1. History-Taking & Physical Examination in Vascular Diseases

2. Aim – To reach for a Presumptive Diagnosis

3. 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.

4. 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.

5. The Present Complains Ask the patient to tell you what made him to seek medical advice. Record the answer in patients words.

6. 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.

7. History of Presenting Complains S – Site O – Onset C – Character R – Radiation A – Association T – Timing/Duration E – Exacerbating & alleviating factors S - Severity

8. Direct Questioning Specific questions about the diagnosis you have in mind. - Risk factors. - Review of relevant system.

9. Past Medical History Drug History Family History Social History Habits

10. Vascular Diseases - Arterial - Venous - Lymphatic

11. Arterial Diseases Electively – Chronic Symptoms Acutely – Limb threatening disorders Pain Intermittent Claudication Rest pain Tissue loss Ulcer Gangrene

12. Acute arterial occlusion Sudden onset Severe, Shocking pain Diffuse Associated Symptoms

13. 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

14. 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.

15. 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

16. Examination Inspection - Expose - Compare

17. Look For

18. Ulcer site, shape, size, no. edge, floor, deapth, discharge, surrounding area. Base

20. 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

21. Venous Filling Normal – veins of foot are full of blood Ischemia – veins are collapsed & looks like pale blue gutters - Guttering of veins

22. Palpation Temperature which foot – warm/cold. level at which change occurs Tenderness Capillary filling

23. Feel for P. pulses & grade

24. Peripheral Nerves Examination - Sensory - Motor Auscultation - Bruit

25. Venous diseases Common Presentation - Varicose veins Asyptomatic, Cosmetic, Dull aching pains, Feeling of heaviness, Itching/Eczema, superficial thrombophlebitis, bleeding, Ulceration, Saphenavarix.

26. Primary – Venous valve failure Secondary – Post thrombotic - Congenital Malformations

28. Examine both supine & standing

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

30. Lymphatic diseases Lymphangitis – inflamation of lymphatics. Lymphedema – faiure of lymph drainage. Protein rich fluid accumulates in tissue

31. Lymphedema Primary - congenital – at birth - Precox - adolescence - Tarda - middle age Lymphatic abnormalities – aplasia, hypoplasia, hyperplasia.

32. Secondary : -Infection -Surgery -Radiation -Trauma