Importance of History Taking

A thorough history is essential in all fields of medicine. It has often been said that a majority of all diagnosis are suggested or made by the history, even more when aided by a careful physical examination. Although technology has greatly advanced and it is tempting to order a battery of tests to aid in diagnosis, the history remains the most valuable source of information concerning the patient’s illness.

The history serves as the primary source for data gathering and should include both the patient’s perspective and account of symptoms as well as information obtained from directed questioning by the examiner. The patient should be allowed to talk without interruption regarding their primary concern, and should also be able to voice an opinion about what he or she believes may be the underlying problem. When more information is needed, the examiner should use nonleading questions to collect further details and permit the patient to answer each question fully before moving on to the next. If the patient is acutely ill, however, it is reasonable for the examiner to limit the patient’s time for response in order to allow for prompt evaluation and treatment. When possible, the examiner should speak with family members or close friends in order to better understand the extent of disability and the impact of illness not only on the patient but also on those around the patient.

Additionally, the time spent during the history allows the patient and examiner to develop a bond that will aid in future diagnosis and therapy. Maintaining eye contact and intent listening will demonstrate the clinician’s compassion and understanding. Asking key questions in words the patient understands and using a nonjudgmental tone will enhance communication, instill confidence, and facilitate a trusting relationship that will lend support to acceptance of therapy and compliance with treatments.

Finally, the history serves as a way to organize the examiner’s thoughts, maximize clinical reasoning, and create a comprehensive differential diagnosis. This in turn leads to a more proficient physical examination, appropriate use of diagnostic aids, and prioritization of therapeutic interventions.

Analysis of a Symptom

Often the patient will present with a main symptom or complaint for which they seek assistance. In accurately evaluating each symptom, it is important to recall the characteristics of symptom analysis (see Table 16-1). Using each attribute to further define an index symptom is fundamental in recognizing disease patterns and developing a detailed differential diagnosis.

Location

In determining location of a symptom, it is important to be as specific as possible. Patients will often include a location in their chief complaint such as “I have leg pain,” etc., however, more precision is needed. For example, is the pain anterior, posterior, hip, thigh, calf, foot, left-sided, right-sided? In addition, does the pain radiate or change location? Some symptoms such as fatigue or weakness may not have a specific location, and this is valuable to document as well.

Quality

For some symptoms, more descriptive adjectives are easily applied. Regarding a chief complaint of pain, one could use words such as burning, pressure, heaviness, sharp, dull, or cramping for further qualification. With other symptoms, like dizziness, patients may have more difficulty expanding on their sensation without the examiner assisting with a question such as “Could you tell me more about what that was like for you?” Sometimes even the patient’s inability to describe the symptom may be a clue in itself. Patient facial expressions and gestures can also be of support.

Quantity or Severity

Quantification of a symptom may use well-known units such as number of pillows for orthopnea, or teaspoons of sputum. An analogue scale from 0 to 10 can be used to evaluate severity for symptoms in which a numerical unit cannot be applied such as with pain. Occasionally quantification can be made in terms of how the symptom is affecting daily activities such as walking to the bathroom or carrying bags of groceries.

Timing

In evaluating the timing of a symptom, the examiner should note the onset, duration, and frequency. When was the symptom first appreciated or how long has it been taking place? In the case of an intermittent symptom, how long does it persist in terms of seconds, minutes, hours, or days when it does arise? Is the symptom a daily occurrence, twice a week, or maybe only once every few weeks?

Setting

Determining the setting of a symptom can be thought of as an expansion on its timing in that the examiner looks to identify when the symptom occurs. Using leg pain as an example, is it related to certain activities such as walking up stairs or prolonged periods of standing? Does it occur at specific times for example upon first waking and getting out of bed or during the night while sleeping? Were there any precipitating factors or events such a fall or car accident?

Alleviating and Aggravating Factors

Often the patient will have already made attempts to stop the symptom when it occurs or preempt it from happening altogether. Inquiries should be made as to anything the patient feels may help relieve the symptom including positional changes or medications, both over-the-counter and prescription. In addition, are there things that make the symptom worse or does the patient avoid certain actions in order to prevent the symptom from happening?

Associated Symptoms

Finally, the examiner should explore whether the patient’s complaint is a lone symptom, or if there are other sensations that transpire along with it. Patients may not even be aware of additional symptoms until questioned. Documentation of a lack of associated symptoms is helpful as well.

Peripheral arterial disease can involve the ascending aortic arch and its branches, the descending aorta and its branches, and all muscular arteries. Symptoms produced by peripheral arterial disease are often governed by the location of the lesion, the severity or chronicity of the lesion, and the status of collateral flow. Several questionnaires have been developed to assess the presence and severity of lower extremity peripheral arterial disease. The Rose Questionnaire was initially developed in 1962 to diagnose both angina and peripheral arterial disease in epidemiological surveys but was limited by low sensitivity. Modifications, including the Edinburgh Claudication Questionnaire and the San Diego Questionnaire, have been created and validated to be more sensitive and specific in comparison to a physician’s diagnosis based on walking distance, walking speed, and nature of symptoms.^1,2,3 Most recently, the Walking Impairment Questionnaire has proven to be a validated instrument even after modification for self-administration (see Figure 16-1).⁴

In evaluating a patient’s symptoms, the examiner must keep in mind risk factors that would yield a vascular etiology to be more likely and assess for them as well. Peripheral arterial disease may be a manifestation of systemic atherosclerosis and therefore shares similar risk factors. Major nonreversible risk factors for atherosclerosis consist of age, male sex, and family history of premature disease. Modifiable risk factors for the development and/or progression of atherosclerotic disease include tobacco smoking, dyslipidemia, diabetes mellitus, hypertension, hyperhomocysteinemia, and elevated C-reactive protein (see Table 16-2).^1,5

Common Vascular Symptoms

Extremity Pain

The term claudication stems from the Latin verb claudicare, which means to limp. Intermittent claudication is one of the most common vascular complaints and is defined as a reproducible discomfort in a particular muscle group brought on by exercise and is relieved with rest (see Table 16-3). The actual muscle discomfort can vary from patient to patient, leading to variable descriptions of which the examiner must be aware including pain, cramping, tightness, burning, weakness, heaviness, or fatigue. The description offered by the patient may be helpful in quantifying the extent of ischemia; terms such as “heaviness” and “tiredness” typically represent minimal ischemic changes, but “pain” and “cramping” usually indicate more extensive disease.⁶ The quantity of discomfort is proportional to the amount and vigorousness of exercise, so questions should be directed so as to determine not only the distance a patient can walk but also at what speed or incline. It is important to note that symptoms of joint or bone pain or those brought on by prolonged standing are typically not claudication and another etiology should be sought (see Table 16-4).

The location of the discomfort gives clues to the arterial system compromised. Most often patients report calf pain which can be attributed to disease in the superficial femoral or popliteal artery; however, patients can also have foot pain from tibial–peroneal disease, gluteal, and thigh pain caused by aortoiliac disease, or arm pain secondary to subclavian involvement. While the occlusive process can be at multiple levels, the initial site of claudication usually reflects the most distal significant lesion or the area with the poorest collateral flow.⁷ Occlusive arterial disease is often bilateral, although patients will frequently report only unilateral symptoms caused by varying degrees of hemodynamically significant obstruction.

Progression of arterial insufficiency can result in rest pain, especially at night when reclined. Often patients will provide a history of past claudication that had progressed, but will now deny claudication due to self-imposed sedentary lifestyle.⁶ Rest pain is classically described as stabbing, burning, or stinging, and can be associated with coldness, numbness, or parasthesias of the toes. Patients will commonly relate that relief is only obtained by placing the feet on the floor, dangling them off the side of the bed, or sleeping in a seated position. This dependent posture permits gravity to assist with perfusion pressure and improve the transport of blood supply to the painful extremities.

Seventy to eighty percent of patients presenting with acute peripheral syndromes have suffered an embolic event, with acute thrombosis or mechanical compression occurring much less frequently.⁸ The patient with acute arterial occlusion classically demonstrates the six p’s: pain, pallor, pulselessness, parasthesias, poikilothermia, and paralysis. Acute arterial occlusion can cause sudden and severe pain that is continuous for the first few hours followed by a period of numbness as ischemic damage progresses. The often-excruciating pain is unrelated to physical exertion and is not relieved by rest or position changes.

Chest Pain

When a patient reports any form of chest pain, the heart is generally considered the most probable as well as the most worrisome source. Varying degrees of chest discomfort, however, can originate from several other noncardiac intrathoracic vascular sources and can be just as serious. The diagnosis and differentiation from myocardial ischemic pain requires careful symptom analysis, including location, radiation, quality, severity, timing, and aggravating or alleviating factors.

Sudden onset of severe chest pain is the single most common presenting symptom for acute aortic dissection, reported in 63% of type B dissections and 79% of type A dissections based on the International Registry of Acute Aortic Dissection (IRAD).⁹ Patients will classically describe the quality of pain as “ripping,” “stabbing,” or “tearing” that often radiates to the back. The intensity of the pain is at its maximum at inception and is often unrelenting in nature; it is not associated with physical activity nor is it relieved by rest or change in body position, although patients have been known to writhe in agony or pace relentlessly in an effort to find some relief. Location and radiation of the pain can be helpful in determining the origin and/or path of the dissection. Anterior chest pain with radiation to the neck, jaw, or face is strongly indicative of involvement of the ascending aorta and one or more arch vessels, whereas chest pain with radiation to the intrascapular or lower back correlates with descending aortic dissections.¹⁰ Other clues to the diagnosis include a history of hypertension or connective tissue disorder such as Marfan’s syndrome, and clinical manifestations depending on the branch arteries involved.

Noncardiac chest pain that is gradual in onset or of a more chronic nature can result from vascular etiologies such as aneurysms of the thoracic aorta (both ascending and arch) and pulmonary arterial hypertension. Although rare, pain secondary to nondissecting thoracic aneurysms is often related to mass effect on neighboring structures, the chest wall, or erosion into adjacent bones and has been described as a deep and steady, dull discomfort, unaffected by exertion or change in position. Substernal chest pain related to pulmonary hypertension, in contrast, is usually described as a pressure sensation, aggravated by effort and associated with dyspnea, cough, or wheeze.

Dyspnea

Dyspnea is the medical term for a range of patient complaints including shortness of breath, feelings of breathlessness, or difficulty breathing. As it is often a slowly progressive symptom over months or years, it may also represent a gradual decrease in exercise tolerance or the increasing need for “breaks” while completing daily activities. Most often dyspnea is related to cardiac decompensation or intrinsic pulmonary disease, however, vascular conditions such as pulmonary arterial hypertension, vascular compression of the left mainstem bronchus, or severe generalized vascular disease that limits oxygen delivery to metabolically active muscles can also result in difficulty breathing. Like cardiac dyspnea, vascular conditions may have associated symptoms such as cough, wheeze, or weakness and may be provoked by exertion. However, vascular dyspnea should not be initiated or made worse by change in body position.

Abdominal Pain

Vascular sources of abdominal pain, including aortic dissection, aneurysmal disease of the aorta and abdominal viscera, visceral ischemia, and celiac compression syndrome can have devastating consequences if not diagnosed quickly and accurately. While the majority of abdominal aortic aneurysms are asymptomatic and discovered incidentally, patients will occasionally complain of a steady, gnawing pain in the lower abdomen or back for hours or days at a time. Although movement does not usually affect aneurysm pain, some patients will note relief in certain positions, like lying supine with the legs drawn up. The development of new or worsening pain suggests expansion or impending rupture; it is classically described as severe and constant with possible radiation into the groin, buttocks, or legs. Actual rupture produces severe, diffuse abdominal pain and tenderness with hemodynamic compromise, although a rupture or leak contained by the retroperitoneum may localize the pain to the flank or groin.

Like aortic aneurysms, visceral aneurysms may remain asymptomatic until discovered by incidental imaging or they expand and impede upon nearby structures. When pain exists, it tends to be greatest over the region of the abdomen near the abdominal visera affected until rupture when it becomes more diffuse with associated tenderness.

The location of the pain induced by acute visceral ischemia may vary based on which arterial branch is occluded, however, symptoms are often nonspecific. With mesenteric disease, symptoms may begin with a very focal area of cramping pain or tenderness that progresses in severity as the duration of ischemia extends. Patients will report difficulty in finding a comfortable position to lie, and will frequently have associated bouts of nausea, vomiting, and bloody bowel movements. Typically, the abdominal examination will lag behind the patient’s complaints of severe pain (i.e., pain out of proportion to the examination findings) which can delay diagnosis. Splenic artery occlusions may be accompanied by epigastric or left upper quadrant discomfort, whereas hepatic artery occlusions are either asymptomatic or present with right quadrant pain. Renal artery occlusions are most often silent, but may eventually evolve into sharp back or flank pain associated with nausea, vomiting, and hematuria. Although all acute occlusions can incur without precipitating factors, the examiner’s suspicion should be raised in patients with recent aortic instrumentation such as takes place with angiography.

Patients with chronic visceral ischemia may also complain of varying pain syndromes. Mesenteric disease again causes a cramping pain, although this pain usually only occurs 15 to 30 minutes after ingestion of a meal and may not be associated with a change in bowel habits. Over time, the pattern of colicky pain becomes so severe that the patient may shun eating altogether in an effort to diminish or avoid the expected abdominal discomfort. Consequently, significant weight loss may be reported by the patient as well.

Celiac compression syndrome (also referred to as median arcuate ligament syndrome, Dunbar syndrome, and celiac axis syndrome) produces abdominal pain through extrinsic compression of the vessels at the celiac axis origin by fibers of the median arcuate ligament of the diaphragm. Symptoms may include weight loss and postprandial pain, which is often augmented by full expiration. Despite many case reports, celiac compression syndrome’s contribution to chronic abdominal pain and mesenteric ischemia remains uncertain given the rich supply of collaterals between the celiac axis and mesenteric arteries, the presence of compression in a significant proportion of asymptomatic patients, and the failure for surgical correction to reliably relieve symptoms. Other etiologies such as involvement of the splanchnic nerve plexus or delayed gastric emptying have been suggested, however, the diagnosis often remains one of exclusion.

Skin Changes

Because of its highly vascular nature, both acute and chronic occlusive arterial disease can lead to alterations in skin temperature, color, or integrity. A common office complaint is cold hands or feet and is often attributable to an individual’s basic vasomotor tone; however, generalized coolness of an extremity can be related to more serious conditions. When temperature differences are asymmetric or involve only one limb, suspicion is higher for an occlusive process. Disease states resulting in an effective ischemia such as poor cardiac output, hemorrhage, or shock will lead to generalized coolness of all extremities.

Skin color varies with blood flow, and therefore can be affected by temperature, physical activity, and emotional stimuli. Patients with Raynaud’s phenomenon will note pale and often painful fingers or toes when exposed to cooler weather, and those with Chilblain lupus (also known as Pernio lupus) report reddish-blue skin nodules occurring in the cold. A violaceous discoloration or cyanosis of a digit or limb that may or may not blanch with pressure is indicative of ischemic disease. Vascultis or atheroembolic disease are common causes of livedo reticularis, a lace-like pattern in the skin consisting of reddish-blue superficial vessels surrounding a central area of clearing sometimes exacerbated by cold exposure (see Figure 16-2). Patients with ischemic rest pain who maintain their feet in a dependent position may develop persistent redness of the toes and feet known as dependent rubor.

In some cases of arterial occlusive disease or emboli, chronic ischemia contributes to hair loss and tissue breakdown. Nonhealing and tender ulcerations are often found in distal areas of limbs such as the toes, heel, or fingertips. Patients with peripheral neuropathy are especially at risk for formation of ulcers in areas of trauma. If ulcerations have developed, the patient often requires significant analgesia to combat the pain. Without proper treatment, ischemic ulcers may progress to tissue necrosis and gangrene, resulting in areas of dead tissue that blackens and sloughs.

Neurologic Manifestations