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