Varicose Vein: Examination

                                                                Varicose Vein: Examination

[A] Inspection

·         Examined in standing position (supine for special tests)

·         Dilated veins: Location

·         Venous                system affected

§  Great saphenous system(in front of medial malleolusàruns medially in leg and thigh àsaphenous opening)

§  Short saphenous system(behind lateral malleolusàruns posteriorlyà terminates in popliteal fossa)

§  Perforators

§  Both great and short saphenous              

·         Extent of involvement

·         Skin of the leg

−        Pigmentation

−        Eczema

−        Ulcer (describe details of ulcer)

−        Texture

−        Colour

§  localized redness- superficial thrombophlebitis

§  White (generalized)- Phlegmasia alba dolens (due to edema/lymphatic obstruction)

§  Blue and congested- Phlegmasia cerulea dolens (due to DVT)

·         Morrisey's test – Cough                impulse                at saphenous opening (present in Saphena varix)

·         Any discrepancy in limb size (local gigantism)

[B] Palpation

1.       Tenderness or thickening of veins along                its course

2.       Cough impulse at sapheno-femoral junction (Morrisey's test)

3.       Brodie Trendelenburg’s                test: Two parts

(To evaluate perforaters and saphenofemoral valve respectively)

·         First Part (for perforator)

Empty veinsàblock SF Junction by tourniquet àmake him stand (keeping tourniquet tied)

Positive –superficial veins get distended (suggest perforator incompetence)

·         Second Part

Empty veinsàblock SF Junction by tourniquet àmake him standà Release tourniquet

Positive – superficial veins get filled quickly from above (suggest              incompetence   of SF junction)

4.       Tourniquet test

Multiple torniquet at the level of each known perforator ( 1above and 1 below)

5.       Schwartz test

·         Tap lower part of long saphenous system àImpulse at saphenous opening (positive test)

6.       Fegan’s                test

·         Crescentic gap felt in deep fascia (site of perforator)

7.       Modified Perthes’ test

·         Block SFJ à walk for about 3–5 minutesàEvaluate change in dilated superficial veins

§  Collapse- deep veins patent

§  More distended and bursting pain- deep veins occluded by thrombosis

8.       Pratt’s test (to look for position of perforaters)

·         Outdated (don’t mention if not asked)

·         Elastic bandage from toe to groin to empty varicose veinàblock SFJ by tourniquetàbandage taken off ànow bandage from groin to toesà blow outs seen at position of perforaters

9.       Palpation of the ulcer

10.   Palpation of arterial pulses

11.   Homan’s sign

·         Outdated, Avoided in most circumstances

·         Passive forceful dorsiflexion of foot with knees extendedàstretches calf muscle àpain

·         Positive in DVT

12.   Moses’ sign

·         Outdated, Avoided in most circumstances

·         Calf muscle squeezed side to sideà Pain

·         Positive in DVT

[C] Auscultation

·         „ Bruit in arterio-venous fistula

Varicose Veins: History

Varicose Veins: History

1.      Chief Complaints

·         Swelling along the veins / dilated veins in lower limb

·         Pain in lower limb for

·         Blackish pigmentation of skin in the  leg

·         Ulcer in leg

2.      History of Present Illness

·         Swelling

Ø  Onset-sudden (DVT) or insidious

Ø  Duration

Ø  Site of onset and progression

Ø  Relieving factor –disappears on lying down

Ø  Any pain or color change along the course of the vein (thrombophlebitis)

·         Pain

Ø  Onset- acute (DVT) or insidious

Ø  Character of pain—dull aching (varicose) /cramping (DVT)

Ø  Mode of occurrence

§  On walking (intermittent claudication- PVD)

§  Towards the end of the day (Varicose)

Ø  Any night cramps

·         Ulcer

Ø  Onset, duration, site

Ø  Associated pain, discharge, bleeding

Ø  Itching, skin color changes

·         Any pain abdomen

·         Any lump in lower abdomen

3.      Past History

(Any history suggestive of deep venous thrombosis)

·         Pain and swelling in the calf with fever

·         Hospitalization           

·         Prolonged immobilization in bed

4.      Personal History

·         OCP intake

·         Smoking

·         Occupational prolonged standing for long time

·         Computer professionals requiring long hours in a sitting posture—E thrombosis

·         Recent long air travel (economy class syndrome)-deep vein thrombosis

5.      Family History

·         Any family history of similar disease (runs in family)

6.      Treatment History

·         History of surgery in lower limb

·         Whether using elastic compression/ Unna boot

·         History of Injection sclerotherapy

7.      Any history of calf pain and leg swelling àpleuritic chest pain, haemoptysis and dyspnea

(DVTà Pulmonary Embolism)

Ulcer: Examination

                                      Ulcer: Examination

[A] Inspection

1.       „Number

2.       „Site: In relation to the region or bony landmark

3.       „Extent

4.       „Shape/Size

5.       „Margin

·         Junction of normal skin and the periphery of the edge of the ulcer

6.       Edge of the ulcer

·         Area of the ulcer between the floor and the margin

§     Sloping- Healing Ulcer

§     Undermined -TB

§     Punched out – Gummatous or deep trophic ulcer

§     Raised and pearly white beaded Edge- Rodent ulcer

§     Rolled out (Everted) Edge- SCC

7.       Floor of ulcer

·         Exposed portion of the ulcer

·         Covered by red granulation tissue/pale granulation tissue/slough

8.       Discharge

·         character, amount, smell

9.       Adjacent area

·         Any swelling

·         Any skin change

·         Any secondary changes, pigmentation, pallor

·         Any associated venous diseases

[B] Palpation

1.       Temperature/ tenderness„

2.       Size of the ulcer

3.       Margin and edge of ulcer

4.       Base: The area on which ulcer rests

·         Feel the base by picking up the ulcer in between the thumb, index and middle finger

·         Marked induration in Scc and Hunterial ulcer

5.       Mobility of ulcer over the deeper structure/ Relationship with deeper structures

6.       Bleeding to touch or not

7.       Surrounding  Skin

Ulcer: History

                                      Ulcer: History

1.       Duration

2.       Mode of onset

3.       Site

4.       Progress of the ulcer: change in size and shape

5.       Pain over the ulcer

·         Site of pain

·         Any radiation

·         Character of pain

·         Severity

6.       Discharge

·         Serous/purulent/hemorrhagic

7.       Associated disease:

·         Diabetes

·         Sickle cell anemia

·         Pulmonary tuberculosis

·         Varicose vein

·         Systemic malignancy/AIDS

8.       Past history of similar ulcer, tuberculosis

9.       Personal history: Smoking, Alcohol intake

Thyroid: Examination

Thyroid: Examination

GPE

1.       Facies- Thyrotoxic facies, myxedema facies

2.       Pulse -rate and rhythm (preferably sleeping pulse)

3.       Wet/Sweaty hands

LOCAL

[A] Inspection

1.       Position and extent of the swelling

(In reference to sternomastoid muscle, suprasternal notch and thyroid cartilage)

2.       Shape

3.       Size (vertical and horizontal dimension in cms)

4.       Surface: Smooth/irregular/nodular.

5.       Margins

6.       Skin over the swelling: Scar/pigmentation/venous prominence.

7.       Any pulsation

8.       Movement of the swelling with deglutition

·         Thyroid Swelling

·         Subhyoid bursitis

·         Prelaryngeal or pretracheal lymph node

·         Any swelling arising from larynx or trachea

·         Thyroglossal cyst

9.       Movement of the swelling with protrusion of the tongue (thyroglossal cyst)

[B] Palpation

1.       Temperature /Tenderness

2.       Movement of the swelling with deglutition

3.       Movement of the swelling on protrusion of the tongue

4.       Position and extent of the swelling

5.       Shape/Size

6.       Surface, margin

7.       Consistency: Hard, firm, soft cystic, variegated

8.       Any pulsation/thrill

9.       Any skin fixity

10.   Mobility: side to side and up and down

11.   Relation of the swelling with sternocleidomastoid muscle

12.   Positions of trachea

13.   Pizzillo’s method (In obese patients with short neck)

·         Patient keeps both his hands on the occiput and extends the neck

14.   Lahey’s method

·         to palpate one lobe push swelling from opposite side e.g. To palpate the left lobe, push the right lobe to the left with the left hand so that the left lobe becomes prominent

15.   Crile’s method

·         Place pulp of the thumb over the swelling àask to swallowàswelling moves up and downà nodularity felt easily

16.   Kocher's test for tracheal compression

·         swelling is pressed slightly on either side of tracheaà stridor if tracheomalacia

17.   Berry’s sign (to look for malignant infiltration of carotid sheath)

·         Carotid pulse not palpable on the side of the swelling but palpable above and below the swelling

18.   Signs of sympathetic trunk palsy (Horner's syndrome)

(Mnemonic- AMPLE)

·         Anhidrosis (loss of sweating)

·         Miosis

·         Pseudoptosis (slight drooping of upper eyelid)

·         Loss of ciliospinal reflex

·         Enophthalmos

[C] Percussion:

·         Dull note over manubrium sterni in retrosternal goiter

[D] Auscultation

·         Any bruit audible or not near upper pole of the thyroid lobes.

[E]Examination of Cervical Lymph Nodes

EXAMINATION FOR TOXIC SIGNS

[A] Pulse

·         rate

·         rhythm

·         volume

·         any special character—collapsing or not

[B] Tremor in hands and tongue

[C] Thrill and bruit over the thyroid gland usually present at upper pole

[D]Eye signs

1.       Exophthalmos: Forward bulging of the eyeball

[Normal                        -Upper lid halfway between pupil and superior limbus

-Lower lid at a tangent to inferior limbus

Lid retraction               -Upper lid raised

-Lower lid normal

(Do not be deceived into thinking this abnormality is caused by exophthalmos.)

Exophthalmos             -Both lids moved away from centre with sclera visible below or all-round the iris]

(Norman Browse)

·         Naffziger method

§  Look from behind neck of the patient (slightly extended)à along superior orbital marginà if eyeball is seen beyond the superior orbital marginàExophthalmos present

2.       Dalrymple’s sign: Visibility of upper sclera due to spasm of upper eyelid

3.       Von Graefe’s sign: lid lag

(Mnemonic- Long neck of Giraffe causes lag in eating grass)

4.       Joffroy’s sign: Loss of wrinkling of forehead on looking up

(Mnemonic- Anger/frown of King Joffery in Game of thrones)

5.       Möbius sign: failure of convergence on accommodation at a near object from a distant object

(Mnemonic- Mobile causes failure of convergence)

6.       Stellwag’s sign: Infrequent blinking (stare look)

(Mnemonic- Still look)

7.       Chemosis

8.       Test for eye movement (any palsy)

EXAMINATION FOR RETROSTERNAL GOITRE

·         Lower margin of swelling. Whether visible or not (on deglutition)

·         Any dilated vein over the neck and chest wall

·         Pemberton's sign

§  patient raises both upper limbs above the head for 2–3 minutesà congestion and puffiness in the face with respiratory distress

·         Percussion over the manubrium sterni—Dull note