The History

The value of a good clinical history is increasingly overlooked as techno-diagnosis advances. One should remember that the history is usually the first interaction that takes place between the doctor and patient. It is at this time that the therapeutic relationship is forged. With skill and practice it is possible to elicit not only symptoms but also their significance to the patients, the patients' expectations and fears, and their attitudes toward treatment. It is possible to avoid unnecessary diagnostic tests and limit the investigative mill that the patient is put through.

VASCULAR SURGERY

There are some general points in the clinical history that warrant mention:

1. Lifestyle. Risk factors that can lead to the progress of vascular disease such as smoking, diabetes, hypertension, and hyperlipidemia are ascertained in the history. Additionally, an adequate exercise history should be elicited. One question that elucidates the rate-limiting organ system is how far patients can walk, and what stops them (leg pain, shortness of breath, chest pain, etc.). It is also important to know if the patient is taking hormonal medications such as oral contraceptives or hormone replacement therapy. These medications can predispose to venous and occasionally arterial thrombosis. It is during the history taking that a physician can begin to address many of these risk factors. By recruiting antismoking clinics or eliciting the help of diabetes and cardiac specialist physicians, a surgeon can improve a patient's overall health both pre-and postoperatively.

2. Family history. It is especially important to question the patient about the prevalence of early cardiovascular disease or thrombosis (i.e., stroke, occlusive limb disease, or cardiac disease) that manifests before age 50. Aneurysm disease has a clear familial association, and an incidence approaching 20% in first-degree relatives.

3. Atherosclerosis. Atherosclerosis is a systemic disorder, so inclusion of a discussion of stroke/transient ischemic attacks and coronary artery disease/myocardial infarction/angina is important.

Although the points covered above may elicit factors predisposing the patient to vascular occlusive or aneurysm disease, they are nonspecific and nondiagnostic. Because the symptoms of occlusive vascular, aneurysmal, and venous disease differ, they will be dealt with separately below. It should be remembered, however, that they may occur in combination.

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