CNS Examination: Important stuff or things i always forget
- To assess judgement, ask what the patient would do if he saw fire in his basket.
- Cognitive function: As a rule, difficulty with immediate recall suggests depression, whereas difficulty with recall after 5 minutes suggests dementia.
- Viewing the optic disc tells you a lot about the bodie's vasculature. Remember to offer to do it
- Test hearing with high frequency tuning fork, and vibration sense with low frequency
- To assess fine motor coordination, ask her to tap her thumb with each of the fingers on the same hand in succession
- Screen for dorsal column dysfunction by the direction-of-scratch test, and do vibration if you find something. This is to save time.
- Test pain. If got findings then test temperature by asking him to compare your finger and the tuning fork.
- To tell between Parkinsonism and benign tremors, ask the patient to move. Tremors should disappear if it's parkinsonism. Essential tremors are also faster.
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Varicose Veins:Main influences on the development of varicose veins:
Heredity:
Female sex
Hormones
Gravitational hydrostatic forces
Hydrostatic dynamic muscular compartment force
Heredity uncertain if dominant or recessive trait
Profound effect of female hormones in pregnancy on development of varicose viens:
70-80% appears in 1st trimester, often within 2-3 weeks of gestation
Indicates that do not develop because of size of a gravid uterus, increased blood flow or iliac venous occlusion
Two mechanical forces act on the heredity and hormonal substrate to produce the elongation and dilatation of the veins:
-Weight of blood column from right atrium to affected vein through valveless conduits of abdomen, pelvis and any incompetent valves of proximal limb veins-constant and called hydrostatic pressure
-Pressure exerted by contracting muscles on adjacent veins-hydrodynamic force: forces blood through open valves in deep veins towards the heart. Incompetence of deep perforators allows transmission of this huge force to unsupported superficial veins and venules.
Clinical Presentation
Asymptomatic:
Unsightly dilated, tortuous veins
Telangiectatic blemishes
Consultation sought by patient on cosmetic grounds
Symptomatic:
Aching pain usually in the calf all worsening as day progresses
Leg heaviness relieved by elevation & rest
Easy leg fatigue maximal on 1st day of menses
Superficial thrombophlebitis
External bleeding
Ankle hyperpigmentation
Lipodermatosclerosis
Venous ulcers
Over time, the elevated pressure in the venous system leads to edema, chronic inflammation, and ultimately sclerosis of the skin and subcutaneous fat. This sign of chronic venous hypertension is known as lipodermatosclerosis (LDS) and is most commonly seen in the lower medial leg, the "gaiter" area.
Acutely where the skin is warm, red, tender, and indurated with indistinct borders. The acute condition is frequently misdiagnosed as cellulitis, but patients with acute LDS are never febrile, and the skin eruption does not spread rapidly as does cellulitis. The proper treatment is external compression stockings, NSAIDs, and ambulation.
Chronically where the skin is indurated, sclerotic, and hyperpigmented, and fixed to the underlying tissue. There is usually no hair growth in these areas, and the induration is easy to distinguish from surrounding normal skin. The involved area may actually be concave due to fat atrophy. Chronic LDS can present as large confluent areas or small brown indurated plaques. The sclerotic skin is extremely susceptible to minor trauma, which can lead to rapid appearance of venous ulcerations.
Obvious varicose veins may or may not be seen in patients presenting with LDS
As a rule, LDS is much more common than cellulitis.
Chronic venous insufficiency :
- worse late in the day, after prolonged sitting or standing, and in hot weather or during menstrual periods
- Asw pain, itching, heaviness, tenderness, swelling, night-time leg cramps, throbbing restless leg syndrome, burning, and stinging.
- Symptoms almost always improve overnight. If a patient's symptoms do not improve with rest and elevation, use stockings during the day for 2 weeks. Significant improvement in the patient's symptoms indicates a probable venous etiology.
- Symptoms that do not improve with compression are unlikely to be connected to venous disease and may be Baker's cyst, arthritis, muscle strain, or diabetic neuropathy.
- Varicose vein disease is frequently overlooked as a cause of nocturnal leg cramps or restless leg.
- Disease symptoms are not always proportional to the size of the affected veins. Refluxing deep or superficial veins can cause symptoms in the absence of visible vein dilatation. A normal-appearing leg does not rule out vein disease.
Dilated veins means incompetence of valves above that level! Usually salphenofemoral junction in the groin.
PE:
- Inspect: cutaneous signs. Lipodermatosclerosis... and examine the medial malleolus for corona phlebectatica, a classic sign of chronic venous insufficiency. This confluence of dark blue or purple dilated venules appears around the medial malleolus or instep and is highly suggestive of venous hypertension.
- Palpate: pulses. No pulse? Then must do ankle-brachial index. Normal >1. Call a vascular surgeon if <0.5.>
- Move: ankle. Is the calf pump working?
- Tests: Medical Students only need to do cough tap and Tredenlenburg. Just mention the rest in general.
Cough test: Thrill felt with examining hand placed just below SF junction when patient coughs-signifies primary SF incompetence
Tap test: Thrill felt with examining hand placed over a bunch of varicosities as other hand gently taps GSV cephalad to examining hand. Basis for this is that the fliud thrill set up by taspping the GSV passes retrogradely through incompetent valves
Trendellenburg's test: For primary SF incompetence. Leg is elevated and veins drained by milking the leg from foot to thigh with patient in reclining position. Examining hand or a tourniquet is placed just below SF junction and the patient asked to stand up off the bed. The bunches of varicosities are examined-if they remain unfilled, then perforators are competent. If bunches of varicosities fill despite control at SF junction-perforators below SF junction and bunches of varicosities are incompetent. Watch as examining hand or tourniquet is removed-if bunches of varicosities fill, primary SF incompetence and incompetence of all valves along the GSV to the varicosities is present.
Modified Trendellenburg’s test: Can be used to determine level of perforator incompetence. In thigh Hunterian perforator mid-thigh; Dodd perforator approximately 1 hand’s breadth above knee. Below knee, Boyd perforator approximately 1 hand’s breadth below knee; then Cockett perforators 5, 10 and 15cm above ankle. Application of a tourniquet at each level just below perforator should control the incompetence and prevent filling of the bunches of varicosities if SF junction is competent or controlled. Removal of the perforator-controlling tourniquet will result in filling of the varicosities.
Fegan’s method (of demonstrating Boyd and Cockett’s perforators and perforator incompetence): with the patient supine and elevating the leg with one hand and running an examining finger along the medial border of the tibia-the position of below knee perforators will be easily palpable as sizable defects or depressions in the deep fascia in patients with chronic perforator incompetence. Finger-tip control with an examining finger will be possible and the modified Trendellenburg test can be performed easily.
Perthe’s test: To detect significant deep venous occlusion or insufficiency. If an tourniquet is placed just below the SF junction tight enough to occlude superficial venous drainage, the patient is asked to push him/her-self up and down on his/her toes for several minutes. If there is significant deep venous occlusion or insufficiency, there will be a bursting pain (as classically described) or tightness in the calf (“venous claudication”). This is because blood cannot be drained out of the leg through the tourniquet-occluded superficial venous system.
Investigate and Treat:
- Doppler looking for:
Deep venous system:
Presence/absence of DVT
Competence of deep venous valves
Competence of perforators
Superficial venous system:
Competence of short and long saphenous vein junctions (primary sapheno-femoral or sapheno-popliteal incompetence)
Competence of valves along the long and short saphenous veins - Pharmacologic: Pentoxifylline (Trental), 800 mg tid, has been shown to be marginally effective in healing venous ulcers.
- Stockings: Full length/below knee. Gradient highest in ankle and falls as it progressess upwards. Below knee same efficacy and less slippage so more compliance so better.
- Operative:
Small incision over surface marking of sapheno-femoral junction in groin or marked junction of sapheno-popliteal junction (located by Duplex scanning as this junction can vary considerably)
Dissection of junction and ligation and division of all named tributaries (failure to do this is the commonest cause for recurrence)
Flush ligation, division and stripping of the long saphenous vein to the knee (unnecessary to strip below knee as this can cause saphenous nerve injury and does not increase benefit)
Stab incisions over marked varicosities and avulsion of these veins - Endovenous ablation therapy is indicated for saphenofemoral or saphenopopliteal reflux into incompetent great or small saphenous veins, respectively
- Bulging or palpable varicosities are usually treated with ambulatory phlebectomy or sclerotherapy (Detergent substances, Hypertonic saline and glucose solutions, Chemical irritants or caustic agents). Nowadays, foam substances are preferred.
