inverted champagne bottle leg” Temperature & Palpation Palpate all the way along the varicosities looking for tenderness and hlebitis Palpate the saphenofemoral junction4cm lateral & inferior to pubic tubercle) ◦ Feel for anysaphena varix (large varicosity at apheno-femoral junction) ◦ Perform the cough test, asking the patient to cough à ?any thrills or dilatations at the junction Assess the temperature - ?signs of phlebitis (inflammation of varicosities) – most common in superficial veins caused by trauma or infection ?Any calf tendernessSpecial tests: Trendelenberg test Trendelenbergst Used to locate site of the incompetent venous valves. Trendelenburgest/tourniquettest. One leg should be assessed at time. - Position patient supine - Lift the patient’s leg up and empty the superficial veins (by milking the leg towards the groin (SFJ)). - Place tourniquet overSFJ - Ask the patient to stand and observe for filling veins: If veins have not filled and remain collapsed, it indicates the incompetent venous valve(s) was/were at the level of the SFJ. If veins have filled up again, it indicates the incompetent valve isinferior to the SFJ - Repeatthe test & placetourniquet 3cm lower than the previous positipt to stand and observe venous filling once again. - Repeatthis sequence until filling stops & location of the incompetent venous valves identified.Management 1. Leg elevation à reduces venous pressure à improves oedema & discomfort. 2. Walking à activates muscle pump à increasing venous return and decreasing venous hypertension. 3. Weight lossdecreases resistance of venous return to the heart à lowering venous hypertension. (varicose veins may become more prominent (subcutaneous fat is lost)). 4. Graduated compression stockinapplies more pressure at the ankle which gradually reduces upwards to the knee. Limits elevated hydrostatic pressure associated with incompetent venous valves. Encourages venous return & reduces venous hypertension. NICE suggests compression hosiery is generally not indicated while awaiting specialist review (may provide relief if symptoms severe and waiting times are long). What do you have to ensure prior to prescribing compression stockings?Compression stockings Class 1 stockings (light compression) exert pressure 14-17 mm Hg Class 2 stockings (medium compression) exert pressure 18-24 mm Hg Class 3 stockings (high compression) exert pressure 25-35 mm Hg. Prescribe 2 pairs of stockings à allow for washing Should replace every 3-6 monthsInterventional treatments 1. Foam Sclerotherapy 2. Laser therapy 3. Radiofrequency ablation Minimally invasive endovenous treatments carried out under local anaesthetic > open surgical techniques (sapheno-femoral junction ligation and stripping of the great saphenous veinreduced morbidity. After any of these interventions, compression therapy usually commenced - between 1 and 4 weeks. Complications: recurrence/bleeding/ DVT/ saphenous or sural nerve injury Endovenous techniques à thrombophlebitis and skin staining Open procedures à wound infection and breakdown Foam sclerotherapyà allergic reactions, risk of stroke (rare).Further investigations Doppler ultrasound further bedside assessment of incompetent venous valves & identify thrombus Venous duplexcanning ABPI measurement Peripheral arterial disease examination Abdominal Examination (rare large mass causing compression on venous system) Important Q to gather from hx.. “red flag” symptoms (weight loss, rectal or VTE assessment vaginal bleeding, change in bowel habit, pelvic Leg swelling pain, and night sweats). Recent surgery/malignancy/immobility/pregnancy (Varicose veins caused by abdominal or pelvic Temperature mass may be more likely if there is unilateral Tenderness varicose veins or leg swelling). Pitting oedema Calf diameters ? Any previous varicose vein treatment or Palpate pulses venous thromboembolism à may affect venous system function à can influence future WELLS SCORE treatment optionsCase example 52F presented to ED with bilateral lower leg swelling and skin changes. Had been put on PO abx by GP fortx of cellulitis. No improvement. No temperatures, felt well generally, inflammatory markers normal. O/E..Practice Q 1. The great saphenous vein runs where in relation to the medial malleolus. A Anterior B Posterior 2. It then proceeds up the medial aspect of the leg and passes over the …. border of the medial epidcondyle of knee. A Anterior B PosteriorAnswer 1. A 2. B3. The small saphenous vein passes …. In relation to the lateral malleolus? A anterior B posterior C overlies itAnswer : B4. The small saphenous vein drains into: A Popliteal vein B Femoral vein C Perforator veinAnswer A5. Class II compression stockings has a pressure of.. A 14-17 mmHg B 16-24 mmHg C 18-24 mmHg 6. The sural nerve has the following nerve roots A S1 S2 B L3 L4 C L5 S1 Thank you! Please complete feedback.. https://app.medall.org/training/feedback/anonymous?organisation=osceprep-3rd-year&keyword=8391a88ba49cece38cbfef4d References Image 1 https://www.ulster.ac.uk/__data/assets/pdf_file/0008/821861/Preparing-for-your-OSCE- TOC-2021-FINAL.pdf 1. Eds Thompson MM, Fitridge R, Boyle J, et al. Oxford Textbook of Vascular Surgery. Oxford University Press, 2016. 2. https://dermnetnz.org/topics/lipodermatosclerosis-images 3. Atkins E , Mughal N A, Place F,Coughlin P A. Varicose veins in primary care BMJ 2020; 370 :m2509 doi:10.1136/bmj.m2509 https://teachmeanatomy.info/abdomen/vasculature/venous-drainage/