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