I. Visual diagnosis 1. Note the location and extent of superficial varicose veins. In primary varicose veins of the lower limbs, superficial varicose veins are often located in the calves, varicose into a mass and convex on the skin, and rarely seen in the thighs. In deep vein thrombosis, superficial varicose veins are more extensive, often found in the hip, lateral femur and lower abdominal wall, perineum varicose veins, while calf varicose is lighter. These varicose veins are not convex to the skin. 2. Pay attention to the color change of the skin of the affected limbs: in case of varicose veins or chronic venous reflux disorder, due to the destruction of red blood cells by extravasation and hyperpigmentation, the pigmented area starts from the inner side of the lower part of the lower leg, and in severe cases, it is in the form of sockpuppet. 3. Swelling and edema: the edema of superficial varicose veins is often limited to the drainage area of the vein. If the iliofemoral vein is obstructed, the swelling and edema can reach the root of the thigh. In femoral vein obstruction, the swelling and edema reaches the knee, and in N vein obstruction, the edema reaches the ankle. 4. Thickening of skin and subcutaneous tissue: This is due to the prolonged edema stimulation and fibrous tissue proliferation, coupled with hyperpigmentation, resulting in the section of the skin is like elephant skin. 5. Dermatitis and eczema. 6. Chronic ulcers: typical varicose vein ulcers, often occurring on the medial aspect of the lower and middle calf junctions. 7. Flame sign: a harbinger of varicose ulcers. Starting from the inner ankle (or sometimes the outer ankle), many small veins are sent out to expand towards the heel, and disappear in the thick skin of the heel, which is called the “flame sign”. Palpation 1. Thrombosed superficial phlebitis. 2. 2. The presence or absence of sclerotic striae or sclerotic nodules within the varicose mass. 3. The presence or absence of tenderness along the course of the deep veins. 4. Swelling due to obstruction of the deep veins, which increases the tension in the soft tissues. 5. Tension in the superficial veins is also increased in deep vein obstruction. Functional examination of superficial veins 1. Cough shock test: If this test is positive, it suggests saphenous vein valvular insufficiency. Place a finger in the thigh root below the opening of the saphenous vein, so that the middle finger is pressed against the saphenous vein, if the saphenous vein can not be seen, then put the finger on the part where it should be, and let the patient cough, such as the saphenous vein and the femoral vein at the connection of the valves of the insufficiency, at this time, the finger that is, the impact can be felt by coughing. 2. Percussion test (Chevrier’s sign): the purpose is to check the function of the valves of the saphenous vein. Method: The examiner puts the index finger of the hand on the distal end of the saphenous vein, and the index finger of the other hand is the percussion finger. When the proximal end of the saphenous vein is percussed, such as valve closure is incomplete, the palpation finger can feel the sensation of conduction impact; if there is no sensation of impact, then the valves are in good function. 3. Trendelenburg test: used to determine the function of the saphenous vein and traffic vein valves, method: the patient is lying down, the lower limbs are elevated, when the varicose vein is empty, the tourniquet is tied around the upper 1/3 of the thigh, the saphenous vein is compressed, the deep vein is kept open, and then the patient is instructed to stand up, the saphenous vein is still empty within 1~2 minutes, and then it is slowly filled up, and the vein rapidly fills up from top to bottom when the tourniquet is released, the vein fills up from top to bottom, and the vein fills up rapidly from top to bottom. When the tourniquet is released, the vein fills rapidly from top to bottom, indicating simple saphenous vein junction valve insufficiency. This is also known as a single positive Trendelenburg test. If the vein fills rapidly below the tourniquet within 30 seconds before relaxation of the tourniquet, then one or more of the traffic branch valves below the tourniquet are incompetent, which is also known as a double-positive Trendelenburg test. The small saphenous vein can also be examined by this method, but the tourniquet should be below the N fossa. 4. Pratt’s test: used to determine the function of the valves of the traffic veins. The patient lies on his back, elevates the affected limb, empties the vein, ties a tourniquet around the root of the thigh, wraps the first elastic bandage from the toe upward to the N fossa, and then ties the second bandage downward from the tourniquet; the patient stands up, unwinds the first bandage downward, and continues to wrap the second bandage downward; if there is a varicose vein between the two bandages, it means that there is a malfunctioning traffic vein in that place. Deep vein function test 1. Perthes test: It is used to determine the state of deep vein reflux. Method: The patient stands up, after filling the varicose vein, use tourniquet to block the superficial venous reflux in the upper 1/3 of the thigh, and ask the patient to kick the leg or do squatting action for 20-30 times, and observe the self-feeling, feel free and easy in the case of normal function of deep vein valves, and can not insist on kicking the leg when it is blocked, and it is painful and uncomfortable to be swollen; check the vein, if the original filling vein is sunken or obviously reduced, it means that the deep vein is smooth, and the test is said to be negative, and the test is called Perthes. The Perthes test is negative. On the other hand, if the filling increases and the patient feels soreness and pain in the calf, it means that the deep vein is obstructed and the Perthes test is positive. 2. Homans sign: a sign of acute deep vein thrombophlebitis of the calf. The patient lies down, the examiner will dorsiflex the affected foot, if the patient feels pain in the gastrocnemius muscle is positive, this is because the gastrocnemius muscle overstretches to stimulate the deep veins, and produce pain, but should pay attention to identify the false positive due to the gastrocnemius muscle itself, such as injuries and inflammation caused by the disease. 3. Gastrocnemius muscle tenderness: it is also a sign of thrombophlebitis of the deep veins or muscular venous plexus of the calf, but attention should be paid to exclude the gastrocnemius muscle itself from the disease which can also cause tenderness. Generally speaking, muscle pain is obvious in the left and right direction of the gastrocnemius muscle, and the pain of deep vein thrombosis increases during anterior and posterior compression, the so-called Luke’s sign. 4. Lowen burg’test: to objectively evaluate the pain of the gastrocnemius muscle area, the cuff is used for measuring the blood pressure, and the tibial bone is pressurized to observe the left and right direction of pressure when pain occurs. The left-right difference in pressure is observed when pain occurs, and it is positive when the affected side is 20-30mmHg lower than the healthy side. Measurement: 1. Bilateral lower limb circumference: Measure the circumference of the affected limbs 20cm above the upper edge of the patella and 10cm below the lower edge of the patella bilaterally. The difference between the circumference of the same part of the lower limbs of both sides is more than 1cm, which is clinically significant. Thickening is seen in the lower extremity deep vein thrombosis, arteriovenous fistula; decrease is seen in arterial ischemic disease. 2. Lower limb length: place the two lower limbs in a completely symmetrical position and measure the distance from the anterior superior iliac spine to the tip of the ipsilateral medial ankle. Congenital arteriovenous fistula patients affected limb growth.