Patient guide

First of all

The first visit is for hearing your story. The more detail you bring, the sooner the doctor can see where to start. If you have a sign today that is urgent (sudden swelling and pain in one leg, lasting chest pain, sudden shortness of breath), put this guide aside and go to the section “When should I call urgently?”. A first visit is not the place for that.

What to bring

• Identification and insurance, if you have insurance.
• A list of your medicines. All of them, including tablets and over-the-counter medicines, supplements and herbal products: the name, how long you have taken it and how you take it. It is best to bring the boxes or photos of the leaflets. If you take a blood thinner, be sure to say so. The UK’s National Health Service (NHS) says to check with a doctor or pharmacist before starting any other medicine and to tell the doctor before surgery or an endoscopy.
• Results of earlier checks. ECG, echo, Doppler ultrasound, blood tests, images and reports from a hospital stay or operation. If you only have phone photos, those help too.
• Your blood pressure record. If you measure at home, bring the notebook or record sheet and bring your monitor too, so it can be compared with the clinic’s.
• Your questions. Write the most important worry first so it is not lost in the rush.

What to note down beforehand

If you are coming for your legs. The NHS lists the symptoms of varicose veins as pain, heaviness, swelling and itching, and says they get worse after standing for a long time and better when the leg is raised. Note these:

• What time of day your leg is worst and what makes it better
• One leg or both
• The skin: itching, darkening, dryness, sores and how long a sore has been there
• An earlier clot, surgery or hospital stay, long journeys and pregnancies
• A family history of varicose veins

A photo of the leg at the end of the day, when the swelling or veins are more noticeable than in the morning, helps. Remember that your leg will be fully seen for the examination. Wear comfortable clothes so you can bare the lower leg and foot (Mayo Clinic).

If you are coming for your heart. Note these:

• When does the chest pain or pressure come? With effort? At rest? How many minutes does it last? What eases it? (The NHS treats these as the key points in angina: the trigger, the length and easing with rest)
• Palpitations: when they started, how long they lasted, what you were doing
• Shortness of breath: with what activity? When lying down?
• Leg swelling or sudden weight gain (NHS, in heart failure)
• A history of high blood pressure, cholesterol, diabetes, smoking and heart disease in the family

How does the visit go?

The doctor first asks questions, then examines the legs and heart and measures blood pressure. Depending on what is heard and seen, an ECG, Doppler ultrasound, blood tests or another check may be requested. For varicose veins the NHS names a Doppler ultrasound as the usual way to confirm and plan treatment, and for angina an ECG and blood tests and, if needed, imaging. Not everyone needs everything.

Treatment is not always settled on the same day; sometimes the results of the checks have to be seen first. The NHS says that for varicose veins, treatment is not always needed.

A few things that help

• Do not hold back the sentence “I don’t know if it matters”. Say it; the doctor decides.
• If you have cut down or stopped a medicine, say so. There is no blame; the doctor needs to know.
• If you come with someone, ask one person to take notes.
• If you did not understand a result or an instruction, ask again.

What does a Doppler do?

An ordinary ultrasound shows structure. A Doppler also shows the movement of blood. The UK’s National Health Service (NHS) calls a duplex Doppler ultrasound a scan that measures blood flow, and says a specialist uses it to confirm the diagnosis of varicose veins and plan treatment. The Mayo Clinic also calls it the standard way to assess varicose veins.

A Doppler answers two main questions:

• Do the vein valves leak? If blood flows back in the vein, the vein is failing and swells. The Doppler shows which vein and from which point.
• Are the deep veins healthy and free of clots? To confirm or rule out a deep vein thrombosis, the NHS names ultrasound as the usual method and says it shows whether blood is flowing normally in the vein.

The American Vascular Surgery and American Venous Forum guideline (2011) recommends that in a patient with varicose veins or chronic vein disease, the history and examination be completed with a Doppler ultrasound of both venous systems, superficial and deep.

Why is it needed before choosing a treatment?

Two legs that look alike can have different causes. The methods we know for varicose veins (compression stockings, sclerotherapy, laser and radiofrequency inside the vein, surgery) each have their place, and the choice between them depends on the map of the leg veins. A Doppler gives this map. Without it, the decision rests on how the vein looks, and appearance is not enough.

One example: the NHS says compression stockings are not suitable when there is a problem with arterial blood flow in the leg, and a specialist checks for this. So sometimes, besides the veins, the arterial blood supply needs to be assessed too.

A Doppler for a clot

When a clot is suspected, a Doppler does something else: it looks for a clot inside the vein. The NHS says that if a doctor suspects a deep clot, the patient should be referred to hospital within 24 hours for an ultrasound. In this case the Doppler does not wait for a routine appointment. Have sudden swelling and pain in one leg seen the same day, and if you also have shortness of breath or chest pain, call 115 (the emergency number in Iran). If you are outside Iran, call your local emergency number.

What to ask the centre

How it is done, the preparation needed (for example clothing, standing or lying, timing) and how long the test takes may differ from one centre to another, and the sources we read for this page do not mention any particular preparation. So when you book, ask:

• Is any special preparation needed for the test?
• Is it a venous Doppler (varicose veins) or a Doppler for a clot? Match this with the doctor’s request.
• When and how do I get the report?
• What should I bring? (the doctor’s request, earlier ultrasounds, a list of medicines)

After the test

Give the report to the doctor who requested it and do not decide from it yourself. The sentences in a report are written for a doctor, and without examining the leg their exact meaning cannot be understood. The result is only one part of the picture; the symptoms and examination are the other.

If you develop a new symptom after the test, or leg swelling and pain suddenly get worse, do not wait for your appointment: see a doctor or go to the emergency department the same day.

Why does daily care matter?

Daily care does not make varicose veins disappear, but the UK’s National Health Service (NHS) says it can help with the symptoms. The same steps help with leg swelling. The list below comes from the NHS.

Things to do every day

• Raise your legs. Whenever you can, lie down with your legs on a pillow, or raise them on another chair while sitting.
• Keep moving. Walking or running improves circulation.
• Do not stand or sit for long periods. The NHS advises against long periods of standing, and against long periods of sitting unless the legs are raised. If your job involves standing (teaching, hairdressing, shop work), sit and raise your legs whenever you can. If your job involves sitting, get up and walk now and then.
• Keep a healthy weight.
• Do not smoke. Smoking damages the veins.
• Keep the skin moisturised. Dry, itchy skin improves with a moisturiser.
• Protect your legs. A knock to a prominent vein raises the risk of bleeding.
• Wear loose, comfortable shoes with a low heel and a soft sole, and avoid tight clothes, socks or shoes.

Compression stockings

If a doctor prescribes compression stockings, the NHS says to put them on in the morning and take them off at night. Stockings do not replace an examination: the size and type are chosen by a doctor or pharmacist, and they are not suitable if you have a problem with arterial blood flow. The articles section says more about stockings.

Look at the skin of your legs every day

The skin of the legs shows how the veins are doing. The NHS lists these among the complications of varicose veins: varicose eczema (itching, dryness and flaking over the veins) and a venous ulcer that is slow to heal. Every day, when washing or changing clothes, look at your lower legs and ankles and show a doctor:

• A sore that has not healed after two weeks
• Skin that has turned dark, hard, itchy or inflamed
• A foul-smelling discharge from a sore. The NHS lists it among the signs of a venous ulcer and says that if the ulcer becomes infected, a doctor decides what treatment is needed

If you have had a venous ulcer once, prevention matters more. The NHS says a new ulcer may appear in the same leg months or years later, and for this reason recommends compression stockings, a healthy weight, movement, raising the legs and stopping smoking.

If you have diabetes

The NHS treats swollen feet and ankles in a person with diabetes as urgent; have them seen the same day. Look at the skin of your feet fully every day and take even a small sore seriously.

Night cramps and end-of-day heaviness

A Canadian health technology report counts night cramps and leg tiredness among the symptoms of varicose veins, and the NHS lists heaviness. These symptoms have other causes as well and cannot be guessed from the symptoms alone. If they keep coming back, have an examination.

Signs that do not wait

• Sudden swelling and pain in one leg, especially with redness or warmth: a deep clot is possible. See a doctor or go to a healthcare facility the same day.
• A hard, painful vein that is red or warm: it may be a superficial clot. Have it seen the same day.
• Shortness of breath, chest pain or coughing up blood along with these: 115 (the emergency number in Iran). If you are outside Iran, call your local emergency number.
• Bleeding from a varicose vein: lie down, raise the leg, press directly with a clean cloth and call 115, or your local emergency number outside Iran (section “When should I call urgently?”).

Why at home?

The UK’s National Health Service (NHS) says that if your first reading is high, you may be asked to measure at home for a few days, and these readings help the doctor. The threshold for high blood pressure at home also differs from the clinic: 135/85 at home, 140/90 in a clinic.

If a doctor has asked you to, follow this guide. If you are measuring on your own initiative, show the reading to a doctor instead of changing your medicine.

The monitor

The AHA recommends an automatic upper-arm monitor (cuff around the arm) and considers wrist or finger monitors less accurate. The monitor should be validated and the cuff should fit your arm. If a doctor or nurse has given you a monitor, follow their training. If you buy your own, the NHS says to follow the instructions for that model, because designs differ.

Take the monitor to a clinic once and compare it with the clinic’s. The AHA says to repeat this once a year.

Before measuring

The AHA says:

• Do not exercise, smoke or drink caffeine for half an hour beforehand.
• Empty your bladder.
• Sit quietly for at least five minutes.

Body position

• Sit on a chair, upright with your back supported, not on a sofa.
• Feet flat on the floor, legs not crossed.
• Arm resting on a table or flat surface, level with the heart.
• Put the cuff on bare skin, not over clothing. Its lower edge should be just above the crease of the elbow.
• Do not talk or use your phone while measuring.

How many times, and when?

The NHS gives the usual schedule as twice a day: once in the morning and once in the evening. Write down the two numbers, wait a minute and measure again. How many days to continue is told by the doctor or nurse. For diagnosis the AHA gives as an example two readings in the morning and two in the evening over one week.

Record both numbers (top and bottom) each time. The AHA also suggests a printed log for recording.

If a reading is high

One high reading on its own is usually not an emergency, unless you also have symptoms. If the reading is above 180/120 and you have chest pain, shortness of breath, weakness or numbness, a change in vision or trouble speaking, do not wait: call 115 (the emergency number in Iran). If you are outside Iran, call your local emergency number. If you have none of these, the AHA says to wait five minutes and measure again. If it is still very high, contact a doctor straight away, and if you cannot reach a doctor, call the emergency number.

The NHS treats repeated headaches, blurred vision and chest pain that comes and goes as urgent; have them seen by a doctor the same day. The signs of a heart attack (sudden, lasting chest pain, pain spreading to the arm or jaw, sweating, nausea, shortness of breath) and of a stroke (a drooping face, weakness on one side, sudden trouble speaking) are an emergency.

If you take medicine

Do not use the home reading as the basis for changing medicine. The AHA says that if you have been prescribed medicine, you should not stop it without talking to your doctor, even when your home pressure is normal. A normal reading may be the result of that very medicine.

Take the notebook with you

The AHA says to bring the monitor and your records to your appointment so the method and the numbers can be compared with the clinic’s monitor.

What is not on this page

Your doctor prescribes medicines, because the doctor looks at your age, conditions, tests and other medicines. This page gives no medicine names, amounts or instructions to start or stop. Its only aim is for you to know what a medicine is for and what to tell your doctor.

One simple rule

Do not reduce, increase or stop a medicine that has been prescribed for you on your own. If you have a side effect, keep forgetting the medicine or think you do not need it, tell your doctor or pharmacist. Make the decision with them. In the same way, do not start a medicine for your heart or veins on your own.

What are the medicines for?

The UK’s National Health Service (NHS) describes the main groups like this:

• Blood pressure. A doctor prescribes medicine when blood pressure is very high, the risk of a heart attack or stroke is high or lifestyle changes do not bring it down. Most are daily tablets and some people need more than one. The AHA reminds you not to stop the medicine without advice even if your pressure is normal at home.
• Heart failure. Medicines that remove extra fluid, medicines that widen the blood vessels and medicines that slow the heart rate.
• Angina. Medicines to stop an attack and medicines to prevent attacks and lower the risk of a heart attack or stroke. The doctor gives the instructions for taking them.
• Irregular heartbeat. Medicines to control the heart rate and rhythm and sometimes a blood thinner to lower the risk of clots and stroke (NHS, for atrial fibrillation).
• Clots. The NHS says a deep clot is usually treated with a blood-thinning medicine, continued for at least three months. Some people need it for longer. The doctor decides the duration.

Blood thinners: a few safety points

A blood thinner in effect slows clotting, and its most common side effect is bleeding more easily. The NHS says that for most people the benefit outweighs the risk.

• Do not stop it on your own. Even if your leg is better or a long time has passed. The doctor decides when to stop.
• Before any procedure or check, from surgery and dental work to things like an endoscopy, tell the doctor you take a blood thinner. The NHS says the medicine may need to be stopped for a short time; that decision belongs to the doctor.
• Before any new medicine or supplement, even without a prescription, ask a doctor or pharmacist. Some medicines change the effect of a blood thinner (NHS).
• If a dose is missed or an extra dose is taken, check the leaflet that comes with the medicine or ask the doctor or pharmacist.
• If you are pregnant or planning a pregnancy, tell the doctor early. The NHS says most of these medicines are not suitable in pregnancy.
• Food. The NHS says that for some of these medicines you should not suddenly and greatly change your usual food and drink. Ask a doctor or pharmacist whether yours is one of them.

Signs of bleeding

The NHS lists these: blood in the urine, blood in the stool or black stool, severe bruising, a nosebleed that lasts a long time, bleeding gums, vomiting or coughing up blood and very heavy periods. If you notice blood in the urine or stool, severe bruising, a nosebleed that lasts a long time, bleeding gums or very heavy periods, let a doctor know the same day and do not stop the medicine yourself.

Call 115 (the emergency number in Iran; outside Iran, your local emergency number) if bleeding is severe or will not stop, if you vomit or cough up blood or pass black stool, or if you get a sudden, severe headache with confusion, trouble speaking or weakness in the arms or legs. After a blow to the head, even if you feel well, see a doctor or go to the emergency department the same day.

Medicines and leg swelling

The NHS counts some blood pressure medicines, contraceptive pills, hormone treatments, antidepressants and steroids among the possible causes of leg swelling. If swelling appeared after starting or changing a medicine, tell your doctor. Do not stop it yourself; the swelling may have another cause.

Always carry your medicine list

Every doctor, dentist and pharmacist should know your full list of medicines: the name, how long you have taken it and how you take it. In an emergency too, the NHS says to take your medicines with you. Keep the list on paper or on your phone and update it each time something changes.

If a medicine has caused a problem

A doctor or pharmacist will assess the side effect. Do not stop the medicine yourself. If the sign is urgent (shortness of breath, chest pain, severe bleeding), call 115, or your local emergency number if you are outside Iran.

First of all

This list is for the moment when you are worried and do not know whether to wait. Many cases of leg pain and swelling, and most palpitations, are not serious, but a few situations do not wait for an appointment.

The emergency number in Iran is 115. If you are outside Iran, call your local emergency number instead. The UK’s National Health Service (NHS) stresses on several pages: do not drive yourself, go by ambulance or ask someone to take you, and take your medicines with you. If you are not sure, call and ask. The operator will guide you.

This list does not cover everything. If something has worried you, trust that.

1. Sudden swelling and pain in one leg

The NHS recognises a deep vein thrombosis by these signs: throbbing pain in the calf or thigh, swelling of one leg, redness or darkening of the skin (harder to see on dark skin) and prominent veins. Usually one leg is affected, and rarely the only sign is pain in the lower abdomen.

• Urgent assessment the same day is needed, even if you are not short of breath. The NHS treats a suspected clot as urgent. See a doctor or go to a healthcare facility the same day. If you cannot get to one, get advice from 115 (the emergency number in Iran).
• If you also have shortness of breath or chest pain, the clot may have reached the lung: call 115 (the emergency number in Iran). No appointment, no waiting.
• If you are pregnant, contact your obstetrician or maternity unit the same day.

After surgery, a hospital stay, a long journey or childbirth, take swelling in one leg more seriously. The NHS counts these among the temporary factors for a clot.

2. Sudden shortness of breath

For a clot in the lung the NHS lists these signs: sudden shortness of breath, chest or upper back pain that gets worse with a deep breath, coughing up blood, a very fast heartbeat and fainting. Call 115 and do not drive yourself.

Coughing up blood should be checked the same day even without the other signs.

3. Chest pain

In these situations call 115:

• Chest pain or discomfort is sudden and does not stop: squeezing, pressure, heaviness or burning, or like indigestion
• The pain spreads to the arm, neck, jaw, shoulder, stomach or back
• The pain comes with a cold sweat, nausea, dizziness or shortness of breath
• The lips or skin have turned pale, blue or grey
• Someone has lost consciousness and is not responding normally

If angina has been diagnosed and the pain does not stop with rest and the prescribed medicine, the NHS says the same: call 115. If angina attacks have become worse, more frequent or longer, or come at rest, see a doctor or go to the emergency department the same day.

Have chest pain that has come and gone seen by a doctor the same day, even if it passed quickly. If the pain comes back and stays, call 115.

4. Palpitations and fainting

The NHS says to call 115 if palpitations do not stop, or come with chest pain, shortness of breath or feeling faint. Even if the symptoms have passed, let a doctor know the same day. If someone faints for no clear reason, even if they come round quickly, call 115.

If you have a fast or irregular heartbeat and any of these as well, call 115 (NHS, for atrial fibrillation): chest pain, shortness of breath, sweating, nausea or vomiting, a severe headache, weakness or numbness on one side of the face or body, blurred or lost vision, confusion or difficulty speaking.

A drooping or weak side of the face, weakness on one side of the body and sudden trouble speaking are signs of a stroke, even without palpitations: call 115 straight away.

5. Heart failure getting worse

If you have heart failure and your breathing becomes short when lying down or doing everyday tasks, or your weight has suddenly gone up, let a doctor know the same day. Call 115 if the shortness of breath is severe (gasping, choking, unable to speak), you cough up pink, frothy phlegm, the lips and skin turn pale or blue, or someone has lost consciousness.

6. Bleeding from a varicose vein

Bleeding from a prominent vein may look very small and quickly become severe. The NHS says bleeding from a varicose vein needs urgent medical attention. Call 115. Until help arrives:

1. Lie down (or sit). Do not stand or walk.
2. Raise the leg above the level of the heart.
3. Press directly on the bleeding spot with a clean cloth or gauze. Keep pressing.
4. Do not tie anything above the bleeding point, on the side towards the heart.

A systematic review in the International Wound Journal says standing makes the bleeding worse and bleeding from a varicose vein can become fatal very quickly, and recommends that the patient be assessed in hospital after first aid. Even if the bleeding stops, a doctor needs to see the vein. This review relies mostly on case reports.

7. A hard, painful vein, redness and warmth in the leg

A hard, painful vein with warm and red or darkened skin around it may be a superficial clot. The NHS asks for urgent help with this sign so that a deep clot can be ruled out, so have it seen by a doctor the same day. If the redness spreads, the leg suddenly gets worse or shortness of breath appears, call 115.

For leg swelling the NHS says the same: severe, painful or sudden swelling, swelling with redness or warmth, fever or chills, and swelling of the face or abdomen should be checked the same day. So should swelling after an injury that is getting worse.

8. A leg sore

A leg sore that has not healed in two weeks should be shown to a doctor (NHS). If the sore has a foul-smelling discharge, or the skin around it has become red, warm and painful, or you have a fever, the same day. In a person with diabetes, have any sore or swelling of the leg seen the same day.

9. A very high blood pressure reading

If the reading is above 180/120 and you have chest pain, shortness of breath, weakness or numbness, a change in vision or trouble speaking, do not wait: call 115. If you have none of these, the AHA says to wait five minutes and measure again. If it is still very high, contact a doctor straight away, and if you cannot reach a doctor, call 115. Have repeated headaches and blurred vision seen by a doctor the same day too (NHS). Do not change your blood pressure medicine on your own.

10. Blood thinners and bleeding

If you take a blood thinner and notice blood in the urine or stool, severe bruising, a nosebleed that lasts a long time, bleeding gums or very heavy periods, contact a doctor the same day (NHS). Do not stop the medicine yourself.

Call 115 if bleeding is severe or will not stop, if you vomit or cough up blood or pass black stool, or if you get a sudden, severe headache with confusion, trouble speaking or weakness in the arms or legs. After a blow to the head, even if you feel well, see a doctor or go to the emergency department the same day.

If you are not sure

The list above is not everything. If something in your body does not seem right, call. If it turns out to be nothing after you call, you have lost nothing; but if it was something and you waited, time may have been lost.