Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
The History and Physical Examination
The ubiquitous nature of arteries, veins, and lymphatic vessels allows for any region of the body to develop vascular disease. This chapter describes the vascular medical history and physical examination—the core components of evaluating patients with vascular diseases. Application of these methods and tailored use of special examination maneuvers facilitate the diagnosis of vascular disease, especially when used in conjunction with vascular tests described elsewhere in this section. This chapter will review the cardinal complaints of patients with vascular disease, and then the physical findings associated with common arterial, venous, and lymphatic diseases. More specific features of the vascular history and examination are discussed in the relevant chapters of each vascular disease.
Vascular history
The medical history is the foundation of the physician-patient interaction, guiding the physical examination, testing, and treatment decisions. A comprehensive medical history can identify the diagnosis the vast majority of the time, but an inadequate one can result in excess testing and inappropriate therapy.
Arterial Disease
Symptoms of arterial disease typically arise as a result of either arterial stenoses or occlusions, although aneurysms also may cause symptoms. The important historical features of arterial disease in selected regional circulations are reviewed first.
Peripheral Artery Disease
In addition to carotid and coronary artery disease (CAD), peripheral artery disease (PAD) is one of the most common clinical manifestations of atherosclerosis. Approximately 50% of patients with PAD have symptoms, described in the following discussion as typical or atypical, and the remainder are asymptomatic. The importance of making the diagnosis of PAD, even in the absence of symptoms, derives from the prognostic information implicit with its diagnosis (see Chapter 16 ). Notably, patients with PAD often have coexisting coronary and cerebrovascular atherosclerosis and are twofold to fourfold more likely than patients without PAD to die of cardiovascular disease. The risk of adverse cardiovascular events is increased in patients with PAD, even among asymptomatic patients. The presence of limb symptoms further increases the risk of adverse cardiovascular and limb outcomes.
Therefore the history of patients with PAD should seek to determine whether the patient has known risk factors for atherosclerosis and whether or not there are concomitant clinical manifestations of atherosclerosis. The historian should elicit information regarding dyslipidemia, diabetes mellitus, hypertension, family history of premature atherosclerosis, and cigarette smoking. Historical evidence of CAD, including prior myocardial infarction (MI), symptoms of angina, or prior coronary revascularization procedures and history of stroke or symptoms of cerebrovascular ischemia, including hemiparesis, hemiparesthesia, aphasia, or amaurosis fugax, should be sought and documented.
Intermittent claudication
A cardinal symptom of PAD is intermittent claudication (see Chapter 18 ). Claudication occurs when limb skeletal muscle ischemia is produced with effort because increased muscle energy requirements are not served by sufficient augmentation in blood supply. Symptoms develop intermittently with activity; the blood flow limitation imposed by peripheral artery stenosis typically does not compromise muscular function at rest. Claudication is variably described as aching, heaviness, burning, fatigue, cramping, and/or tightness in the affected limb. Symptoms occur with reproducible amounts of exercise: for example, one block of walking, one flight of stairs, or 5 minutes on a bicycle. Discomfort may develop in any muscular portion of the leg—buttocks, hip, thigh, calf, or foot. Areas of the limb to develop discomfort are related to the arterial segments with stenoses. Iliac artery disease typically produces hip or buttock claudication, whereas femoral artery disease causes thigh or calf claudication. Arm claudication is unusual but may occur in patients with innominate, subclavian, axillary, or brachial artery stenosis. Cessation of activity relieves the exercising muscle’s demand-supply mismatch and enables restoration of oxidative metabolism. Therefore patients typically report that discontinuation of activity relieves the discomfort after several minutes.
Atypical symptoms also occur and may include reduction of leg discomfort despite continued effort, gait disturbance, and slower walking speed. Atypical claudication may be more common than traditional symptoms because of the high frequency of other conditions present in this older age group: spinal stenosis, venous insufficiency, and degenerative joint disease. Patients with intermittent claudication often slow their walking speed by a third to regulate muscle use and prolong walking distance. Thus, when a physician solicits the history of walking impairment, patients may report no change in distance walked before symptoms occur, despite a progressive decline in functional ability.
Several questionnaires for PAD have been devised and validated. These provide a standard to accompany the interview when querying patients about symptoms of PAD. The Rose questionnaire was the initial PAD-related questionnaire, but limited diagnostic sensitivity minimized its utility. The San Diego questionnaire is a modified version of the Rose questionnaire and a more reliable instrument to assess intermittent claudication (see Chapter 18 ). The disease-specific Walking Impairment Questionnaire has been validated and can be used to assess walking difficulty in patients with PAD. It has four subscales: severity of pain with walking, distance, speed, and stair climbing.
Critical limb ischemia
Critical limb ischemia (CLI) occurs when limb blood flow is inadequate to meet the metabolic demands of the tissues at rest. This may result in persistent pain, especially in the acral portions of the leg (toes, ball of the foot, heel). Additional foot symptoms include sensitivity to cold, joint stiffness, and hypesthesia. As a consequence of the effects of gravity on perfusion pressure, patients may report worsening of pain with leg elevation, or even when lying in bed, and reduction in pain with limb dependency (e.g., when the feet hang over the bed onto the floor). CLI may cause tissue breakdown (ulceration) or gangrene.
Acute limb ischemia
Acute limb ischemia is most often due to embolism or in situ thrombosis (see Chapter 44 ). Other causes include arterial dissection or trauma. The presentation of acute arterial occlusion ranges from asymptomatic loss of a pulse, to worsened claudication, to sudden onset of severe pain at rest. Symptoms may develop suddenly over several hours, or over several days. Acute ischemic symptoms are more likely to occur when no or few collateral vessels are present, rather than when there is a well-developed collateral network. Acute arterial occlusion may cause symptoms in any portion of the leg distal to the obstruction. The five Ps—pain, pallor, poikilothermia, paresthesias, and paralysis—characterize the historical features and findings of patients with acute limb ischemia. Severity of symptoms does not discriminate among etiologies.
Atheroembolism
Atheroembolism is embolization of atherosclerotic debris that compromises distal arteries (see Chapter 45 ). Atheroemboli vary in composition, from larger fibroplatelet particles that occlude small arteries to cholesterol emboli, nanometers in size, that occlude arterioles. Causes of atheroemboli include catheterization and cardiovascular surgery, but approximately half of such events occur without a known precipitant.
Symptoms reflect occlusion of the small distal vessels in the limb, and patients will commonly present with calf, foot, or toe pain and areas of violaceous discoloration or cyanosis in the toes (blue toe syndrome). Symptoms develop hours to days after the event; ulcerations may develop and are slow to resolve. Symptoms may be unilateral or bilateral, depending upon the origin of emboli proximal to or beyond the aortic bifurcation. If atheroemboli arise proximal to the renal arteries, renal insufficiency is a potential sequela.
Other peripheral artery diseases
Uncommon diseases of the peripheral arteries should be considered in patients with claudication or evidence of ischemia but whose age is less than that typically affected by atherosclerosis or in those with atypical symptoms. These diseases include thromboangiitis obliterans (TAO) (see Chapter 42 ), Takayasu arteritis (see Chapter 40 ), and giant cell arteritis (GCA; see Chapter 40 ), and vascular compression syndromes, such as those affecting the thoracic outlet, iliac artery, and popliteal artery (see Chapter 63 ).
Takayasu arteritis is a large-vessel vasculitis that generally occurs between the ages of 20 and 40 years. Women are more likely to develop the disease than are men. Constitutional and vascular symptoms occur (e.g., fevers, weight loss, fatigue, arthralgias, myalgias) and may be present months to years without overt evidence of vascular disease. Approximately 50% of patients complain of muscle or joint pains, and headache has been reported in up to 40%. More than 50% of patients will have a diminished pulse or claudication of an upper extremity. Approximately 30% of patients will report neck pain and have a tender carotid artery (i.e., carotidynia ). Lightheadedness is also common and may be secondary to vertebral artery involvement.
Patients with GCA are typically older than 50 years of age. GCA predominantly affects the branches of the thoracic aorta and the intracranial arteries. Some 50% of patients have constitutional symptoms related to inflammation, and 50% have coexisting polymyalgia rheumatica. The most common complaint is headache that typically affects the occipital or temporal region; it occurs in more than 60% of patients with GCA. In patients with headache, scalp tenderness may be present. Partial or complete vision loss develops in 20% of patients, and approximately 50% of these individuals report amaurosis fugax (i.e., transient episodes that involve one eye and last 10 minutes or less). Patients may present with upper limb claudication, and 40% report jaw claudication. Tongue claudication and swallowing difficulties are less common.
TAO (Buerger disease) is a small- to medium-vessel vasculitis that affects the distal vessels of the arms or legs and usually occurs before 40 years of age in cigarette smokers. It affects more men than women. The classic triad of TAO is claudication, Raynaud phenomenon, and superficial thrombophlebitis. Claudication of the hands or feet may progress to ulceration of the fingers or toes.
Neurovascular compression syndromes
Claudication in the upper extremities raises the possibility of thoracic outlet syndrome (see Chapter 63 ). Compression of the axillary or subclavian artery by a cervical rib, abnormal insertion of the scalene anticus muscle, or apposition of the clavicle and first rib may result in arterial compression during head turning, arm use above or behind the head, or arm extension. Weakness, burning, aching, or fatigue in the arms can result. Examples of triggers include wall painting, hair washing, and housecleaning.
Popliteal artery entrapment should be considered in a young person with leg claudication but preserved pulses at rest. , Anatomical variants in the course of the popliteal artery may result in its compression by the gastrocnemius muscle during exercise and can cause symptoms of claudication.
Vasospastic and Related Diseases
Raynaud phenomenon is the most common vasospastic disorder encountered in clinical practice (see Chapter 46 ). , Patients typically report that the digits become pale or cyanotic during cold exposure. Fingers are most commonly affected, but the toes develop symptoms in 40% of affected individuals. Less commonly involved areas include the tongue, nose, and ear lobes. Patients may experience paresthesias or pain in the digits if ischemia persists. With rewarming and release of vasospasm, digital rubor due to reactive hyperemia may develop. A pulsating or flushed feeling may accompany the hyperemic phase. All color phases are not required for diagnosis. Indeed, with an appropriate history, the diagnosis can be made with only one color change.
There are two categories of Raynaud phenomenon: primary and secondary. Differentiating between the two is important because of the information it provides about cause and prognosis. Primary Raynaud disease is benign, typically affects fingers (and toes) symmetrically, and recovery is predictable with rewarming. Some 70% to 80% of patients with primary Raynaud disease are women. In patients with secondary Raynaud phenomenon , pallor may occur in only one or several digits. In severe cases, cyanosis is unremitting and tissue loss may occur. Raynaud phenomenon that has its onset after age 45 years should prompt an investigation for an underlying cause. The history should include questions to elicit evidence of disease or conditions that cause secondary Raynaud phenomenon, including connective tissue disorders, arterial occlusive disease, trauma (vibration, hypothenar hand injury), neurovascular compression syndromes, blood dyscrasias, and drug use.
Acrocyanosis is a vascular disorder characterized by bluish discoloration of the hands and feet exacerbated by cold exposure (see Chapter 47 ). Unlike Raynaud phenomenon, the discoloration is not confined to the digits, and pallor does not occur. However, warming can ameliorate cyanosis and restore normal skin color. Acrocyanosis typically occurs in persons aged 20 to 45 years, and women are affected more often than men.
Pernio is a vascular inflammatory disorder in which skin lesions and swelling occur in fingers and toes, particularly in cold moist climates (see Chapter 49 ). Other exposed portions of the body may be affected. The typical lesions described by the patient are pruritic and painful blisters or superficial ulcers.
The complex regional pain syndromes, reflex sympathetic dystrophy (RSD), and causalgia are associated with limb symptoms, often following a relatively minor injury. Hand or foot pain is a frequent complaint. This may be associated with hyperpathia, hyperesthesias, coolness, cyanosis, hyperhidrosis, and swelling. Symptoms are typically out of proportion to severity of the initial injury. Patients may observe brittle nails that develop ridges and report muscle, skin, and subcutaneous tissue wasting and limited joint mobility in the affected limb.
Renal Artery Disease
No symptoms specific to renal artery stenosis are elicited by history. Unlike other end organs, symptoms of chronic renal ischemia are not localized to the kidney but reflect systemic pathophysiological alterations that result from activation of the renin-angiotensin system and disturbances of salt and water balance. Historical clues that raise suspicion of renal artery stenosis include onset of hypertension younger than age 30 or older than age 55, malignant hypertension, hypertension refractory to three concurrently prescribed antihypertensive medications, azotemia subsequent to administration of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker, unexplained azotemia, recurrent congestive heart failure, and episodic pulmonary edema (see Chapter 23 ). Renal artery stenosis should be considered in patients with these clinical clues, particularly if they have evidence of atherosclerosis in other regional circulations (e.g., CAD, PAD, aortic disease).
Mesenteric Artery Disease
Most patients with atherosclerosis of the celiac, superior mesenteric, or inferior mesenteric arteries are asymptomatic unless two or all three of these arteries are occluded. Symptoms of chronic mesenteric ischemia include postprandial epigastric or midabdominal pain that may radiate to the back (see Chapter 26 ). Onset of abdominal discomfort is 15 to 30 minutes after eating, and symptoms may persist for several hours. Patients tend to avoid food to prevent these symptoms, and weight loss ensues.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here
