1) History first

• Leg heaviness, aching, swelling, itching, night cramps, worse on standing
• Visible tortuous veins, skin discoloration, eczema, ulcer history, bleeding episodes
• Prior DVT, thrombophlebitis, trauma, surgery, pregnancy, family history
• Occupation with prolonged standing

2) Inspection (standing position is essential)

• Dilated, tortuous superficial veins along GSV/SSV territories
• Edema (ankle/calf)
• Skin changes of chronic venous hypertension:
  • Hyperpigmentation
  • Venous eczema
  • Lipodermatosclerosis
  • Atrophie blanche
  • Healed or active ulcer (usually gaiter area)

3) Palpation

• Temperature and tenderness over veins (suggests thrombophlebitis)
• Compressibility of varicosities
• Saphenous trunk tenderness or cord-like segments
• Pitting edema
• Peripheral pulses (to exclude mixed arterial disease before compression therapy)

4) Bedside special tests (classical; now less used)

1. Brodie-Trendelenburg test
   • Supine, elevate leg to empty veins, apply proximal thigh tourniquet, then stand.
   • Rapid filling may indicate perforator/deep system incompetence; delayed filling after release suggests superficial reflux patterns.
     (Harrison, p. 7796)
2. Perthes test
   • Tourniquet to occlude superficial flow, then patient walks.
   • Pain/increased distension suggests deep venous obstruction or poor deep outflow.

5) Confirmatory investigation (current standard)

• Duplex venous ultrasound is the key test for:
  • Reflux location (SFJ, SPJ, GSV, SSV, perforators)
  • Reflux duration/severity
  • Deep venous patency and prior DVT changes
  • Pre-procedure planning

6) Document severity (exam output)

• C0-C6 clinical class (from no visible disease to active ulcer)
• Etiology, anatomy, pathophysiology (reflux/obstruction)

Varicose veins OSCE examination script

1) Opening

• Wash hands, PPE as needed
• Adequate exposure: from groin to feet (with dignity/chaperone)
• Ensure good lighting

2) Initial overview

• Is patient comfortable?
• Any walking aid/compression stockings/dressings?
• Visible varicosities, ulcers, edema, skin changes

3) Examination in standing position (most important)

Inspection

• Dilated tortuous superficial veins (GSV/SSV distribution)
• Edema (ankle/calf)
• Skin changes of chronic venous disease:
  • Hyperpigmentation
  • Venous eczema
  • Lipodermatosclerosis
  • Atrophie blanche
• Ulcers/healed ulcers (gaiter area)
• Scars from prior venous procedures
• Signs of thrombophlebitis (localized erythema over vein)

Palpation

• Temperature, tenderness over varicosities
• Induration/cord-like tender superficial vein
• Pitting edema
• Peripheral pulses (DP/PT) to assess arterial status before compression decisions

4) Supine examination

• Reassess varicosities after elevation (emptying)
• Palpate long saphenous path if needed
• Check for calf tenderness/asymmetry if DVT concern

5) Special tests (mention and perform if required in exam)

1. Brodie-Trendelenburg test
   • Elevate leg to empty veins, apply upper-thigh tourniquet, ask patient to stand
   • Observe filling before/after release
   • Used to infer superficial vs perforator/deep incompetence
     (Harrison’s, p. 7796)
2. Perthes test
   • Tourniquet to occlude superficial veins, patient walks/heel-raises
   • Pain/distension suggests poor deep venous outflow

6) Close examination

7) Presentation to examiner (concise)

8) What to say for CEAP (quick OSCE add-on)

• C0 no visible disease
• C1 telangiectasia/reticular
• C2 varicose veins
• C3 edema
• C4 skin changes
• C5 healed ulcer
• C6 active ulcer

9) Suggested “to complete exam” line

• Perform/arrange duplex venous ultrasound,
• Assess VTE risk and DVT history,
• Check ABPI if compression therapy is being considered,
• Do a focused cardiovascular and abdominal exam if secondary causes are suspected.”

Key points

• Usually contains preperitoneal fat/omentum, less often bowel
• Presents as a midline swelling above the umbilicus, often more obvious on coughing/straining
• May be asymptomatic or cause pain/discomfort

Clinical features

• Visible/palpable lump above umbilicus
• Cough impulse may be present
• Reducible in many cases
• Pain can worsen with exertion

Red flags (urgent)

• Sudden severe pain
• Irreducible tender swelling
• Vomiting, abdominal distension, constipation
• Skin erythema over swelling

Management

• Definitive treatment is surgical repair (open or laparoscopic, often with mesh depending on defect size and patient factors)
• Watchful waiting may be considered in small minimally symptomatic hernias, but persistent symptoms generally favor repair
• Optimize risk factors: weight, smoking, chronic cough, constipation

Supraumbilical (epigastric) hernia examination (OSCE style)

1) Introduction

• Hand hygiene, chaperone, adequate exposure (xiphisternum to pubis)

2) Inspection

• Examine from end of bed and then at abdominal level
• Look for:
  • Midline swelling above umbilicus (linea alba)
  • Size/shape, skin changes, scars
  • Multiple swellings (can have more than one defect)
  • Visible cough impulse

• Cough
• Raise head/shoulders (or do a mini crunch) to accentuate hernia

3) Palpation

• Check local temperature/tenderness
• Identify exact site in midline between xiphisternum and umbilicus
• Assess:
  • Size of swelling
  • Consistency
  • Reducibility (gentle pressure)
  • Cough impulse on palpation
• Try to feel fascial defect margins (often small, elliptical)

4) Assess for complications

• Irreducible painful lump
• Marked tenderness
• Overlying erythema
• Features of obstruction (vomiting, distension) from history

5) Complete abdominal exam

• General abdominal palpation for other masses/tenderness
• Check for additional ventral hernias (umbilical, paraumbilical, incisional)
• Optional: examine hernial orifices if differential includes other hernias

6) Closing

7) Presentation summary to examiner