Chronic Venous Insufficiency and Venous Ulcers

 

Chronic Venous Insufficiency

Pigmentation (lipodermatosclerosis ulcer)

LEGS

  1. Lipodermatosclerosis
  2. Eczema
  3. Gaps (ulcers) causing white patches “atrophie blanche”
  4. Swelling (edema not in the dorsum of the foot due to subfascial fobrosis)

Venous Ulcer

Number  inspection Palpation

As inspection

LNs

Base

Mobility

Induration

lipodermatosclerosis

Extent

Tenderness

Site Gaiter or ulcer bearing area

Medial and lateral maleolai

Shape Rounded or any
Size Usually superficial
Floor Granulation tissue
Margin Pigmentation
Edge Sloping
Discharge Color – Amount – odor

Varicose Veins

 

Varicose Veins

Aim of examination

  1. The anatomical distribution of the veins
  2. Type primary or secondary
  3. Competence of saphenofemoral junction and other communicating veins
  4. Condition of deep system
  5. Presence of complication

Inspection

  1. Site and size of varicosities including Saphena varix
  2. Skin changes, ulcers and scars
  3. Swelling of the ankle

Palpation

  1. State of skin and subcutaneous tissue
  2. Sites of fascia defects
  3. Site of incompetence (Trendelenburg test + cough impulse)

Percussion 

  1. Tape test (Chevrier’s tape sign)
  2. palpation of the varicosities and pulse

Complete by Auscultation

  1. Spheno-femoral incompetence by hand-held Doppler
  2. If any bruit
  3. Examine the abdomen

History Taking for a patient with Varicose Veins

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Cosmetic disfigurement
  • Pain (Discomfort, restless leg – Dull, heavy, bursting with sense of hotness – At end of the day – On prolonged standing – Relieved by elevating the limb)
  • Night cramps
  • Vermiculation
  • Symptoms of complication
    • Haemorrhage – Thrombophlebitis – Oedema – Skin pigmentation – Atrophie blanche – Varicose eczema – Lipodermatosclerosis – Venous ulceration
  • Possible cause
  • Predisposing factors
    • Primary varicose veins
      • Female sex – High parity – Marked obesity – Constricting clothes – Estrogen intake e.g. contraceptive pills – Occupation requiring prolonged standing
    • Secondary varicose veins
      • Presence of complication – History of DVT – History of Traumatic or congenital AV fistula – History of pelvic tumors – Pregnancy

Assessment of venous circulation in lower limb

 

Assessment of venous circulation in lower limb

Ask patient to stand up

Inspection

  • Site of visible veins
  • Shape of visible veins
  • Size of visible veins
  • Effect of elevation
  • Effect of dependency
  • Ankle swelling
  • Ankle ulcer
  • Skin color

Palpation

  • Trunk of long saphenous vein
  • Trunk of short saphenous vein
  • Saphenofemoral junction
  • Saphenopopliteal junction
  • Fascial defects
  • Venous ulcer
  • Texture of skin and subcutaneous tissue

Percussion

Percussion wave conduction

Auscultation

Bruit over prominent varices
Tourniquet tests
Doppler ultrasound