Varicose vein examination

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Varicose Vein Examination (Clinical/OSCE format)

1) Preparation

Wash hands, introduce yourself, confirm patient identity
Explain exam and obtain consent
Ensure good exposure: from groin to feet (both legs), with chaperone if needed
Examine standing first (best for visible varicosities), then supine

2) Inspection (Standing)

Look from front, sides, and behind:

Distribution of dilated veins
- Long saphenous territory: medial leg/thigh
- Short saphenous territory: posterior calf
Skin changes of chronic venous disease
- Hyperpigmentation (gaiter area)
- Venous eczema
- Lipodermatosclerosis
- Atrophie blanche
- Healed/active venous ulcer (usually medial malleolus)
Edema (ankle/calf)
Scars (previous varicose surgery/endovenous procedures)
Signs suggesting DVT/post-thrombotic disease (asymmetry, diffuse swelling, collateral veins)

3) Palpation

Check local warmth/tenderness over veins (superficial thrombophlebitis)
Palpate for saphenofemoral junction (SFJ) area tenderness/varix in groin
Assess pitting edema
Feel peripheral pulses (DP/PT) to exclude major arterial disease before compression therapy
Cough impulse at SFJ (if visible groin varix)

4) Bedside Clinical Tests (classic; less used now than duplex)

A. Tap test (percussion)

Tap distal varix, feel transmitted impulse proximally
Suggests valvular incompetence in connected superficial segment

B. Cough impulse test (at SFJ)

Finger over SFJ, ask patient to cough
Expansile impulse suggests SFJ incompetence

C. Trendelenburg test

Patient supine, leg elevated to empty superficial veins
Apply tourniquet upper thigh (occlude superficial, not deep system)
Patient stands:
- Rapid filling before release suggests perforator/deep-to-superficial reflux
- Sudden filling after release suggests SFJ reflux

D. Multiple tourniquet/perthes-type tests (historical)

Can help localize incompetent perforators/deep patency, but duplex ultrasound has replaced these in routine practice

5) Examine for Complications

Bleeding points from superficial varix
Superficial thrombophlebitis
Venous ulceration/infection
Chronic edema and skin fibrosis (advanced chronic venous insufficiency)

6) Confirmatory Investigation (Gold standard)

Duplex venous ultrasound:
- Maps reflux (superficial, deep, perforator)
- Identifies junctional incompetence (SFJ/SPJ)
- Excludes/assesses DVT and obstruction
- Essential for treatment planning

7) Useful Documentation

CEAP style summary:
- Clinical class (e.g., C2 varicose veins, C4 skin changes, C6 active ulcer)
- Etiology/anatomy/pathophysiology from duplex findings

8) Typical OSCE Presentation Line

“This patient has varicose veins predominantly in the [long/short] saphenous distribution with [no/yes] signs of chronic venous insufficiency (pigmentation/eczema/lipodermatosclerosis/ulcer). I would confirm extent of reflux and deep venous patency with duplex ultrasound and then discuss conservative versus interventional management.”

If you want, I can give you a 1-minute OSCE viva script and a comparison table of Trendelenburg vs Perthes tests.

Yes please

1-minute OSCE viva script (Varicose veins)

“I examined this patient standing and supine with adequate exposure.
On inspection, there are dilated, tortuous superficial veins in the [medial leg/thigh = long saphenous] / [posterior calf = short saphenous] distribution.
I looked for complications and chronic venous insufficiency signs: edema, gaiter hyperpigmentation, venous eczema, lipodermatosclerosis, and ulceration around the medial malleolus. I also checked for scars of prior venous procedures.

On palpation, I assessed tenderness or warmth suggesting thrombophlebitis, checked for pitting edema, and examined peripheral pulses to ensure arterial sufficiency before any compression therapy.

I performed bedside reflux tests (Trendelenburg/cough impulse), though these are historical and less accurate than imaging.
My provisional diagnosis is primary varicose veins with [or without] chronic venous insufficiency.

I would complete assessment with duplex venous ultrasound to map superficial/deep/perforator reflux and exclude obstruction or DVT.
Management would include lifestyle and compression where appropriate, and if symptomatic with confirmed truncal reflux, discuss endovenous ablation, foam sclerotherapy, or surgery depending on anatomy and local expertise.”

Trendelenburg vs Perthes test (quick comparison)

Feature	Trendelenburg test	Perthes test
Main purpose	Detect superficial junctional/perforator reflux	Assess deep venous patency (historical)
Patient start position	Supine (leg elevated to empty veins), then stands	Standing
Method	Tourniquet at upper thigh, observe filling before/after release	Tourniquet applied to occlude superficial veins, then patient walks or calf pumps
Positive finding	Rapid filling before release = perforator/deep reflux; sudden filling after release = SFJ reflux	Pain/increased venous distension on walking suggests deep venous obstruction/incompetence
Interpretation focus	Source of reflux into superficial system	Whether deep system can handle venous return
Current role	Largely replaced by duplex	Largely replaced by duplex
Limitation	Operator-dependent, less accurate	Uncomfortable, poor diagnostic precision

10-second exam summary template (for examiner)

“Findings are consistent with [long/short] saphenous varicose veins, with [no/yes] signs of chronic venous insufficiency and [no/yes] complications. I would confirm with duplex ultrasound and plan treatment accordingly.”

If you want, I can also give you a marks-oriented OSCE checklist (what gets points in intro, inspection, palpation, tests, closure).

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