What topics should be covered in the medical
First of all you want to ask about the major
complaint. Why did the patient come to see
you on that particular day?
You want to know the family history because
there are genetic implications. Are there
diseases that run in this patient’s family
that they might be suffering from?
You want to know a past history. For example,
did the patient have a heart attack in the
past? In other words, do they already have
hardening of the arteries – atherosclerosis
– in their body?
And then there’s a general review of any
other symptoms that sometimes are related
and sometimes not related to the particular
reason that they came to see you.
So in particular when we’re taking a vascular
history, it’s important to know whether
patients have discomfort when they’re walking.
And often it’s helpful for the physician
to show them a diagram of the legs and to
ask, “Yes, if you have discomfort when you’re
walking, where does that discomfort occur?”
It turns out, when there is obstruction to
blood flow to the legs, patients may get inadequate
blood flow to their muscles in the legs when
they’re walking. And this results in the
symptom called intermittent claudication.
Why intermittent? Because it occurs when walking
and goes away when the patient stops and rests.
What’s the reason for that? It’s because
the muscle doesn’t get adequate blood flow
when it’s exercising, when the patient’s
walking. But, when they rest, the blood flow
is able to get into the muscles and to satisfy
the lack of blood flow there and relieve the
symptom. Usually the symptom of intermittent
claudication – that is discomfort in muscles
when walking – occurs in either the calf
– the back of the leg on the lower leg – or
in the buttock. The more severe the narrowings,
the more likely the symptoms will be in the
buttock. The less severe the narrowings, the
more likely it’ll just be in the calf. Again,
the important critical thing in the history
is that the symptom appears when the patient
walks and disappears when the patient rests.
This suggests arterial obstruction to the
It’s also important to know: does the patient
have risk factors for atherosclerosis? Do
they have a history of high blood pressure,
which is a risk factor for developing atherosclerosis?
Do they have diabetes mellitus, another factor
that increases the likelihood of having atherosclerosis?
Do they have a history of an elevated blood
cholesterol level? Again, the higher the blood
cholesterol level, the more likely the patient
will be to have atherosclerosis.
Similarly, elevated triglycerides – which
are very common in diabetic patients – also
are associated with more atherosclerosis.
Are they smokers? This is a major factor in
the development of atherosclerosis.
Have they already got evidence of having had
an event because of narrowing in the blood
vessels because they previously had a myocardial
infarction or heart attack? Have they had
cardiovascular surgery for narrowed blood
vessels? In other words, that tells you, “Yes,
this patient already has this disease of atherosclerosis
in the blood vessels. Or have they been taking
medicines for problems related to poor blood
circulation? All of those clues tell you already
where you’re going in terms of making a
It’s also important to ask the patient about
their diet because we know that certain diets,
particularly diets heavy in simple carbohydrates
– the simple carbohydrates are flour, white
rice, white potato and sugar – and diets
that are very heavy in fat also increase the
risk for developing atherosclerosis. So you
want to know: is the patient a vegetarian?
Less risk for atherosclerosis. Are they omnivorous?
That is do they eat everything? Meat and vegetables
and so forth. Are they a vegan? Which is a
very strict vegetarian diet without any animal
products. Or are they a raw vegan? In which case
they don’t eat any cooked vegetables but
only raw vegetables. Do they follow some religious
diet? For example, Islamic and Jewish don’t
eat pork. Hindu don’t eat beef. These things
are also important. And also it’s important
to know the quantity if they are eating beef.
How much they are eating and how fatty it
is and so forth? Are they carnivorous?
In others words, is their diet consisting
mostly of meat or are they a pescetarian? In
other words they don’t eat meat but they
eat fish. All of these things will give you
some clues as to the risk factor for atherosclerosis.
And again, as we mentioned before, there are
certain lifestyle issues which increase the
risk for atherosclerosis.
Cigarette smoking is public enemy number one.
Heavy use of alcohol can cause damage to the
heart and may impair the circulation.
Failure to exercise often leads to obesity
and, if one is fat and inactive, that also
increases the risk for atherosclerosis.
And then, of course, what drugs they take
particularly are they taking street drugs
such as amphetamines that can also increase
the risk for developing atherosclerosis.