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 | |
| Systemic appearance | ||
| Evidence of increased VTE risk | ||
| Clues in bed-space | ||
| Leg Inspection | Inspect standing (anterior/posterior/lateral) | |
| Colour | ||
| Scars | ||
| Swelling | ||
| Evidence of chronic venous insufficiency | ||
| Evidence of varicose veins | ||
| Further inspection with patient reclining at 45° | ||
| Calf measurement | ||
| Leg Palpation | Temperature | |
| Pitting oedema | ||
| Calf tenderness | ||
| 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 to look for a blood clot. 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)
- Systemic appearance (e.g., are they well or unwell, or are they breathless)
- Evidence of increased VTE risk (e.g., pregnancy, stigmata of recent surgery)
- Clues around the bed space (e.g., walking aids, compression bandages, oxygen, dressings, etc)
Leg Inspection
With the patient standing inspect the legs for:
- Colour – unilateral redness may indicate DVT
- Scars
- Swelling – unilateral leg swelling or unilateral pitting oedema may indicate DVT
Inspect the legs for signs of concurrent venous disease including chronic venous insufficiency (skin changes, especially in the gaiter region of the legs) or varicose veins (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.
Measure the calves to objectively assess for unilateral swelling. The calf circumference should be measured 10 cm below the tibial tuberosity. When assessing for DVT, a discrepancy of >3 cm between claves is significant and scores on the Wells Score.
Leg Palpation
Palpate the legs to assess for the following:
- Temperature – a unilateral hot, swollen limb may indicate a DVT
- Pitting oedema – unilateral pitting oedema may indicate DVT
- Calf tenderness – tenderness of the deep venous system (applying pressure over mid-posterior calf and moving proximally) may indicate DVT
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 calculate a Wells Score for risk stratification of DVT and carry out further investigations including Doppler ultrasound and D-Dimer
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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