Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Leg swelling |
DVT |
Risk factors: malignancy, pregnancy, recent surgery, hormonal treatments, long-haul travel, immobility.
Unilateral hot swollen red and tender calf. Affected calf measures >3 cm larger than unaffected side. May be associated with symptoms of pulmonary embolism. |
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Chronic venous insufficiency |
Older patient, associated obesity or immobility.
May have associated venous disease e.g., varicose veins. Bilateral swelling & associated skin changes in gaiter region. Skin: eczematous, red, haemosiderosis, lipodermatosclerosis, atrophie blanche. |
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Post-thrombotic syndrome |
Presentation as for chronic venous insufficiency caused by previous DVT. May present years after DVT. | ||
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Varicose veins |
Risk factors: age, pregnancy, obesity, prolonged standing.
May be asymptomatic. Heaviness, aching, dragging sensation uni/bilateral legs. Itching or burning sensation, cramping pain, restless legs. May be associated with chronic venous insufficiency. |
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Superficial thrombophlebitis |
Common in people with pre-existing varicose veins.
Acute pain, itching and swelling over superficial vein. Hardened, tender vein with associated redness to skin. |
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| Leg skin changes |
Venous eczema |
Sign of chronic venous insufficiency. Bilateral changes likely
Red, dry, flaky, inflamed skin in gaiter region of legs. |
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Haemosiderin deposition |
Sign of chronic venous insufficiency. Bilateral change likely.
Brown or red skin discolouration, staining of skin in gaiter region of legs. |
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Lipodermatosclerosis |
Sign of chronic venous insufficiency. Bilateral change likely.
Inverted champagne bottle appearance to lower legs. Skin is hardened, tight and gaiter region is narrowed. |
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Cellulitis |
Acute redness, swelling, heat and pain to skin of lower leg.
May be associated with systemic upset e.g., pyrexia. Can be a consequence of chronic venous insufficiency. Unilateral change. |
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| Leg ulcer |
Venous ulcer |
Associated with chronic venous skin changes e.g., Eczema.
Arise in gaiter region just above the ankle/below calf. Larger, less painful, irregular edges, superficial, bleeding. Pain improved with leg elevation: relief of venous pressure. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient standing | ||
| Appropriate exposure of lower limbs | ||
| General Inspection | Body habitus | |
| Clues in bed space | ||
| Leg Inspection | Inspect standing (anterior/posterior/lateral) | |
| Colour | ||
| Scars | ||
| Swelling | ||
| Evidence of varicose veins | ||
| Further inspection with patient reclining at 45° | ||
| Venous eczema | ||
| Haemosiderosis | ||
| Lipodermatosclerosis | ||
| Atrophie blanche | ||
| Venous ulcers | ||
| Evidence of co-existing arterial disease | ||
| Leg Palpation | Pitting oedema | |
| Skin texture | ||
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to examine your peripheral venous system. This involves looking at the veins in your legs. You can ask me to stop at any time. Are you happy for me to do that?”
Position the patient standing initially.
Ask the patient to expose their lower limbs.
General Inspection
Look at the patient and around the bed space for useful signs:
- Body habitus (e.g., overweight or underweight)
- Clues around the bed space (e.g., walking aids, compression, bandages, etc)
Leg Inspection
With the patient standing, inspect the legs for:
- Colour (e.g., redness, pallor, haemosiderosis)
- Scars
- Swelling – unilateral or bilateral
Inspect the legs for any signs of varicose veins; these present as visible, prominent, tortuous, and dilated superficial veins of the lower limb.
Then reposition the patient on the couch reclining at 45° for further inspection of the legs.
Inspect the legs for signs of chronic venous insufficiency; skin changes found in the gaiter region of the legs (area between the top of the foot and inferior aspect of the calf muscle):
- Venous eczema – dry, red, flaky, itchy, inflamed skin caused by chronic inflammatory response
- Haemosiderosis – red or brown staining of the skin caused by haemoglobin leaking out of blood vessels
- Lipodermatosclerosis – inverted champagne bottle shape of lower legs; thickening and fibrosis of skin and subcutaneous tissue due to chronic inflammation leads to scarring
- Atrophie blanche – smooth white areas of scar tissue
- Venous ulcers – large, irregular border, shallow, minimally painful ulcers
Inspect the legs for evidence of co-existing arterial disease which may complicate compression treatment of chronic venous insufficiency (e.g., pallor, mottling, hair loss).
Leg Palpation
Skin changes associated with chronic venous insufficiency may cause the lower legs to feel hard and thickened. Assess for pitting oedema, which can be caused by chronic venous insufficiency.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings and your differential diagnosis, you may wish to carry out further investigations, including Doppler ultrasound to assess for venous valvular incompetence, as well as ABPI to exclude arterial disease and confirm suitability for compression treatment.
Last updated Dec 2024
Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.
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