Varicose veins case pro-forma

Sunday, 14 January 2024 2:29 PM

• Name, Age , Sex , Address:

•
• HISTORY
• Chief Complaints :
• Swelling along veins in Rt/Lt leg Since
• Pain in Rt/Lt/ both leg Since
• Pigmentation of skin of leg since
• Ulcer in the leg Since

• HISTORY OF PRESENT ILLNESS:

• Patient was apparently asymptomatic…days back when he developed
• 1.Swellings-site [Greater saphenous/Short saphenous], Onset, duration ,progression ,relation to standing/ walking ,reduces on lying down, any pain or colour change along vein course
• 2.Pain:Onset, character, severity, time of occurrence (towards end of day), Aggravating and relieving factors, any night cramps
• 3.Ulcerations: Site,Onset (traumatic ,spontaneous) , pain in ulcer,
• Discharge/ bleeding, progression
• H/O itching , change in colour of limb
• H/O Constipation
• H/O lump in abdomen
• H/O Trauma
• H/O Bladder Symptoms (BPH)

• PAST-HISTORY
• H/O Similar Complaint in the past
• Any H/O HTN , DM, CAD, TB Hypo/Hyperthyroidism/ Epilepsy/ Asthma/ COPD/ Blood Transfusion
• Any history of prolonged immobilisation

• DRUG AND TREATMENT HISTORY

• Previous Surgery, Stocking use

• FAMILY HISTORY:
• None of the patients parents, siblings or first degree relatives have or have had similar complaints or any significant co-morbidity

• Obstetric and Menstrual History

• Diet, Appetite, Bowel , Bladder, Spleen, Addictions ( alcohol and smoking)
• OCP Use in Pregnancy-White legs

• ANY ALLERGY

• PHYSICAL EXAMINATION

•
• GENERAL SURVEY

• - General assessment of illness - ECOG( Zubroad scale / Karnofsky Scores)

• -Mental State and Intelligence (CCC)
• -Build,State of nutrition
• -Decubitus and Attitude, Any facies

• A…..year old patient, supine decubitus who is…..built….nourished is conscious, coherent, and comfortably seated/lying on the bed, well oriented to time, place and person.

• Check Pallor, Icterus, cyanosis, koilonychias,generalised lymphadenopathy And pedal edema.

• VITALS:
• Temperature
• B.P
• RR
• PULSE

• LOCAL EXAMINATION [Vericose vein]

• After taking informed consent, patient is examined in standing

• INSPECTION:
• -Assess Great (medial)and Short saphenous (lateral) veins,popliteal swellings.
• -Look for (Redness) superficial thrombophlebitis/ generalised swelling of DVT.
• -Skin of limb : - 1) Colour
• 2)Textures: Streched/shiny due to edema , eczema/ pigmentation (Gaiter area) ,ulceration ( Examine like ulcer) , Sacr of operation of varicose or healed venous ulcer, toes-loss of
hair/ increased brittleness

• - COUGH IMPULSE ( Saphenavarix)

• - any ankle flare/ venous stars

• PALPITATION
• Confirm inspection findings
• 1.Skin Temperature
• 2.Skin Tenderness (local tenderness)
• 3.Brodie Trendelenberg test 1 and 2
• 4.Multiple Tourniquet test (Oschner Mahoner Test)
• 5, Modified Perthes Test =to find deep veins thrombosis
• - Important preliminary to do this test is that there should not be any perforator incompetence to do this test.Tourniquet is applied below the saphenofemoral junction ( no need to milk the
veins before applying tourniqute) Ask the patient to walk with tourniquet

• Observation:

• -Shrinking of vericose veins: indicates that there is normal deep veins and perforators.
• Note: if there is perforator incompetence there will not be shrinking of veins , hence can not be done in case of perforator incompetence )
• -More prominence of vericose veins associated with severe cramp like pain: indicate there is deep vein thrombosis .
• Note:-Advantage over Perthes is that here the result is objective( veins becoming prominent) as well as subjective (Cramps like pain ).
•
• 6.SCHWARTZE TEST : -