Case

1. Surgery Case Presentation
Ritodip Nandi
Final year MBBS
Medical College Kolkata

2. Patient particulars
• Name- Mr. ABC
• Age- 51 years
• Sex- Male
• Religion- Hinduism
• Residence- Nadia, West Bengal
• Occupation- Long standing machine work
• Date of admission- 06.09.21
• Date of examination- 07.09.21

3. Chief Complaints
• Swelling along the veins in left lower limb for 3 years
• Pigmentation of skin around left ankle for 1½ years
• Pain in left lower limb for 6 months

4. History of Presenting Illness
• Patient was apparently well 3 years back when he first noticed swelling along the
veins of the left lower limb. It was insidious in onset, gradually progressive,
started in the lower part of left leg around the ankle and later extended up to the
upper part of thigh. The swelling gets aggravated after prolonged standing or
walking and in the evening, and gets reduced on lying down.
• Patient also complains of pigmentation around left ankle for 1½ years, which was
insidious in onset, gradually progressive, not associated with itching. Patient had
an ulcer over the inner side of left ankle 7 months back, which healed with oral
and local medications from the local practitioner in 1 month. The ulcer was
associated with bleeding.

5. History of Presenting Illness
• Patient complains of pain in the left lower limb, particularly around the calf
muscles for last 6 months. It was insidious in onset, gradually progressive, dull
aching in character, increased after prolonged standing or walking, and towards
the evening, relieved on lying down, mildly affecting daily activities.
• No history of: Fever, active ulcer or bleeding from the swellings, pain in abdomen,
lump in abdomen, constipation or obstruction during micturition.

6. Past History
• No major medical ailments in the past. Patient is normoglycemic and
normotensive.
• No major hospitalisation or surgeries in the past.

7. Personal history
• Patient is a non-smoker, non-alcoholic.
• On mixed diet, sleep is adequate, bowel and bladder habits are within
normal range.
• Patient is a machine worker in a factory involving long hours of
standing.
Family history
• Married, with 2 sons. Sons and wife are all healthy.
• No similar ailments in family.

8. Treatment and Allergy History
• Patient had not undergone any treatment for the disease.
• The ulcer in left lower limb that developed 7 months ago was healed
using local and oral medications from the local practitioner.
• Patient doesn’t use any elastic stockinette.
• No allergy to any drug or known substance

9. General Survey
• Patient is alert, conscious and cooperative, well oriented to time, place and
person.
• Built- Well built, Nutrition- Average, Decubitus of choice, Facies- Normal,
Hydration Status- Well hydrated.
• No pallor, icterus, cyanosis, clubbing, engorged neck veins or palpable neck
glands.
Temperature- 98.9 F
Blood pressure- 124/80 mm Hg
Pulse- 70 bpm, regular, normal volume, arterial wall not palpable, no
radio-radial or radio-femoral delay.
Respiratory Rate- 16 cycles/min, regular, abdomino-thoracic

10. Systemic Examination
Nervous System: No focal neurological deficits
Cardiovascular System: Apex beat at left 5th ICS slightly medial to
MCL. S1, S2 heard. No murmurs.
Respiratory system: B/L Normal vesicular breath sounds heard. There
were no added or adventitious sounds.
Per abdominal examination: Soft, elastic and non-tender abdomen, no
organomegaly.

11. Local examination
Examination of diseased limb:
Inspection- In standing and sitting positions
• Dilatation and tortuosity of Great Saphenous System of veins,
extending from dorsum of foot to upper thigh in left limb.
• Skin of the leg- Dark pigmentation over left ankle present, no ulcer or
venous stars.
• Cough impulse over saphenous opening present. (Morissey’s test)
• Attitude of the limbs- Normal with no deformity

12. Local examination
Palpation
• Tenderness over veins present.
• No thickening of the veins.
• Cough impulse over sapheno femoral junction felt.
• Trendelenburg test: +/+, suggesting perforators below SF junction, as well
as SF junction itself are incompetent.
• Two tourniquet test at each perforator site: Below knee perforator and
medial ankle perforators at 15cm, 10 cm and 5 cm levels incompetent.
• Schwartz test: Negative
• Fegan’s test: Crescentic gap felt over the incompetent perforators.
• Modified Perthes test, Homan’s sign, Moses sign: Negative
• All arterial pulses of left limb palpable.

13. Local examination
Auscultation- No bruit heard over the dilated veins.
Examination of other limb- Within normal levels

14. Summary
Mr. ABC, a 51 year old gentleman from Nadia, a machine worker by
occupation, presented with insidious onset of swelling of legs along the
inner aspect of left leg for last 3 years. Patient noticed the swelling
along the vein which started in the left ankle and ascended to the lower
thigh. Patient also complains of dark pigmentation over left ankle for
last 1½ years and dull aching pain in right calf region for last 6 months.
On examination, there is varicosity over great saphenous system of
veins in the left limb. Trendelenburg’s test is +/+, Multiple tourniquet
test reveals incompetence at perforators, Fegan’s test positive, Modified
Perthe’s test negative. All arterial pulses palpable. Dark pigmentation
over left ankle. Right lower limb is essentially normal.

15. Provisional Diagnosis
This is a case of varicose vein affecting Great saphenous system of
veins in left lower limb with incompetence at SF junction and below
knee, and medial ankle perforators at 15, 10, 5 cm levels; CEAP
classification- 𝐶5𝑆𝐸𝑃𝐴𝑆𝑃𝑃𝑅

16. Investigations
• Investigations to support my diagnosis:
1. Duplex imaging of venous system of lower limb
2. Ascending venography (optional)
• Pre-operative investigations:
1. Blood for Complete Hemogram, ESR
2. Blood for Sugar, urea, creatinine
3. Chest X ray
4. ECG