case history of varicose veins

2. CASE HISTORY
PRESENTED BY
NATASHA
BMS02100007
FINAL YEAR MBBS

3. BIO DATA
 NAME = Mohammad Imraan
 Age = 36 years
 Sex = Male
 Marital status = Married
 Occupation = Garments Factory worker
(in past cook for 7 years )
 Address= Greentown Lahore
 Date of admission = 8 April 2015
 Mode of admission = OPD

4. PRESENTING COMPLAINT
 Multiple engorged veins in left leg from
last one year.
 Multiple engorged veins in right leg from
last 6 months
 Pain in left leg from last 3 months

5. CASE HISTORY
 History of presenting illness
 My patient was in usual state of health ONE year back
when while taking a bath he noticed
DILATED VEINS ON LEFT LEG that extended from
medial malleolus to mid thigh on the poster-o-medial
side. Initially they were small in size, but gradually
increase in size.
After 6 Months he noticed similar DILATED VEINS ON RIGHT
LEG present on posterior side of mid thigh. They were
small & there was no change in their size.

6. Case history ( Contd..)
Gradually over the last 3 months, he felt pain in the left leg, it
was dull in nature, mild to moderate in intensity.
 It increases throughout the day and aggravates on
prolonged standing .
 It was relieved in sitting position ,by walking & by
elevation of leg.
 It was associated with pigmentation around the ankle.
 There is NO history of itching , ankle or leg swelling , or
night cramps, bleeding ,ulceration , numbness or weakness
of limbs or pain in resting position of limbs.

7. Systemic inquiry
 General ; No weight loss, appetite , sleep was normal
 Alimentary system: No significant history
 Cardiovascular system: No significant history.
 Respiratory system: No significant history.
 Urinary system: No significant history.
 CNS: No significant history.
 Loco motor : No significant history.
 Endocrine system : No significant history.

8. PAST HISTORY
No co-morbidities present i. e
Diabetes Mellitus
HTN
IHD
Asthma
But he had DENGUE FEVER four years back, he took medication from
local GP and was not admitted.
PT. was admitted in this hospital 5 years
back for three days because of a road accident. His mandible was
fractured but no associated limb injury . But there were no serious
complications & no blood transfusion.

9. FAMILY HISTORY
 His elder brother also has varicose veins. He is a
cook by profession.
 His mother is diabetic.
 He has five sisters & one brother.

10. PERSONAL HISTORY
 He is addicted to Naswar from last 25 years
 Non Smoker
 No other drug addiction
SOCIOECONOMIC
 Pt belongs to low socio economic status

11. General Physical Examination:
My patient M . Imran 36 years of age is a well built man , well co-operative , well
oriented in time ,place and person & lying comfortably on bed.
His vitals were
 Pulse >>>> 84 beats/min (normal rate ,rhythm and volume)
 B.P >>>> 130/ 80 mmHg
 Resp >>>> 18 breaths /minute
 Temp >>>> A febrile
No clubbing , leuconychia , koilonychias or any type of palpable nodes ,no
palmar erythema or muscle wasting ,sweating or pigmentation.
No pallor, no cyanosis,, no jaundice, no peri orbital puffiness ,JVP was normal, thyroid was not
enlarged. No palpable lymph nodes. No pedal edema

12. LOCAL EXAMINATION
After getting his consent, I exposed
him in standing position from
umbilicus till the toes, in the presence
of an attendant and under strict
privacy. I examined both limbs from
front as well as back.

13. INSPECTION
SITE : There were large & prominent veins on the
poster-o-medial side of the LEFT leg . Also few
prominent veins were present on RIGHT leg on
the posterior side near mid thigh.
 EXTENT : They extend from medial malleolus to
mid thigh on left leg.
 There was discoloration on the gaiter area of
left leg.
 Hair distribution was normal on both sides.
 No ulceration , no eczema on either leg.

14. INSPECTION (Contd..)
 On Both Sides :-
 Cough impulse is not visible.
 Toe nails were normal.

15. PALPATION :-
 No tenderness along the venous course on
either leg.
Saphena varix is not palpable.
 Trendelenburg test & Multiple tourniquet
test were performed bilaterally and
Saphenofemoral junction was found
incompetent.

16. PALPATION ( Contd..)
 FAGANS TEST was positive on LEFT leg
 PERTHES TEST was negative !
 Distal neurovascular bundle was intact.

17. PERCUSSION :-
 SCHWARTZ TEST was positive on left leg.
AUSCULTATION :-
No sounds were heard on auscultation at
SFJ.

18. SYSTEMIC EXAMINATION
 GIT :- Non tender, no viseromegaly or pelvic
mass. any other pathology. Bowel sounds are
audible.
 CVS:- Apex beat is localized in the left 5th
intercostal space .No cardiac murmur or
another pathology.
 Respiratory system :- No significant finding
 CNS :- No significant finding
 Musculoskeletal :- No significant finding

19. Differential Diagnosis:
 Varicose veins

20. INVESTIGATIONS
 CBC
WBC =7.4
Hb = 14.4
HCT= 42
Platelets = 200000
PT = 13
INR= 1.0
 RFT
Urea= 100
Creatinine=2.6

21. INVESTIGATIONS (Contd..)
 Serum electrolytes
Na =137
K= 3.9
 LFT
Total Bilirubin = 0.5
ALP= 200
SGPT= 33
SGOT=37
 Viral markers= negative

22. DOPPLER ULTRASOUND:
On Doppler ultrasound report
the SFJ of leg was
COMPETANT, No evidence of
DVT.

23. TREATMENT
On the basis
of clinical
examination
the
proposed
treatment
was SFJ
ligation &
long
saphenous
stripping. But
After
Doppler
report , it was
recommend
ed that there
is no need
for surgical
intervention
Now he was given,
1 )Tab Daflon 500mg BD
2) Cap Omega 20 mg BD
3) Compression stockings

24. Thank You.