Pain – History

Pain analysis

  • Site & referral (where is it? Where it goes?)
  • Onset (sudden or gradual?)
  • Course (how often does it happen?)
  • Duration (when did it start?)
  • Severity (how bad is it?)
  • Character (Burning, throbbing, stabbing, constricting, tightness, colicky or just a pain) (what does it feel like?)
  • Relieving factors (what eases it?)
  • Exacerbating factors (what brings it?)
  • Cause like trauma (why do you think you’ve got it?)

Lymphatic Disorders

 

Lymphadenopathy

Inspection

Number Multiple
Site
Shape
Size
Surface
Skin and color Inflammatory signs Acute lymphadenitis
Infiltrative signs Advanced malignancy
Sinus TB
Special signs Transmitted pulsations Para-aortic LN
Move with deglutition Para-tracheal LN

Palpation

Relations to the surroundings

Mobility

Relation to skin
Relation to muscles
Relation to nerves
Relation to arteries
Relation to veins
Other swellings Generalized lymphadenopathy
Temperature
Tenderness
Edge Well defined Scattered

Discrete

Ill defined Matted

Amalgamated

Reducibility
Solid, fluid or gas

Consistence

Fluctuation

Hard Advanced lymphoma
Firm TB

Chronic lymphadenitis

Cystic Cold abscess
Percussion Sternum for  :  Mediastinal masses

Tenderness in leukaemia

Auscultation Despine sign in case of mediastinal lymph nodes
After examination we will be able to answer these questions
  • Anatomical diagnosis
  • Localized or generalized
  • Aetipathologicaly (Infective, Neoplastic, Others )
  • Functional ( Pressure manifestations, Metastasis )

Lymphedema (Lower limb)

Inspection

  1. Grossly swollen legs
  2. Preserved skin creases
  3. Buffalo hump (dorsum of the foot) 
  4. Square toes

Palpation

  1. Non pitting edema
  2. Inguinal lymph nodes

TAKING HISTORY FROM A PATIENT WITH A LYMPHADENOPATHY

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Lumps (lymphadenopathy)
  • Pressure symptoms (according to the site of lymphadenopathy)
    • Neck lymphadenopathy
Dyspnea Trachea or larynx
Dysphagia Oesophagus
Hoarseness Recurrent laryngeal nerve
Horner’s syndrome Sympathetic chain
Fainting attacks Carotid artery compression
Face oedema IJV compression
  • Abdominal lymphadenopathy
Abdominal pain
Jaundice Nodes in porta hepatis
Leg edema Compression of iliac veins or IVC by iliac or para-aortic LN
Renal pain Ureteric compression
  • Chest lymphadenopathy

Chest pain

Cough

Dyspnea

  • Axillary lymphadenopathy
  • Oedema of the affected limb
Vein compression
  • Tingling
  • Numbness
Nerve compression
  • Ischemia
  • Gangrene
Artery compression
TAKING HISTORY FROM A PATIENT WITH A LYMPHEDEMA

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

Swollen limb (lymphoedema)
  • Pain
  • Fever
Hectic abscess formation
Night fever TB
Pel Ebstien fever Hodgkin’s lymphoma
  • History suggesting the cause
    • If localized lymphadenopathy
      • Ask about the drainage area for (Infection – Malignancy)
    • If generalized lymphadenopathy
      • TB manifestations (Night sweat – Night fever – Loss of weight – Loss of appetite)
      • Leukaemia manifestations (Bleeding tendency – Bone aches)
      • Lymphoma manifestation (Pruritus – metastasis manifestation)
    • Secondary lymphoedema
      • Post-traumatic
        • Injuries as circumferential scars of the limbs
        • Operations as block dissection of regional lymph nodes
        • Burns at the site of lymph nodes
        • Irradiation of regional lymph nodes
      • Post-inflammatory
        • Non-specific infection
          • Recurrent non-specific lymphangitis
          • Recurrent cellulitis due to evident focus of infection
            • Interdigital infection
            • Chronic leg ulcer
          • Post-erysipelas lymphoedema
        • Specific infection (Filarial – TB)
      • Neoplastic
Differential diagnosis of swollen lower limb (lymphoedema)
  • Edema
    • Local causes
      • Venous (DVT – 1ry varicose veins – 2ry varicose veins)
      • Lymphatic obstruction) (Post traumatic – Post inflammatory – Neoplastic – Primary)
      • Arterial (Arterio-venous fistula – Post-revascularization)
      • Traumatic
      • Inflammatory
    • General causes
      • Cardiac – Hepatic – Renal – Nutritional – Allergic – Hypoalbuminaemia (Hepatic – Renal – Nutritional – Bowel – Trauma to thoracic duct)
  • Not edema
    • Local gigantism – Hemi hypertrophy – Tumor – Lipidaema in females (Cyclic – Non cyclic)
Types of primary lymphoedema

Congenita

Praecox

Tarda

Incidence 10% 80% 10%
Age At or within 1 year of birth Usually adolescence After 35 years
Sex M>F F>M M=F
Site Commonly bilateral and involve the whole leg Commonly unilateral and below the knee Usually unilateral

Chronic Venous Insufficiency and Venous Ulcers

 

Chronic Venous Insufficiency

Pigmentation (lipodermatosclerosis ulcer)

LEGS

  1. Lipodermatosclerosis
  2. Eczema
  3. Gaps (ulcers) causing white patches “atrophie blanche”
  4. Swelling (edema not in the dorsum of the foot due to subfascial fobrosis)

Venous Ulcer

Number  inspection Palpation

As inspection

LNs

Base

Mobility

Induration

lipodermatosclerosis

Extent

Tenderness

Site Gaiter or ulcer bearing area

Medial and lateral maleolai

Shape Rounded or any
Size Usually superficial
Floor Granulation tissue
Margin Pigmentation
Edge Sloping
Discharge Color – Amount – odor

Varicose Veins

 

Varicose Veins

Aim of examination

  1. The anatomical distribution of the veins
  2. Type primary or secondary
  3. Competence of saphenofemoral junction and other communicating veins
  4. Condition of deep system
  5. Presence of complication

Inspection

  1. Site and size of varicosities including Saphena varix
  2. Skin changes, ulcers and scars
  3. Swelling of the ankle

Palpation

  1. State of skin and subcutaneous tissue
  2. Sites of fascia defects
  3. Site of incompetence (Trendelenburg test + cough impulse)

Percussion 

  1. Tape test (Chevrier’s tape sign)
  2. palpation of the varicosities and pulse

Complete by Auscultation

  1. Spheno-femoral incompetence by hand-held Doppler
  2. If any bruit
  3. Examine the abdomen

History Taking for a patient with Varicose Veins

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Cosmetic disfigurement
  • Pain (Discomfort, restless leg – Dull, heavy, bursting with sense of hotness – At end of the day – On prolonged standing – Relieved by elevating the limb)
  • Night cramps
  • Vermiculation
  • Symptoms of complication
    • Haemorrhage – Thrombophlebitis – Oedema – Skin pigmentation – Atrophie blanche – Varicose eczema – Lipodermatosclerosis – Venous ulceration
  • Possible cause
  • Predisposing factors
    • Primary varicose veins
      • Female sex – High parity – Marked obesity – Constricting clothes – Estrogen intake e.g. contraceptive pills – Occupation requiring prolonged standing
    • Secondary varicose veins
      • Presence of complication – History of DVT – History of Traumatic or congenital AV fistula – History of pelvic tumors – Pregnancy

Assessment of venous circulation in lower limb

 

Assessment of venous circulation in lower limb

Ask patient to stand up

Inspection

  • Site of visible veins
  • Shape of visible veins
  • Size of visible veins
  • Effect of elevation
  • Effect of dependency
  • Ankle swelling
  • Ankle ulcer
  • Skin color

Palpation

  • Trunk of long saphenous vein
  • Trunk of short saphenous vein
  • Saphenofemoral junction
  • Saphenopopliteal junction
  • Fascial defects
  • Venous ulcer
  • Texture of skin and subcutaneous tissue

Percussion

Percussion wave conduction

Auscultation

Bruit over prominent varices
Tourniquet tests
Doppler ultrasound

Gangrene

 

Gangrene

Aim of examination

Gangrene or not?

What is the cause?

Demarcated or not?

Which type?

Cardinal signs (Gangrene or not?)

Oh! Press and see how color fades

Oh! Odor

Press Pulse: Loss of pulsation and Sluggish capillary circulation

See Sensation Loss of sensation

How Heat Loss of heat

Colour Color Fixed color changes / Blue and later black

Fades Function Loss of function

What is the cause?

Traumatic Direct trauma Crushing

  • Pressure ‘bed sores’
  • Indirect trauma Injury of main vessel
  • Delayed Vascular repair after tissue death

Physicochemical

  • Burn
  • Frost-bite
  • Trench foot

Infective

Specific Clostridial gas gangrene

Non specific:

  • Carbuncle (Skin)
  • Anaerobic cellulitis (Skin)
  • Cancrum iris (Mouth)
  • Noma vulvae (Vulva)
  • Phegendena (Breast)
  • Melenery’s ulcer (Perineum and abdominal wall)
  • Fournier syndrome (Scrotum)

Arterial

  • Thrombosis Atherosclerosis
  • Diabetes
  • Beurger’s disease
  • Artritis
  • Embolic
  • Vasospastic Raynaud’s disease
  • Ergotism

Venous Major outflow obstruction

Neuropathic

  • Diabetes
  • Syringomyelitis
  • Leprosy

Demarcated or not?

Demarcation

    • Depend on (VascularityInfectionTrauma)
    • Stages (Zone of demarcationLine of demarcationPlane of demarcation)
    • Line of demarcation should be (Complete ‘all around’Well definedConstant place)
    • Plane of separation may be
      • Ulceration at the expense of dead tissue ‘depth’
      • Suppurative at the expense of living tissue ‘abrupt stop’
    • Failure of demarcation (In continuity – Skip lesions – Dye back phenomenon)

Which type?

Moist vs. Dry

  • Swollen  vs. Shrunken
  • Stretched skin   vs. Wrinkled skin
  • With bullae  vs. No bullae
  • Soft  vs. Hard
  • Less dark  vs. Darker in color
  • Less odor  vs. With characteristic odor
  • May be septic or aseptic

Causes of Moist Gangrene 

  • Sudden arterial obstruction
  • Venous obstruction
  • Generalized edema
  • Liquefaction of tissues

Ischemic ulcer

 

Ischemic ulcer

Inspection

Number Single or multiple
Site Tips of toes – Over pressure points
Shape Most often elliptical
Size and depth Vary from small, deep lesions, a few millimeters across, to large, flat ulcers 10 cm or more wide on lower leg

Usually very deep and may penetrate down to and through deep fascia tendons bone or even underlying joint

Floor Grey-yellow sloughs covering flat, pale, granulation tissue
Edge Punched out if no attempt at healing

Sloping if begin to heal

Margin Blue-grey color

No lipodermatosclerosis

Discharge Clear fluid – Serum – Pus
Surroundings
Arteries Distal pulse is invariably absent
Nerves There may be loss of superficial and deep sensations, weakness of movement and loss of reflexes if the ulcer is caused by neuropathy
Bones and joints May be exposed

Palpation

Lymph nodes Not normally enlarged
Base
Extent and motility May stuck to, or be part of, any underlying structure

And it is quite common to see bare bone, ligaments and tendons exposed in the base of an ischemic ulcer

Induration
Tenderness Very tender

Removing of dressing can cause exacerbation of pain lasts for several hours