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 AngleOr Buerger’s angleNormal-straight leg can
be raised by 90* & foot rmains pink.
Ischemia – elevation to 15-30*cause pallor
• Dependant rubor
• Venous FillingNormal – veins of foot
are full of bloodIschemia – 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 ageLymphatic abnormalities – aplasia,
hypoplasia, hyperplasia.
• Secondary :- Infection- Surgery- Radiation- Trauma