- Mrs.rani
- 50 years old female
- Housewife
- Residence: t.nagar
- Socio economic class: lower middle
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CHIEF COMPLAINTS
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- Dilated veins in the left leg for the past 5 years
- Pain in the left leg for the past 2 years
History of presenting illness
Dilated vein in the left leg for the past 5 years insidious in onset initially appeared below the knee and gradually progressed up to thigh
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Associated with PAIN:
- past 2 years
- insidious in onset
- dull aching pain
- intermittent in nature
- not radiating / referred
- aggravated on prolonged standing and walking
- usually towards end of the day
- relieved by lying down
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- H/O prolonged standing present
No History of :
- night cramps
- prolonged immobilisation
- itching, hyperpigmentation, ulcer
- fever
- trauma
- abdominal distension
- loss of weight, loss of appetite
- constipation
- swelling of legs
- Use of Oral Contraceptive Pills
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Past history
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- No H/O similar complaints in the past
- No H/O diabetes mellitus, hypertension, tuberculosis, asthma, epilepsy
- H/O sterilisation 20 years back
- No H/O prolonged hospitalisation or immobilisation
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Personal history
- Consumes mixed diet
- Normal bowel and bladder habits
- Does not consume alcohol or tobacco in any form
- Normal sleep
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Menstrual history
- Age of menarche: 14 years
- No H/O OCP use
- Attained menopause at the age of 48 years
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Family history
- No significant family history
General examination
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- Patient examined after obtaining consent
- Patient is conscious, oriented, moderately built and nourished
- Afebrile
- No pallor
- No icterus
- No cyanosis
- No clubbing
- No pedal edema
- No generalised lymphadenopathy
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Vitals
- Pulse rate: 80/min
- regular, normal volume, no specific character, all peripheral pulses are felt, no RR/RF delay, no vessel wall thickening
- Respiratory rate : 13/min
- BP : 110/80 mm Hg measured in right upper arm in sitting posture
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Examination of left leg
- Patient in STANDING POSITION exposing from umbilicus to toes
- INSPECTION: dilated, torturous veins seen on the medial aspect of leg, extending from infront of medial malleolus coursing along medial aspect of leg upto medial aspect of lower 1/3rd thigh
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Inspection
Skin :
normal in colour and texture no edema no scars, ulcers no loss of hair no brittleness of nails cough impulse not seen
Palpation
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- Not warm, not tender
- No thickening of skin
- No pitting pedal edema
Following tests are performed after milking the veins
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TRENDELENBERG TEST 1
Observation: veins fill rapidly from above downwards
Inference: saphenofemoral in competence
TRENDELENBERG TEST 2
Observation: veins fill gradually
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Inference: perforator incompetence
MULTIPLE TORNIQUET TEST
Observation: dilated veins appear between the 2nd and 3rd torniquet
Inference: below knee perforator incompetence
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FEGAN TEST
Observation: defect in the fascia felt as pit along the course of dilated veins just below the knee
MODIFIED PERTHE TEST
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(performed without emptying the veins)
Observation: dilated veins do not become prominent and there is no pain on walking
Inference: patent deep vein
MORRISSEY'S COUGH IMPULSE TEST
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Observation: cough impulse not felt on the SFJ
No lymph nodes palpable
Percussion
SCHWARTS TEST
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Observation: impulse not felt at the SFJ
Auscultation
- No bruit heard
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Examination of peripheral arterial system
- Femoral, popliteal, posterior tibial, dorsalis pedis pulses felt equally in both lower limb
- No distal neurological deficit
- Examination of right lower limb: normal
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Other system examination
ABDOMEN
- soft
- no organomegaly
- no mass palpable
- no free fluid
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CVS: S1, S2 heard; no murmur
RS: normal vesicular breath sound heard no added sounds
CNS: no focal neurological deficit
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Spine and Cranium: normal
Diagnosis
Primary varicose veins of the left lower limb involving the great saphenous vein with Saphenofemoral and below knee perforator incompetence with clinical class C(2)E(p)A(s+p)P(r )without any complication
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Investigation
- Routine:
- CBC
- BT, CT
- blood grouping & typing
- blood sugar, urea, serum creatinine
- urine sugar, albumin
- ECG
- Chest X-ray
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SPECIFIC
- Duplex study
- Ultrasound abdomen
Treatment
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Saphenofemoral flush ligation with stripping of great saphenous vein up to knee and sub-facial perforator ligation-LEFT SIDE
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This download link is referred from the post: MBBS Final Year Case Presentation (Clinical Case Examination, Discussion and Treatment)