Universitatea de Medicin i Farmacie Victor Babe

Timioara

VARICOSE VEINS

Paca Emanoil Ioan

Seria D
Grupa 22

Definition
Varicose veins are veins that have become enlarged and twisted.
The term commonly refers to the veins of the leg, altough varicose
veins can occur elsewhere.

Veins have pairs of leaflet valves to prevent blood from flowing

backwards(venous reflux). Leg muscles pump the veins to return
blood to the heart, against the effects of gravity. When veins become
varicose, the leaflets of the valves no longer meet properly, and the
valves will cease to work as they should. This allows blood to flow
backwards and they enlarge even more. Varicose veins are most
common in the superficial veins of the legs, which are subjects to
high pressure when standing. Although viewed as mainly a cosmetic
problem, it can lead to serious complications and will deliver a great
deal of pain while standing.

Causes
Standing is regarded as the Major Cause for varicose veins to form. And
let us not think about simply standing for a few minutes or so. To develop
varicose veins, one must be engaged into a daily activity that revolves
standing for hours, like a job or daily chores at home. Standing or sitting
for large periods of time will, thus, lead to an incorrect blood flow and
valves dysfunctions.

Another cause of varicose veins is the Age. As one gets older, his/her
veins will lose elasticity and stretch. This will lead to a weakening of the
valves in your veins, allowing blood that would otherwise flow towards the
heart to flow backwards. The veins appear blue because they contain
deoxygenated blood.

Pregnancy is another cause for developing varicose veins as pregnancy

increases the volume of blood in your body but at a decreased rate of flow
of blood from the legs to the pelvis. Although this circulatory change is
meant to support the growing fetus, enlarged veins are often the side-effect.
Nonetheless, varicose veins formed during pregnancy will regress in most
cases in the first 3 months after delivery.

Symptoms
Symptoms and signs associated with varicose veins may include:

Veins that are dark purple or blue in color

Veins that appear twisted and bulging; often like cords on your legs
An achy or heavy feeling in your legs
Burning, throbbing, muscle cramping and swelling in your lower legs
Worsened pain after standing or sitting for a long time
Itching around one or more of your veins
Skin ulcers near your ankle, which mean that you may have a serious form
of vascular disease that requires medical attention
Apparition of spider veins(telangiectasia) in the affected leg
A brownish-yellow skin discoloration near the affected veins
Minor injuries in the area may bleed more or take a longer time to heal
A more vivid manifestation of some of these symptoms and signs during
evening/night

Treatments and drugs

Fortunately, treatment usually
doesnt mean a hospital stay or a long,
uncomfortable recovery. There are
different approaches on treatment,
conservative or active, with a high
dependency rate based on the gravity of
the situation.
Self Care
Self-care, such as exercising, losing
weight, not wearing tight clothes,
elevating your legs, and avoiding long
periods of standing or sitting can ease
pain and prevent varicose veins from
getting worse.
Compression stockings
Wearing compression stockings is often
the first approach before moving to
other treatments. They are worn all day
and they steadily squeeze your legs,
helping veins and leg muscles move
blood more efficiently. Can be found at
most pharmacies and medical supply
stores.

Treatments and drugs

If you dont respond to self-care, compression stockings or the condition is
more severe, your doctor may suggest one of these varicose veins treatments:
Sclerotherapy. In this procedure, your doctor injects small- and medium-sized
varicose veins with a solution that scars and closes those veins. In a few weeks,
treated varicose veins should fade. Although the same vein may need to be
injected more than once, sclerotherapy is effective if done correctly.
Sclerotherapy doesn't require anesthesia and can be done in your doctor's
office.
Laser surgeries. Doctors are using new technology in laser treatments to close
off smaller varicose veins and spider veins. Laser surgery works by sending
strong bursts of light onto the vein, which makes the vein slowly fade and
disappear. No incisions or needles are used.
Vein stripping. This procedure involves removing a long vein through small
incisions. This is an outpatient procedure for most people. Removing the vein
won't adversely affect circulation in your leg because veins deeper in the leg
take care of the larger volumes of blood.

Patient
Name:

Paca
Camelia
Age: 60
Weight: 255
pounds(115 kg)
Height: 5.80 feet
(1.75m)
Job: Pharmacist
Other details: Mitral
insufficiency, class I
obesity

Introduction

Doctor: Good morning! My name is Alex

Maxwell and I will be your doctor today. What
is your name, Madame?
Pacient: Good morning, doctor! My name is
Paca Camelia.
D: A pleasure to meet you, Mrs. Paca!
Please, take a seat and make yourself
comfortable. We are going to start deciphering
the reason for our meeting quite soon.
P: Nice to meet you too, Dr. Maxwell! Thanks
for the hospitality!

Main Complaint

D: All right, Mrs. Paca! What seems to be the problem that has brought
you here today?
P: Well, Doctor, to be honest with you, I do know bits of my problem but I
will try to explain what is happening in hope of finding a better treatment
for it.
D: Please do so, Mrs. Paca!
P: It is about my legs, in the past few years, they are always swollen,
especially the lower parts of the legs, with a terrible pain appearing most
often during the evening or prolonging into the night. The veins are all
twisted and have taken a strange color, like a dark purple or a sickening
blue. My legs are always heavy and achy, and these problems greatly
manifest after long periods of standing or even sitting.
D: I see, that is quite the hassle you are going through. But, I need to know
a little more of the problem. What else have you noticed in regards to the
legs, Mrs.? Did the pain become unbearable just recently or it took a while
to settle in?
P: I might have deceived you with that past few years statement, Dr.
Maxwell. Truth be told, the first few issues with my legs began maybe
around 15 years ago, which is more than a few, but I didnt pay much of an
attention back then, being with a little child to care for and also with a job
and marriage, I still felt young. But in the last few years, I couldn't but
notice how weird my leg veins turned and how badly the aching, the itching
became and just how horrible my legs shaped into.

Main Complaint
D: Dont worry, Madame, it is understandable and, although
unfortunate, people do seem to care more about their problems
once these worsens, I deal with that everyday. I would like to
know just a bit more about the shape of the legs and veins,
before taking a look myself.
P: The veins are enlarged and curled around my legs,
hazardous alike, as if like they are not following a certain path
like they used to. And near them, it itches and it aches in the
same time, mostly during the late hours of the day, as I said
before.
D: As a conclusion, Mrs. Paca, you have experienced in the
last few years a great deal of changes regarding your legs, but
mostly regarding the superficial veins from your legs, that have
become enlarged, twisted, darker, chaotic in direction and with
constant swellings, pains that are often unbearable, itches,
irradiating towards the ankle and with a higher rate of
occurrence during evenings or nights or after periods of standing
or sitting.
P: Pretty much that, Doctor!

History of present condition

D: Mrs. Paca, to be more precise, you stated that the

first few symptoms appeared around 15 years ago, but
they only worsened in the last years?
P: Yes, you are right, Doctor! But I cannot accurately
tell just how recently the issues altered, just the general
condition of my legs turned out for the worst in the
meaning that I felt that something had to be done
D: What do you mean by that statement, Mrs. Paca?
P: You remember that I did say at first that I know
something about my problem?
D: Yes, that would be true. Please, continue!
P: Well, after seeing how my legs and veins turn out, I
started asking around and found out that the issue with
my legs might be called varicose veins and learnt of a
few things that I could do to maybe ease the pain a little

History of present condition

D: You are right, Mrs. Paca, that is what I suspect to

be the problem, varicose veins, but more into that later,
when I will be sure of that. But you got me intrigued by
those few things to ease the pain that you mention of,
something like a self-care, which, all in all, it doesnt
sound like a bad idea but would like to hear more into
it.
P: Sure, Doctor! I learnt that elevating the legs or
putting a pillow under my legs so that they are at a
higher height while sleeping does wonders at times, or
wearing something elastic around my legs, such as
compression stockings, if the name is right. I dont know
the exact reason why, but these little things do help.
D: Indeed, they help, and are the right things to be
done. As for the reason of your improvement while
following these little tricks, I will explain it soon
enough, Madame!

Social History

D: I would like to ask some questions regarding your lifestyle! That might
give us some clues regarding the problems that brought you here today.
What are you doing for a living, Mrs. Paca?
P: What I am doing and, soon, what I was doing, as my retirement
approaches. I am working as a pharmacist at the hospitals pharmacy. Not
the most energy consuming work at a first sight but the time spent standing
surely drains the life of me.
D: I see, that in itself is a definite reason for your problem, Mrs. Paca.
Standing for large periods of time will lead to a faulty blood flow through
the veins of the legs which will lead to serious issues, such as you
encountered. Furthermore, what is your everyday life at home?
P: Oh, Doctor, I have to say it is quite a burden at times...lots of chores to
do, that happens when my husband is always busy and my younger son is
pretty lazy, sometimes I wish I had a daughter, but, oh, well, one cannot
have everything. Nevertheless, doing chores means that I have to spend a
great deal of time standing at home as well, which further degrades my
condition.
D: That sure stirred a smile on my face, Mrs. Pa ca! My mother used to
think the same thing, always wishing for a daughter to help her with the
chores. As I can see, almost everything you do involves standing, but, what
about the diet, a little info might be appreciated.

Social History
P: After a certain age, one doesnt care all that much about diet or exercising
and, unfortunately, the negative results start to appear. My life is quite
sedentary and thus, been gaining some weight along the years. And I wont lie,
I always enjoyed eating, and that can hardly be considered a crime.
D: Right you have, Madame, but one must always think about his lifestyle,
more so, after a certain age just for not to reach in the situation to look for our
health issues at that very age. Judging your medical record and facts proven by
your answers, you suffer from a mitral dysfunction and type 1 obesity, which is
not all that serious as one might think. Next comes a question that finds its way
in almost any situation, how often you feel stressed or anxious?
P: After reaching a certain breakpoint in your life, you start wondering and,
better yet, worrying, and this time the worries doesnt concern you alone, but
also your family, your children, how well will they fare with life, how long you
have left to live, wishes that you can see them fulfilled and all these things add
up quite fast and so, all of a sudden, your life becomes more stressed than
ever.
D: You neednt worry all that much about these certain things, Madame! After
all, you are 60, plenty of years ahead and with no serious issues regarding your
health. Nonetheless, the age, the sedentary lifestyle, the stress, are all valid
constraints that put their print on your legs and, better said, on the veins, as
theres always a connection between all these little things.

Family history

D: Do you have any cases such as yours in the family, in regards with
the legs or maybe with a cardiovascular dysfunction or obesity, or all of
them are anew?
P: My mother was working at a kindergarten, always on the move,
thank God, she didnt have not even the slightest problem concerning
veins of the legs, or any other problem except her hearing, all those years
of working with children were quite noisy and she was almost deaf at a
later age. My brother has some issues with his arterial tension, but
nothing too serious whereas my father, an engineer, led quite an active
life and, thus, he didnt suffer from any heart issues, and much less
obesity or leg problems. Unfortunately, it seems like cancers do run in
the family, but even there, theres hardly a connection.
D: I see, I am sorry to hear that cancers run in your family, it is such a
tragic disease but alas, we have other things to concern about now.
Judging all of these, there arent many connections to your problems
which might not imply anything genetic related to them, which is mildly
encouraging. More so, does that mean that nobody in your family had
any problems with being overweight, it might be of importance this
aspect?
P: Yes, you are right, Doctor, nobody had any issues with the pounds,
well, except for me. Quite the greedy type, when it comes to food!
D: Ha ha, I wouldnt got that far, it can hardly be noticed!

Further testing

D: I will now have to take a look at your legs and see just how
serious the issue is and then I will be able to explain certain things.
Besides looking, we will also do a lower limbs venous
ultrasonography which is of help to see if inner veins might also be
affected.
P: Sure, Doctor!
D: Oh, dear, I am afraid that you were right at the beginning
saying that you are looking for treatments, the legs and the veins in
particular are exactly as you described them and judging by the
gravity of the looks, it is common to experience those pain
episodes quite frequently. Furthermore, a simple self-care, while it
does good, it wont be able to improve but mainly tender the pain
or diminish the swellings.
P: Oh, Doctor, is it that bad?
D: Well, truth be told, it is that bad, but, fortunately enough, this
issue is hardly life threatening but managing to make the person
with it quite uncomfortable and with a terrible cosmetic look on
the legs. I will have it explained right away!

Diagnosis
D: Mrs. Paca, your condition is called varicose veins, as you might have heard by
now, but this time around, there is an explanation for it. Varicose veins are veins
that have become enlarged and twisted, most common in the superficial veins of
the legs. Luckily, after seeing for myself and with the help of the ultrasonography
it appears that only the superficial veins are affected which is a good thing. Veins
have pairs of leaflet valves to prevent blood from flowing backwards(venous
reflux). Leg muscles pump the veins to return blood to the heart, against the effects
of gravity. When veins become varicose, the leaflets of the valves no longer meet
properly, and the valves will cease to work as they should. This allows blood to
flow backwards and they enlarge even more. The reason why they are common in
superficial veins is that they are subjects to high pressure while standing.
Fortunately, the majority of the blood flow from legs to heart is being taken care of
by the inner veins and therefore, the actual circulation does not suffer huge
alterations but cosmetic and pain wise, the legs suffer from these twisted veins.
P: That sure explains a lot, something along the lines is happening with my mitral
dysfunction, I guess
D: I am not the specialist in that domain, but things do occur a little differently out
there, in the heart, although one of the base results is a minor regurgitation of
blood, that should only flow in one direction. Also, there are sings of spider veins
in your legs, which is known as telangiectasia, but that is a minor issue that will be
corrected by treatment, speaking of which, an idea that might suit this situation
accordingly already sprung into my mind and would certainly do wonders.
P: Yes, I am looking forward for a treatment that would once and for all,
rejuvenate my legs if possible or, at the very least, get me rid off those unbearable
pains.

Treatment
D: Mrs. Paca, we must have a few words regarding the treatment. Until now,
you tried to manage the varicose veins with self-care treatment such as elevating
the legs, wearing compression stockings and, more or less, exercise. What I
strongly advice you is that you continue doing these activities and a lot more
exercise, if possible, some 15 minutes strolls in the evening are bound to do
wonders. But, in addition to this, I will also prescribe a flavonoid such as
Diosmin which is an effective ointment for people with varicose veins in easing
the pain and preventing the heavy legs and withdraw the swellings of the legs.
However, all of these things, in this very case are all supplementary. The real
treatment that I am thinking about, with quite the efficiency rate will be
discussed right away!
P: What treatment are you suggesting, Doctor? Is it harmful in any way?
D: Fear not, Madame, as its not quite invasive as one might think. It is called
sclerotherapy. This procedure involves the injection of small- and mediumsized varicose veins with a solution of Polidocanol that will scare and close
those veins. Nevertheless, this might take a few weeks of treatment for the
varicose veins to fade and thus, might lead to the injection of a vein more than
once. It is highly effective if done right and does not require anesthesia. I have
personally did this operation countless times as it is booked in my specialty and
can state that it is a more preferred treatment compared with the vein stripping
which is bound to leave scars and quite the painful action to be taken.
P: Seems like the best idea, Doctor, although I didnt imagine it would go as
far as this but, if its for the best then I will have to comply.

Treatment

D: That is the brightest thing to do, in my

opinion. I will have you scheduled on a three
times per week , namely Monday, Wednesday
and Friday , for three weeks for the beginning
and we shall see how the situation evolves.
That being said, do not forget to follow with
the self-care and exercise and using the
ointment I prescribed.
P: Thanks a lot, Doctor! That means next
Monday we will start the treatment?
D: Precisely! Goodbye, Mrs. Paca!
P: Goodbye, Dr. Maxwell!

Results

D: And here we are, 4 weeks into the treatment, Mrs. Pa ca! It seems that the
progress is quite extraordinary and this might be our last session of
sclerotherapy. I must say that I am thanked with the results thus far, most of the
varicose veins have closed or withdrew completely and there is little evidence
there were any signs of spider veins ever on your legs. I assume you are going
through with the self-care and with the ointment because this improvement
couldnt be done based on sole sclerotherapy?
P: Yes, Doctor, I must admit I am astonished by the results. And thats not a
little thing coming from my part as I was always a bit negative or distrustful and
fail to see the final result at times. More than ever, I kept following the self-care
treatment and have to say, those 15 minutes strolls are really worth it, it feels like
freedom, a lot less pain, no more heavy legs and itching and I couldnt be more
glad about it.
D: I have to admit I am flattered by your high-spirited will that I seem to have
awaken in yourself. Told you that little walks of merely 15-20 minutes are of
great help, not only for the legs and circulation but also for the weight and
vascular problems that you have and also as a general way to clear the mind for a
little time. Sometimes, the best remedy for anything that we encounter is a
crystal clear mind that helps us see through everything.
P: Oh, Doctor! You could always pass as a psychologist in your patients eyes!
D: Thanks, it is true, however, I always fancied psychology and philosophy, I
think medicine goes hand in hand with these two sciences.
P: I do not doubt that, Doctor!

Before-After

Conclusion

D: As it stands right now, this is the last sclerotherapy session that we had
to do because the results speak for themselves. However, I cannot stress
enough just how important is to continue with the self-care treatment, such
as elevating the legs and the daily exercise and I think it is safe to say that
compression stockings are no longer needed at this stage. Furthermore,
this doesnt mean that the varicose veins arent subjects to reappearing but
that would take a lot of negligence from your part and I dont think that
will happen. Nevertheless, you shall still encounter some mild
manifestation of pain or itching or heavy legs but definitely not like
before. I will schedule you to an appointment after 3 months to see how
everything goes because a timed check is going to be needed. For any
difficulty or question that you might find, do not hesitate to call me and I
will try to answer them.
P: Thank you very much, Dr. Maxwell! I am grateful to have had such a
dedicated doctor in taking care of me! I will do my best in following the
advice you gave me!
D: Youre welcome, Mrs. Paca! Well see in 3 months! Goodbye!
P: Goodbye, Dr. Maxwell!

Bibliography
http://en.wikipedia.org/wiki/Varic

ose_veins
http://www.mayoclinic.org/disease
s-conditions/varicoseveins/basics/definition/con20043474
http://www.emedicinehealth.com/
varicose_veins/article_em.htm