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Chapter 7: History and Physical Examination

Amir Darki; Jessica A. Sutherland; Dina P. Dadabhoy; Aravinda Nanjundappa; Robert Love; Leonard Clavijo; Ross Milner; John J. Lopez; Robert S. Dieter

HISTORY

History Gathering Is Valuable

Despite major advances in imaging technology, the history and physical examination remains the primary measure for assessing patients with peripheral vascular disease. The goal of the medical history is to obtain a detailed vascular profile of each individual patient, focusing on the history of the present illness and associated symptoms.1

History taking is the first step in development of the patient–physician relationship. To enhance communication, eye contact with careful listening in a compassionate stance (i.e. at level with the patient, if possible) is necessary. Using vocabulary the patient understands in an easily comprehensible pace and a nonjudgmental tone is essential to establish a working relationship with the patient.

To maximize history taking, a combination of open-ended and directed questions is necessary regarding the primary concern. Open-ended questioning allows for a more thorough understanding of the patient's concerns. In addition, valuable situational information may be unveiled that can impact patient care, such as lack of resources to take medications as prescribed. If the patient is acutely ill, however, it is reasonable to limit the patient's time for response to allow for prompt evaluation and treatment. After the patient has been given an opportunity to discuss his or her concerns in his or her own words, directed questioning should be used to further define and clarify the patient's symptoms.

Greeting and Exploration of Symptoms to Develop the Differential Diagnosis

After a short greeting, the physician inquires about the chief complaint. Then an exploration of each symptom in detail is necessary. Details about the symptoms include the location, quality, severity, timing, alleviating and aggravating factors, and associated manifestations (Table 7-1). Understanding the symptoms in the context of a pathophysiologic base will allow for recognition of disease pattern and aid in the development of a differential diagnosis.

TABLE 7-1.Characteristics of a Symptom
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TABLE 7-1. Characteristics of a Symptom
Location Specifics about location of symptom. For example, is "leg pain" located in the anterior, posterior, hip, thigh, calf, foot, left or right side? Does the pain radiate or change location?
Quality Specifics on the experience of the symptom. For example, is "leg pain" a sharp, dull, burning, aching, heaviness, or cramping in nature? How does the experience feel?
Quantity or severity Quantifiable parameters. For example, in an analogue scale from 0 to 10, how severe is the pain? How does the symptom differ from how you were doing at baseline?
Timing Clarification on onset (when symptom was first appreciated), duration (seconds, minutes, hours, or days), and frequency (daily, weekly, or monthly)
Setting Clarification on when the symptom occurs. For example, does the leg pain start with walking up stairs or with prolonged periods of rest? Does the pain occur first thing after getting out of bed or ...

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