General Physical Examination
• Pulse: _______/min
• Blood Pressure: _____mmHg
• Respiratory Rate: _______/min
• Temperature: ___ °F
• BMI: ___ kg/m²
• Built and nourishment: ______________
General examination findings:
• Pallor: Present / Absent
• Icterus: Present / Absent
• Cyanosis: Present / Absent
• Clubbing: Present / Absent
• Lymphadenopathy: Present / Absent
• Pedal edema: Present / Absent
Local Examination of Lower Limbs
Inspection (Standing Position)
• Side involved: Right / Left / Bilateral
• Dilated, tortuous and elongated superficial veins: Present / Absent
• Distribution of varicosities:
- Aspect involved: medial/lateral
- Extent: From ______________ to ______________
- Veins involved: Long saphenous vein/ Short saphenous vein/ Tributaries
• Visible perforators: Present / Absent
Skin changes:
• Edema: Present / Absent
• Hyperpigmentation: Present / Absent
• Venous eczema: Present / Absent
• Lipodermatosclerosis: Present / Absent
• Atrophie blanche: Present / Absent
• Venous ulcer: Present / Absent
• Healed ulcer scar: Present / Absent
• Cellulitis: Present / Absent
• Gangrene: Present / Absent
• Active bleeding: Present / Absent
If ulcer is present:
• Site: ______________
• Size: __ × __ cm
• Number: ______________
• Floor: ______________
• Edge: ______________
• Surrounding skin: ______________
• Scar of previous varicose vein surgery: Present / Absent
• Swelling of limb: Present / Absent
• Calf muscle wasting: Present / Absent
• Gait: Normal / Abnormal
• Examination of opposite lower limb: Normal / Similar findings present
Palpation
• Local rise of temperature: Present / Absent
• Tenderness: Present / Absent
• Veins are:
- Soft / Thrombosed
- Compressible / Non-compressible
- Empty on elevation: Yes / No
- Induration around ulcer: Present / Absent
Saphenofemoral junction:
• Cough impulse (Morrissey’s sign): Present / Absent
• Palpable venous thrill: Present / Absent
Calf circumference:
• Right:_____cm
• Left: _____cm
Pitting edema: Present / Absent
Special Tests
• Brodie-Trendelenburg test: Positive / Negative
• Multiple (Three) Tourniquet test: Positive / Negative
(Suggestive of ______________ perforator incompetence)
• Schwartz test: Positive / Negative
• Fegan’s test: Positive / Negative
Assessment of Venous Competence
• Saphenofemoral junction: Competent / Incompetent
• Saphenopopliteal junction: Competent / Incompetent
• Perforators: Competent / Incompetent
• Venous refilling: Rapid / Slow
Peripheral Arterial Examination
• Femoral pulse: Present / Absent
• Popliteal pulse: Present / Absent
• Posterior tibial pulse: Present / Absent
• Dorsalis pedis pulse: Present / Absent
• Evidence of arterial insufficiency: Present / Absent
Examination for Deep Venous System
• Calf tenderness: Present / Absent
• Increased calf circumference: Present / Absent
• Dilated collateral veins: Present / Absent
• Clinical evidence of deep vein thrombosis: Present / Absent
Examination of Inguinal Region
• Swelling: Present / Absent
• Lymphadenopathy: Present / Absent
Examination of Abdomen
• Mass: Present / Absent
• Ascites: Present / Absent
• Dilated abdominal veins: Present / Absent
• Evidence of proximal venous obstruction: Present / Absent
Causes of secondary varicose veins:
• Previous deep vein thrombosis: Present / Absent
• Pregnancy: Present / Absent
• Pelvic mass: Present / Absent
• Abdominal malignancy: Present / Absent
Systemic Examination
CVS
Normal S1 & S2 are heard.
Respiratory System
B/L air entry present, no added sounds.
Abdomen
Non-tender.
No organomegaly.
How to present the examination findings.
The patient is conscious and oriented to time, place and person. He/She is examined in a well-lit room, adequately exposed, in standing and lying positions, after taking verbal consent.(in presence of female attendant [if female patient])
General physical examination revealed pulse _/min, blood pressure _ mmHg, respiratory rate _/min, temperature ___°F and BMI _. The patient is moderately built and nourished. Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Pedal edema are present or absent accordingly.
On local examination in standing position, dilated, tortuous and elongated superficial veins are visible over the ______ aspect of the right/left lower limb extending from ______ to ______. The distribution of the varicosities corresponded to the course of the long/short saphenous vein and its tributaries. Visible perforators are present/absent.
The overlying skin showed ______. Associated findings included edema, hyperpigmentation, venous eczema, lipodermatosclerosis, atrophie blanche, healed ulcer scars or venous ulceration as applicable. The ulcer, if present, measured __ × __ cm and is situated over the ______ region. No active bleeding, cellulitis or gangrene are noted. There are no scars suggestive of previous varicose vein surgery.
Both lower limbs are compared for symmetry. Swelling of right/left limb is present/absent. Calf muscle wasting is present/absent. Gait is normal/abnormal.
Inspection findings are confirmed by palpation. Local rise of temperature and tenderness are present/absent. The varicosities are soft/thrombosed, compressible and emptied on elevation of the limb. Cough impulse at the saphenofemoral junction (Morrissey’s sign) is present/absent. A palpable venous thrill is present/absent. Induration around the ulcer is present/absent.
The veins refilled rapidly/slowly after release of pressure during special tests. The saphenofemoral junction is clinically competent/incompetent. The saphenopopliteal junction is competent/incompetent. Perforator incompetence is present/absent.
Special tests are performed as follows:
• Brodie-Trendelenburg test: positive/negative.
• Multiple (Three) Tourniquet test: suggestive of ______ perforator incompetence.
• Perthes/Modified Perthes test: positive/negative.
• Schwartz test: positive/negative.
• Fegan’s test: positive/negative.
Peripheral arterial pulses including femoral, popliteal, posterior tibial and dorsalis pedis arteries are palpable and normal. There is no evidence of arterial insufficiency.
Calf circumference measured __ cm on the right and __ cm on the left. Pitting edema is present/absent. There is no calf tenderness or other clinical evidence suggestive of deep vein thrombosis.
Examination of the inguinal region revealed no swelling or lymphadenopathy. Examination of the abdomen revealed no mass, ascites or dilated abdominal veins suggestive of proximal venous obstruction. There is no clinical evidence of pregnancy, pelvic mass or other causes of secondary varicose veins.
The opposite lower limb showed/no evidence of varicose veins.
Systemic examination revealed normal cardiovascular, respiratory and abdominal findings.
Summary
This is a case of primary/secondary varicose veins involving the long/short saphenous venous system of the right/left lower limb associated with ______ (saphenofemoral incompetence, saphenopopliteal incompetence, perforator incompetence, edema, eczema, lipodermatosclerosis, venous ulcer, etc.), with no evidence of arterial insufficiency or deep venous thrombosis.
One-line Case Presentation
This is a case of primary varicose veins involving the long saphenous venous system of the left lower limb with saphenofemoral and perforator incompetence, presenting with dilated tortuous veins and features of chronic venous insufficiency without evidence of arterial disease or deep venous thrombosis.
