VARICOSE VEINS
A 50-year-old male patient, tea master by occupation presented with c/o
tortuous, dilated veins over lower part of left leg extending up to upper
thigh for 2 years.
H/o dragging type of pain for 1 month.
H/o ulcer over inner aspect of left ankle above medial malleolus for 1
month.
On local examination, there is varicosity affecting the GSV.
2*2 cm ulcer with a discharge noted above the medial malleolus of left
ankle.
Arterial pulses in lower limb are normal.
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Name: Rajesh
Age/Sex: 50/M
Address: Pallavaram
Occupation: Tea master
C/C:
Dilated veins over left lower limb for 2 years.
HOPI:
The patient was apparently normal 2 years back after which he
developed dilated veins in the left lower limb which was insidious in
onset, initially started in the ankle region and gradually progressed
to the upper thigh, increases in size on walking and decreases in
size on lying down.
The swelling is associated with pain over the left lower leg for 1
month which was insidious in onset, dragging type of pain,
aggravated on walking and prolonged standing, relieved on lying
down.
H/o ulcer over the inner aspect of left ankle above medial malleolus
for 1 month which is insidious in onset, initially small in size and
gradually progressed to attain the current size, associated with a
discharge which is serous in nature, not foul smelling, not blood
stained and is not associated with pain.
No H/o blackish discoloration in the ankle region.
No H/o trauma.
No H/o night cramps.
No H/o chronic fever with cough with expectoration.
No H/o abdominal mass.
No H/o bleeding PR.
No H/o breathlessness. (pulmonary embolism)
No H/o swelling in the other leg.
Past H/o
No H/o similar complaints in the past.
No H/o DM, HTN, TB, Asthma.
No H/o previous surgeries. (Rule out previous surgeries)
No H/o past treatments like sclerotherapy, elastic bandage.
(Ask H/o OCP intake for females)
Personal H/o
Mixed diet.
Normal bowel and bladder habits.
Normal sleep pattern.
Non-alcoholic and non-smoker.
Family H/o
No significant family H/o.
General examination
The patient is conscious, oriented, moderately built and nourished.
No pallor, icterus, cyanosis, clubbing, significant lymphadenopathy
and pedal edema.
No local gigantism. (AV fistula).
Vital signs
Afebrile.
Pulse: 82/min, regular in rate and rhythm, normal in volume and
character. No radio radial or radio femoral delay.
RR: 16/min
BP: 110/70 mm Hg, left upper limb in sitting position.
Examination of right lower limb:
After getting consent from the patient, the patient was exposed both legs
from umbilicus to toes and examined in a well illuminated room standing
on a stool.
Inspection:
Localized, tortuous, dilated veins seen extending from medial
malleolus passing over medial aspect of leg, knee joint and reaching
up to upper thigh.
On lying down, the collapse of venous system is seen.
No loss of hair.
No deformity seen.
No colour change seen.
No scars, scratch marks seen.
Cough impulse: Absent.
The other limb appears to be normal.
A single ulcer of size 2*2 cm is seen over the inner aspect of ankle
above medial malleolus, circular in shape, sloping edges, floor is
covered with granulation tissue, serous discharge is seen. No
hyperpigmentation is seen around the ulcer.
Palpation:
Warmth and tenderness seen.
All inspectory findings are confirmed on palpation.
No thickening of skin.
Examination of varicose veins:
Brodie-Trendelenburg test 1: Positive
Brodie-Trendelenburg test 2: Negative
Multiple torniquet test: Negative
Perthes test: Negative
Modified Perthes test: Negative
Morrisey cough impulse: Positive
Ulcer:
Warmth present. No tenderness present.
All inspectory findings are confirmed on palpation.
Sloping edges with well-defined margins.
Floor is covered with granulation tissue.
Serous discharge is seen.
Induration is seen extending 1 cm from the margin.
Mobile.
Does not bleed on touch.
Examination of opposite limb: Normal
Examination of peripheral pulses: Normal
Examination of nerves: No neurological deficit.
Examination of lymph nodes:
No significant enlargement of lymph nodes.
Other systems
CVS: S1S2 heard, No murmurs.
RS: NVBS heard.
Abdomen: Soft, non-tender, No organomegaly.
CNS: No focal neurological deficit.
Spine: Normal
Provisional diagnosis:
Chronic primary varicosity of left limb of great saphenous vein with
saphenofemoral incompetence with varicose ulcer.
Investigations:
Routine:
Blood- Hb, TC, DC, ESR, BT, CT
Blood grouping and typing.
Urine- Sugar, protein, deposits
Serum- Urea, creatinine
ECG
CXR
Specific:
Varicose veins:
Doppler scan
Duplex scan
Ulcer:
Culture and sensitivity
Blood sugar (FBS, PPBS, HbA1c)
Mx:
Varicose veins: Trendelenburg Sx
Ulcer: BISGAARD REGIMEN
Educate the patient about cleanliness and the cause for ulcer.
Elevation
Massaging the limb.
Active and passive exercises.
Elastic stockings.
If ulcer less than 2 cm in size, remove the slough.
Regular cleaning and dressing of ulcer.
Wound debridement.
Local application of antibiotic. (Done till ulcer is covered with
healthy granulation tissue)
If ulcer more than 2 cm in size, skin graft.
