History-Taking & Physical Examination in Vascular

Diseases

Aim – To reach for a Presumptive Diagnosis

How to take the History

• Establish a rapport with patient introduce yourself.

• Initiate by asking – what made him to seek medical advice.

• Listen without interruption.

• Wait for answers before asking another question.

Don’ts of history taking

• Do not interrupt the patient.

• Do not use medical terminology.

• Do not ask irrelevent questions

• Do not ask leading questions.

• Do not be abrupt or impatient.

The Present Complains

• Ask the patient to tell you what made him to seek medical advice.

• Record the answer in patients words.

History of Presenting Complains

• Details of the history of the main complaints.

- when did it start

- what was the first thing noticed

- progress since then

- ever had it before.

History of Presenting Complains

• S – Site

• O – Onset

• C – Character

• R – Radiation

• A – Association

• T – Timing/Duration

• E – Exacerbating & alleviating factors

• S - Severity

Direct Questioning

• Specific questions about the diagnosis you have in mind.

- Risk factors.

- Review of relevant system.

• Past Medical History

• Drug History

• Family History

• Social History

• Habits

• Vascular Diseases

- Arterial

- Venous

- Lymphatic

Arterial Diseases

• Electively – Chronic Symptoms• Acutely – Limb threatening disorders• Pain

Intermittent Claudication

Rest pain• Tissue loss

Ulcer

Gangrene

• Acute arterial occlusion

Sudden onset

Severe, Shocking pain

Diffuse

Associated Symptoms

• Chronic Arterial Insuffciency: Intermittent Claudication Site – depends on the level & extent of

arterial disease - Cramp like pain - Consistantly reproduced by same level of

exercise - Completely & quickly relieved by rest - Claudication distance

• Rest Pain

- continuous severe pain, aching in nature

- occurs in distal part of foot

- often relieved by putting the leg below the

level of heart

- movement or pressure causes exacerbn.

• Ulcer – area of discontinuity of surface epithelium• Gangrene – Dead tissue - Duration, Site. - what drew the patient’s attention to the ulcer - other symptoms - progression - persistance - multiplicity

Examination

• Inspection

- Expose

- Compare

• Look For

• Ulcer

site, shape, size, no.

edge, floor, deapth, discharge, surrounding area.

Base

• Vascular Angle

Or Buerger’s angle

Normal-straight leg can be raised by 90* & foot rmains pink.

Ischemia – elevation to 15-30*cause pallor

• Dependant rubor

• Venous Filling

Normal – veins of foot are full of blood

Ischemia – veins are collapsed & looks like pale blue gutters

- Guttering of veins

Palpation

• Temperature

which foot – warm/cold.

level at which change occurs

• Tenderness

• Capillary filling

Feel for P. pulses & grade

• Peripheral Nerves Examination

- Sensory

- Motor

• Auscultation

- Bruit

Venous diseases

• Common Presentation

- Varicose veins

Asyptomatic, Cosmetic, Dull aching pains, Feeling of heaviness, Itching/Eczema, superficial thrombophlebitis, bleeding, Ulceration, Saphenavarix.

• Primary – Venous valve failure

• Secondary – Post thrombotic

- Congenital Malformations

Examine both supine & standing

Touniquet Test–Identify clinically site of reflux from deep to superficial veins-Identify incompetant perforators – tie tourniquet above suspected perforator

Lymphatic diseases

• Lymphangitis – inflamation of lymphatics.

• Lymphedema – faiure of lymph drainage.

Protein rich fluid accumulates in tissue

Lymphedema

• Primary

- congenital – at birth

- Precox - adolescence

- Tarda - middle age

Lymphatic abnormalities – aplasia, hypoplasia, hyperplasia.

• Secondary :

- Infection

- Surgery

- Radiation

- Trauma