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History-Taking & Physical Examination in Vascular
Diseases
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Aim – To reach for a Presumptive Diagnosis
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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.
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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.
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The Present Complains
• Ask the patient to tell you what made him to seek medical advice.
• Record the answer in patients words.
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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.
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History of Presenting Complains• S – Site• O – Onset• C – Character• R – Radiation• A – Association• T – Timing/Duration• E – Exacerbating & alleviating factors• S - Severity
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Direct Questioning
• Specific questions about the diagnosis you have in mind.
- Risk factors. - Review of relevant system.
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• Past Medical History• Drug History• Family History• Social History• Habits
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• Vascular Diseases
- Arterial
- Venous
- Lymphatic
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Arterial Diseases
• Electively – Chronic Symptoms• Acutely – Limb threatening disorders• Pain Intermittent Claudication Rest pain• Tissue loss Ulcer Gangrene
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• Acute arterial occlusion Sudden onset Severe, Shocking pain Diffuse Associated Symptoms
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• 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
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• 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.
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• 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
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Examination
• Inspection - Expose - Compare
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• Look For
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• Ulcer site, shape, size, no. edge, floor, deapth,
discharge, surrounding area.
Base
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• Vascular AngleOr Buerger’s angleNormal-straight leg can
be raised by 90* & foot rmains pink.
Ischemia – elevation to 15-30*cause pallor
• Dependant rubor
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• Venous FillingNormal – veins of foot
are full of bloodIschemia – veins are
collapsed & looks like pale blue gutters
- Guttering of veins
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Palpation
• Temperature which foot – warm/cold. level at which change occurs• Tenderness• Capillary filling
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Feel for P. pulses & grade
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• Peripheral Nerves Examination - Sensory - Motor • Auscultation - Bruit
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Venous diseases
• Common Presentation - Varicose veins Asyptomatic, Cosmetic, Dull aching pains,
Feeling of heaviness, Itching/Eczema, superficial thrombophlebitis, bleeding, Ulceration, Saphenavarix.
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• Primary – Venous valve failure • Secondary – Post thrombotic - Congenital Malformations
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Examine both supine & standing
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Touniquet Test–Identify clinically site of reflux from deep to superficial veins-Identify incompetant perforators – tie tourniquet above suspected perforator
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Lymphatic diseases
• Lymphangitis – inflamation of lymphatics.• Lymphedema – faiure of lymph drainage. Protein rich fluid accumulates in tissue
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Lymphedema
• Primary - congenital – at birth - Precox - adolescence - Tarda - middle ageLymphatic abnormalities – aplasia,
hypoplasia, hyperplasia.
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• Secondary :- Infection- Surgery- Radiation- Trauma