INTRODUCTION: ORGANIZATION OF THE CLINICAL EXAMINATION
The physician must first explore the patient’s presenting complaint and its history, along with his or her general and vascular history. Functional disorders and aesthetic complaints are addressed. The physical examination (including Doppler auscultation) is initially performed with the patient standing, and then in the supine and prone positions. A preliminary assessment is thus performed that includes diagnosis of the primary varicose veins and their regions of involvement. Further evaluation is required to quantify functional and aesthetic impairment, to assess the risks of possible complications, and to establish a plan for management that will be medically appropriate and acceptable to the patient.
As in all good medical practice, evaluation of the patient with varicosities begins with a complete history. The clinical history should include general medical and surgical information, as well as information about vascular disease. Apart from the presenting complaint, it is important to document the onset of the problem and the clinical course of the disease. Any predisposing or aggravating factors and any situations that improve the symptoms are also recorded. The patient should be explicitly asked about each of the common symptoms that are seen with venous insufficiency, including leg heaviness, exercise intolerance, pain or tenderness along the course of a vein, pruritus, “restless” legs, night cramps, edema, and paresthesias. Many of these symptoms will improve after treatment. The history form that patients complete prior to the physical examination is available in Chapter 25.
Patients may consult the phlebologist because of symptoms or aesthetic concerns, for advice on the medical implications of varicose veins, or simply seeking to know methods of treatment. Some visits are prompted by complications such as the rupture of a varicose vein with bleeding or the recent development of dermatitis, thrombophlebitis, cellulitis, or ulceration. Treatment that does not properly address the patient’s primary concerns will not result in a satisfactory overall outcome. Both cosmetic and medical concerns need to be addressed. Patients also need to have a thorough understanding of the nature of gravitational influence and genetics on the formation of new veins.
The general history information of the patient should include the following:
Sex, age, weight, and height.
Medical history, including hypertension, diabetes, allergy history, tobacco consumption, rheumatological history, and general disease.
Surgical history, including any fractures or surgical operations.
Gynecological and obstetric history, including the number of pregnancies and miscarriages; plan for future pregnancies1; duration, dosage, and effect on venous complaints of hormone replacement therapy or oral contraception; and any variation of symptoms with the menstrual cycle.
History of Vascular Disease
The history of vascular disease of a patient should include the following: