Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

OSCEazy ROHAN VYAS THE VASCULAR STATION SESSION TIME: 1-1.5 HOURSTHE VASCULAR STATION VASCULAR HISTORY DEEP VEIN THROMBOSIS BUERGER’S DISEASE VARICOSE VEINS PERIPHERAL ASCULAR DISEASE ABDOMINAL AORTIC ANEURYSMS VASCULAR EXAMINATION Role Foundation Year 1 Doctor (FY1) STUDENT Setting Emergency Department Patient Mr Kent presents with pain in his legs. Student taskTake a focused history and initiate a management plan including pertinent INSTRUCTIONS investigations. SPOT DIAGNOSIS A 62 year old obese woman presents with pain in her legs. On VARICOSE examination, you notice dilated veins in the legs with eczema and VEINS hyperpigmentation of the skin. A 34 year old pregnant woman presents to the emergency department with pain in her legs. She has been spending frequent time resting on her couch. OnVEIN examination, you notice warmth and swelling, and she is now struggling toHROMBOSIS walk. A 56 year old man presents to the emergency department with severe PERRIPHERAL pain in his legs. He has a history of heavy smoking and obesity. On ARTERIAL DISEASE examination, you feel no pulses in his feet and legs. (ALTI) A 62 year old man presents to the emergency department with significant episodes of pain in his legs. Whilst taking a history, he mentions that the pain occurs specifically when walking downhill, but SPINAL STENOSIS improves upon sitting. A 48 year old woman presents with swelling and redness in her legs, alongside several episodes of fever. Both legs seem to be red and CELLULITIS swollen on examination, with severe pain around the shins. • Introduceourself • Identify Patient INTRODUCTION • Explain • Confidentiality • Consent LEG P AIN HISTOR Y - FOCUSSED QUESTIONS HISTORY OF PRESENTING COMPLAINT REVIEW OF SYSTEMS • So tell me what the problem has been? (PC) • Unexplained weight loss •OCRWhere is the pain? • What causes/caused the pain? • Night sweats • Describe the pain? • Loss of appetite • Do you get any other symptoms?? Both legs? • Fever • How long does the pain last? • Syncope/Dizziness • pain?relieves the pain? What makes it worse? How much can you walk ti•l yChest paine • Please rate the pain on a scale of 1-10, with 10 being unbearable. • Shortness of Breath • Associated back pain? • Protruding vessels?/rashes? • Back pain • Any swelling noticed? • Joint pain or decreased mobility PAST MEDICAL/SURGICAL HISTORY SOCIAL, FAMILY , DRUG HISTORY , ICE • Diabetes? • Family history of arterial disease? • Muscular or nerve issues? • Smoker? If so, pack years? • Hypertension? • Alcohol? • Recreational drugs? • Cholesterol? • Over the counter medications? e.g. NSAIDs, COCP • DVT • Allergies? • Vascular diseases? • Housing, independent functionality? • Recent or previous surgeries? • Psychological impact?Peripheral arterial disease Chronic Venous Insufficiency Leg Compartment Syndrome Leg pain that goes away with rest Leg swelling Pain during strenuous exercise (Intermittent claudication) Intermittent claudication Neurological problems in legs Leg ulcers/skin (Hemosiderin deposition) Sudden pain after trauma History of smoking/hypertension Varicose veins Muscle bulging/tightness Restless leg syndrome Numbness, tingling, weakness Critical limb ischaemia or acute? Deep Vein Thrombosis Lymphoedema Non Vascular examples Swelling in affected leg Large swelling in leg Sciatica (Non-pitting) Pain in legs, cramping or soreness Muscle cramps Redness or discolouration Skin thickening Tendinitis Trauma Warmth, tenderness Cancer treatment Arthritis Loss of flexibility Consider history Cellulitis Trauma Could also be due to superficial thrombophlebitisPRESENTING THE HISTOR Y PATIENT DETAILS & KEY PRESENTING COMPLAINT HISTORY OF PRESENTING COMPLAINT RELEVANT NEGATIVES RELEVANT PMH/PSH/SH/DH ICE TOP DIFFERENTIAL & WHY OTHER DIFFERENTIALSLeg Pain INVESTIGATIONS SPECIFIC EXTRA INVESTIGATIONS Leg Compartment General Leg Pain PAD CVI Syndrome DVT Lymphoedema ABCDE ASSESSMENT Basic observations ABPI Calculate BEDSIDE ABPI Intercompartmental Well’s Score Lower limb exam pressures Vascular Examination Glucose Lipid Profile Lipid Profile BLOODS FBC Clotting ScreenClotting Screen Creatine Kinase D-Dimer HbA1c HbA1c U+Es Duplex Duplex IMAGING Ultrasound Ultrasound & MRI Scan Proximal Leg Magnetic Magnetic Vein UltrasoundLymphoscintigram SPECIAL X-Ray Scan resonance TESTS resonance angiography angiography DVT CAUSES Trauma Hormonal Relatives OrthoSurgery Malignancy Blood disorders Old age/Obesity Syndromes (Antiphospholipid, Nephrotic, etc) Immobilization Serious Illnesses (HIV/Infections) https://www.researchgate.net/figure/rchows-triad-of-the-three-broad-categories-of-factors-that-are-thought-to-contribute-to_fig1_317266064 BASED ON NICE GUIDELINES DVT Suspected, then: WELLS score DVT Likely DVT Unlikely (2 points or more) 1 point or less • Carry out proximal leg vein • Carry out a D-dimer test within 4 ultrasound within 4 hours hours • Positive Anticoagulation • If not within 4 hours, interim • Negativeà D-dimer anticoagulation • If positive, stop • Negative D-dimerà anticoagulation, repeat scan Negative for DVT in 6-8 days • Positive D-dimer • Ultrasound delayedà D-dimer with Proximal leg vein interim anticoagulation, and ultrasound ultrasound within 24 hours • Ultrasound delayedà D- dimer with interim anticoagulation, and ultrasound within 24 hours DEEP VEIN THROMBOSIS MANAGEMENT CONSERVATIVE MEDICAL/SURGICAL DEPENDENT ON DVT ANTICOAGULATION (DOAC, LMWH, UFH, WARFARIN)- NOTE THAT IF WELLS SCORE UNPROVOKED OR ACTIVE CANCER, THEN GIVE FOR 3-6 MONTHS EITHER ULTRASOUND OR D-DIMER PERUTANEOUS MECHANICAL THROMBECTOMY- MASSIVE DVT ANTICOAGULATION IVC FILTER- TO PREVENT PE AND IN OR WAIT THOSE WITH ANTICOAGULATION CONTRAINDICATED DEEP VEIN THROMBOSIS ANTICOAGULATION MANAGEMENT Renal Anti- phospholipid NO ISSUES Impairment Active Cancer syndrome • Apixaban or • CrCl 15 to 50ml/min, then Rivaroxaban follow normal guidance • Consider a DOAC • To give dabigatran, • LMWH and VKA offered CrCl must be • DOAC not suitable, for 5 days or until • If neither suitable, >30ml/min then: • CrCl less than 15ml/min • LMWH INR at least 2.0 then either: offer one of: • LMWH for 5 days • LMWH • LMWH and VKA for on two followed by Dabigatran • UFH 5 days OR until INR consecutive or Edoxaban • LMWH or UFH and VKA at least 2.0 on 2 • LMWH and VKA for 5 for 5 days, OR until INR consecutive readings, then days OR until INR at at least 2.0 on 2 readings, then VKA VKA alone least 2.0 on 2 consecutive readings, consecutive readings, then VKA alone alone then VKA aloneDefinition • Inflammation due to thrombosis in a superficial vein • Commonly affects the long saphenous vein Associations • Associated with underlying DVT • May progress to DVT Superficial • The more severe the condition, the more likely to be associated with or cause a DVT (>5cm of inflammation) Thrombophlebitis Management • Compression stockings- consider ABPI • NSAIDS • Anticoagulation (LMWH or Fondaparinux) • Ultrasounds scans to exclude concurrent DVT VARICOSE VEINS RISK FACTORS SYMPTOMS • Age Consider AEIOU: • Female • Aching • Pregnancy • Eczema • Itching • Compression of pelvic veins • Oedema due to pregnancy • Ulceration • Obesity COMPLICATIONS MANAGEMENT • Usually unnecessary unless pain or other complications • Deep vein thrombosis • Conservative/Lifestyle • Elevate legs • Superficial thrombophlebitis • Exercise • Venous ulcers • Weight loss • Stockings • Bleeding • Radiofrequency r Laser vein ablation • Sclerotherapclosure of vein • Skin changes • Surgery- ligation or vein stripping ABPI Ankle-Brachial Pressure Index Calculation https://onlinelibrary.wiley.com/doi/abs/10.5694/j.13265377.2004.tb06206.x>1.2, 1.0-1.2, 0.6-0.9, 0.3-0.6, <0.3 the following ABPI values: ABPI Interpretation/Correlation Stiff arteries indicating >1.2 calcification- seen in elderly OR diabetes ABPI 1.0-1.2 Normal Ankle-Brachial 0.6-0.9 Claudication/Mild 0.3-0.6 Pain during rest/Moderate Pressure Index Ratio of systolic blood pressure in lower leg to arms <0.3 Limb-threatening ischaemia/SevereINTERMITENT CLAUDICATION SYMTPOMS/INVESTIGATIONS DIAGNOSTICS SYMPTOMS VASCULAR PAIN IN LEGS ASSESSMENT/EXAMINATION AFTER MOVEMENT OR EXERCISE ABPI- DIABETICS NEED FURTHER ASSESSMENT RELIEVED BY REST DUPLEX ULTRASOUND PAIN IS NOT MAGNETIC RESONANCE PRESENT AT REST ANGIOGRAPHY IF INTERVENTION DECIDEDCRITICAL LIMB ISCHAEMIA ABPI usually less than 0.5 Includes one or more of: • Rest pain for more than 2 weeks • Ulcer/Gangrene/Tissue loss • Systolic ankle pressure of <50mmHg Acute Limb-Threatening Ischaemia SYMPTOMS CAUSES Look for one or more of the 6 Ps: Split into two causes: • Pale • Thrombosis • Painful • Pre-exisitingclaudication and PAD • Pulseless • Embolus • Paraesthetic • Paralysed • Sudden pain • Perishingly Cold • Can be secondary to AF , MI INVESTIGATIONS MANAGEMENT • ABPI • DR ABCDE approach • Handheld Arterial Doppler • Analgesia via IV opioids • Angiography • Anticoagulation- UFH • Surgical Thrombolysis Severe Hypoperfusion of limbs. It is a surgical • Surgical Embolectomy- must do ASAP if emergency that needs to be treated quickly. embolus cause • Amputation if too late CHECK IF PATIENT IS TALKING AND IF THE AIRVOICE- IFTENT THROUGH A CONSIDER BREATH SOUNDSN LIFT RESPIRATORY RATE PERCUSSION OF CHESTS B LUNG AUSCULTATION PULSE OXIMETRY ABG ACUTE HIGH FLOW OXYGEN CAPILLARY REFILL TIME LIMB PULSE C BLOOD PRESSURE AUSCULTATION OF THE HEART ISCHAEMIA ECG CONSIDER IV ACCESS, HEPARIN INFUSION, IV FLUIDS ANALGEACUTE MANAGEMENT CHECK AVPU LEVEL D CHECK IF PUPILS ARE EQUAL & REACTIVE TO LIGHT CHECK CAPILLARY BLOOD GLUCOSE AND BLOOD KETONE LEVELS INSPECT FOR SIGNS OF PERIPHERAL VASCULAR DISEASE VASCULAR EXAMINATION CHECK TEMPERATURE E PERFORM URINALYSIS INSERT A CATHETER & CLOSELY MONITOR URINE OUTPUT REFER TO VASCULAR SURGERY ASAP ACUTE LIMB ISCHAEMIA RUTHERFORD’S CLASSIFICATION https://www.researchgate.net/figure/Classifi-cation-of-Acute-Limb-Ischaemia-Adapted-from-Rutherford-RB-Clinical-Staging_tbl2_322357772 PERIPHERAL ARTERIAL DISEASE GENERAL MANAGEMENT RISK FACTORS MEDICAL SURGER Y ANTIPLATELET THERAPY TREAT THE FOLLOWING RISK FACTORS CLOPIDOGREL 75MG ONCE DAILY ENDOVASCULAR AND COMORBIDITIES: OR ASPIRIN IF CLOPIGODREL IS NOT REVASCULARISATION FOR SHORT TOLERATED SMOKING- STRONGLY LINKED TO PAD DISCRETE STENOSIS (<10CM) AND LIPID LOWERING THERAPY- HIGH RISK PATIENTS HYPERTENSION ATORVOSTATIN 80MG (ANGIOPLASTY, STENTS) OBESITY/DIET/ALCOHOL SURGICAL REVASCULARISATION HYPERTENSION MANAGEMENT FOR LONG STENOSIS (>10CM) DIABETES DIABETIC CONTROL (BYPASS, ENDARTERECTOMY) CONSDIER: EXERCISE PROGRAMMES NAFTIDROFURYL OXALATE- AMPUTATION- IF CRITICAL LIMB VASODILATOR WHICH ALLEVIATES ISCHAEMIA AND OTHER CHARITIES (BHF, Circulation Foundation)- USE IN REPLACEMENT OF INTERVENTIONS ARE UNSUITABLE EXERCISE THERAPY RUPTURED AAA PRESENTATION MANAGEMENT PULSATILE AND EXPASILE MASS IN IMMEDIATE VASCULAR REVIEW WITH ABDOMEN SURGICAL REPAIR (CT SCAN ASAP) ABDOMINAL PAIN, MAY RADIATE TO IF HAEMODYNAMICALLY UNSTABLE, THE BACK CLINICAL DIAGNOSIS, SO STRAIGHT TO THEATRE HYPOTENSION TACHYCARDIA SHORTNESS OF BREATHWhat is the normal aortic size? Ranges for small, medium and large AAA, and the recommendations for these? Screening for AAA UNRUPTURED AAA SCREENING AORTIC SIZE RECOMMENDATION <3CM NORMAL 3-4.4CM SMALL AAA- YEARLY ABDOMINAL ULTRASOUND 4.5-5.4CM MEDIUM AAA- ABDOMINAL ULTRASOUND SCAN EVERY 3 MONTHS 5.5CM OR ABOVE LARGE AAA- SURGERY- REFER TO VASCULAR SURGERY WITHIN 2 WEEKS SCREENING SINGLE ABDOMINAL ULTRASOUND SCAN FOR MALES AGED 65 OR ABOVE UNRUPTURED AAA LOW RISK HIGH RISK • Asymptomatic with aortic diameter • Symptomatic with aortic diameter below 5.5cm above 5.5cm • Carry out recommended screening • OR enlarging more than 0.5cm in 6 • Conservative management through months or more than 1.0cm in 12 months lifestyle • Refer within 2 weeks to vascular surgery • EVAR (Endovascular Repair) is preferred over open surgery BUERGER’S DISEASE THROMBOANGITIS OBLITERANS SMALL AND MEDIUM VESSEL VASCULITIS LEADING TO THROMBUS FORMATION CAUSING ISCHAEMIA SYMPTOMS INVESTIGATIONS MANAGEMENT EXCLUSION OF DIFFERENTIALS (DVT, PERIPHERIES WITHOUT A HISTORY OF THISATHEROSCLEROTIC DISEASE, SMOKING CESSATION NRT (PREGNANCY) RAYNAUDS PHENOMENON AUTOIMMUNE DISEASES) BUPROPION VAREN ICLINE SUPERFICIAL THROMBOPHLEBITIS ARTERIALS DOPPLERS TO CONFIRM PRESENCES PULSES ISHCAEMIC ULCERS VASOACTIVE MEDICATION ARTERIAL DUPLEX OR CT/MR (NIFEDIPINE) GANGRENE ANGIOGRAPHY DEBRIDEMENT OF GANRENOUS RISK FACTORS: MARTORELL’S SIGN ON DUPLEX- HEAVY SMOKERS CORKSCREW SHAPED COLLATERAL TISSUE MIDDLE AGED VESSELS MALE RAYNAUD’S DISEASE COLD PERIPHERIES WITH NUMBNESS, TINGLING • YOUNG AND COLOUR CHANGES • FEMALE (BLUE OR PALE) • SYMMETRIC • MILDER • NO UNDERLYING CAUSE VS • OLDER • SYMMETRIC OR ASYMMETRIC • INTENSE SYMPTOMS • UNDERLYING DISEASE (E.G. RA, VASCULITIS, WHEN WARMED, ETC) STINGING PAIN, THEN STRESS RELIEF WITH RAYNAUD’S PINK/RED SKIN COLOUR PHENOMENON Role Foundation Year 1 Doctor (FY1) STUDENT Setting Emergency Department Patient Mr Rogers presents with some mild chest pain and abdominal pain, and shortness of breath. Student taskCarry out a focussed vascular examination and present your findings. Suggest any INSTRUCTIONS investigations and next management steps in this scenario. SPOT DIAGNOSIS A 62 year old man presents with tearing chest pain. He has a history ofDING hypertension and smoking. A vascular examination finds weak pulses AORTIC in the peripheries. There are some changes in the X-ray. DISSECTION A 70 year old man presents with some chest pain and abdominal pain RUPTURED radiating to the back. Upon examination, you find a mass in theABDOMINAL AORTIC abdomen. He presents with signs of shock. ANEURYSM A 33 year old pregnant woman presents with some chest pain. The cPULMONARY pain worsens during breathing in. A history reveals that she has fEMBOLISM leiden. A 70 year old woman presents with severe chest pain. A history reveals a history of smoking, hypertension and hyperlipidaemia. She says thatCORONARY the pain is starting to spread to her neck and shoulder. SYNDROME WASH HANDS (PPE) W Clearly show all 7 steps of handwashing “Hello, my name is… and I am a … at …” I PATIENT DETAILS, EXPLAIN, CONFIDENTIALITY AND CONSENT “Can I please confirm your name and date of birth?” “I have been instructed to carry out a smalvessels.ation of your blood WIPER P What that will involve is me examining your arms and legs and the pulses to within the medical team. Is this okay with you?”ation I gain will be kept strictly EXPOSE E Torso, Arms and Legs “Are you in any pain at the moment?” REPOSITION THE BED R Position the bed at a 30 degree angleGENERAL INSPECTION SCARS LIMBS MEDICATION PARAPHENALIA PATIENT • Scars (bypass surgery, ulcers, etc) • Limbs (amputation, pallor, cyanosis) GENERAL • Medication (oxygen, GTN, etc) INSPECTION • Paraphernalia (cigarettes, mobility aids) • Patient (general look, comfortable, etc)GENERAL INSPECTION ARMS SCARS INSPECTION LIMBS TEMP/CAPILLARY TIME MEDICATION PULSES PARAPHENALIA BLOOD PRESSURE PATIENT • GANGRENE • Necrosis of tissue due to lack of blood supply • PERIPHERAL CYANOSIS • Bluish discolouration- think Raynaud’s, or poor perfusion UPPER • PERIPHERAL PALLOR • Whiteish discolouration- think LIMBS anaemia or poor perfusion • TAR STAINING (Inspection) • Smoker (consider potential risks) • XANTHOMATA • Associated with hyperlipidaemia, inspect tendons BE SURE TO COMPARE BOTH ARMS TEMPERATURE • Use back of your hands (dorsum) to feel temperature on both arms symmetrically moving up • Lack of warmth suggests poor perfusion UPPER LIMBS CAPILLAY REFILL TIME (Inspection) XANTHOMATA TAR STAINING BYPASS SCAR https://www.medicinenet.c-collection/xanthomatosis_1_picture/picture. https://www.sciencephoto.com/media/267193/view/handwith-tar-stains-from-cigarette-smoking http://www.secondscount.org/treatments/treatments-detail-2/incision-care-after-coronary-bypass-surgery-3#.YpT8TC-ZM1I RAYNAUD’S https://www.healthline.com/health/raynaudsphenomenon UPPER RADIAL LIMBS (Pulses) • Palpate radial pulse on wrist with 2 fingers, comment on rate and rhythm • Palpate both wrists • Radio-radial delay BRACHIAL • Arm should be externally rotated. Palpate both arms, comment on volume https://www.assh.org/handcare/safety/vessels BLOOD PRESSURE • Measure in both arms • Consider differences in Systolic and Diastolic UPPER • Wide Pulse Pressure (100mmHg) - aortic regurgitation and aortic LIMBS dissection (Blood Pressure) • Consider BP differences in both arms, • More than 20mmHg associated with aortic dissectionGENERAL INSPECTION ARMS CAROTIDS SCARS INSPECTION AUSCULTATE LIMBS TEMP/CAPILLARY TIME THEN PALPATE MEDICATION PARAPHENALIA PULSES PATIENT BLOOD PRESSURE CAROTIDS AUSCULTATE • Check for bruit • Could indicate Aortic Stenosis • Bruit Carotid Stenosis Then PALPATE • Patient must be at rest • DON’T palpate both • Comment on character and volume https://medlineplus.gov/ency/imagepages/9800.htmGENERAL INSPECTION ARMS CAROTIDS SCARS INSPECTION AUSCULTATE LIMBS TEMP/CAPILLARY TIME THEN PALPATE MEDICATION PARAPHENALIA PULSES PATIENT BLOOD PRESSURE ABDOMEN INSPECTION PALPATION AUSCULTATION ABDOMEN INSPECTION PALPATION AUSCULTATION BOTH HANDS TO PALPATE AUSCULTATION OVER AORTA AND SUPERIOR TO UMBILICUS, MIDLINE RENAL ARTERIES (LATERAL TO MIDLINE) OBSERVE FOR COMMENT ON IF EXPANSILE AND AOBDOMINAL PULSATION PULSATILE MASS AORTIC BRUIT SUGGESTS ABDOMINAL OR ABDOMINAL SCARS AORTIC ANEURYSM CHECKING FOR ABDOMINAL RENAL BRUIT SUGGESTS STENOSIS AORTIC ANEURYSMGENERAL INSPECTION ARMS CAROTIDS SCARS INSPECTION AUSCULTATE LIMBS TEMP/CAPILLARY TIME THEN PALPATE MEDICATION PARAPHENALIA PULSES PATIENT BLOOD PRESSURE ABDOMEN LEGS INSPECTION INSPECTION TEMP/CAPILLARY TIME PALPATION PULSES AUSCULTATION SENSATION LOWER LIMB (Inspection) AMPUTATIONS - DUE TO ISCHAEMIA OR DIABETES GANGRENE - TISSUE NECROSIS DUE TO LACK OF BLOOD SUPPLY - LACK OF BLOOD SUPPLY REDUCES HAIR GROWTH HAIR LOSS MUSCLE - THIS IS COMMON IS PVD WASTING PARALYSIS - CAN OCCUR IN CRITICAL LIMB ISCHAEMIA OR ACUTE LIMB -THREATNEING ISCHAEMIA PERIPHERAL CYANOSIS - BLUEISH DISCOLOURATION OF SKIN PERIPHERAL - PALE WHITE COLOUR OF SKIN PALLOR - PREVIOUS ULCERS SCARS ULCERS - ARTERIAL- SMALL, DEFINED, DEEP AND PAINFUL OCCURING AROUND PERIPHERAL AREAS - VENOUS- LARGE BUT SHALLOW, AND NOT VERY PAINFUL - DEVELOP MEDIALLY XANTHOMATA - MAY BE ON KNEE OR ANKLE DUE TO HYPERLIPIDAEMIA LOWER LIMB (Inspection) TEMPERATURE CAPILLARY REFILL TIME USE DORSAL PART OF HAND SIMILAR METHOD TO HANDS, BUT ON TOES MOVE UP THE LIMB SYMETRICALLY TO FEEL FOR DIFFERENCES ASSESSED AND INTERPRETED SIMILARLY TO HANDS COOL LIMBS SUGGEST POOR PERFUSION LOWER LIMB PULSES https://twitter.com/hp_ems/status/1358164823666745347 Assesses for peripheral neuropathy (PVD). Pattern of loss? LOWER LIMB (Sensation) Provide example of light touch on sternum with cotton wool (eyes closed, yes for feel) Assess light touch distal to proximal, compare both sides Eyes closed, ask them to respond yes when they feel… If distally okay, stop If sensory weak distally, keep moving proximally till patient feels and record this https://www.researchgate.net/figure/Figure-Stocking-and-glove-distribution-of-diabetic-peripheral-neuropathy_fig3_233763397 DEEP VEIN THROMBOSIS VARICOSE VEINS LYMPHAEDOEMA https://pereaclinic.com/dvtand-working-from-home/ https://www.fsavein.com/blog/whatare-varicose-veins https://lermagazine.com/article/expertcommentary-lymphedema-of-the-lower-extremities GANGRENE CHANGES IN PAD FOOT ULCER https://blog.avinger.com/bl-on-the-foot-causes-symptoms-risks-and-how-to-treat https://www.vascularsociety.org.uk/patients/conditions/12/arterial_ulcer https://www.drcumming.com/educationalmusings/clinical-evaluation-for-peripheral-arterial-diseaseGENERAL INSPECTION ARMS CAROTIDS SCARS INSPECTION AUSCULTATE LIMBS TEMP/CAPILLARY TIME THEN PALPATE MEDICATION PULSES PARAPHENALIA BLOOD PRESSURE PATIENT BUEGER’S TEST LEGS ABDOMEN INSPECTION INSPECTION TEMP/CAPILLARY TIME PALPATION PULSES AUSCULTATION SENSATION 1. Position the patient in supine position Buerger’ s 2. Raise one of the legs of the patient, but keep the leg straight while raised 3. Keep the leg raised for around a minute and watch for the colour of the Test leg 4. Pallor indicates poor peripheral arterial pressure 5. Note the angle at which pallor occurs- Buerger’s angle 6. Ask patient to sit up with legs hanging of the side of the bed 7. Due to gravity, the leg should get blood supply 8. May note a blue colour due to deoxygenated blood, then red due to reactive hyperaemia, as a build up of metabolic waste occurs https://www.medistudents.com/osce-skills/peripheral-vascular-examination https://www.thieme-connect.com/products/ejournals/pdf/10.1055/a-0865-7947.pdfGENERAL INSPECTION ARMS CAROTIDS SCARS INSPECTION AUSCULTATE LIMBS TEMP/CAPILLARY TIME THEN PALPATE MEDICATION PULSES PARAPHENALIA BLOOD PRESSURE PATIENT BUEGER’S TEST LEGS ABDOMEN INSPECTION INSPECTION TEMP/CAPILLARY TIME PALPATION PULSES AUSCULTATION SENSATION Thank patient & restore clothing! • THANK THE PATIENT , OFFER TO HELP DRESS • WASH YOUR HANDS CONCLUDING • SUMMARISE FINDINGS THE FURTHER ASSESSMENTS EXAMINATION • Cardiovascular Exam • Upper/Lower Limb Neurotion of leg • ABPI FURTHER INVESTIGATIONS You find a pulsatile and expansile mass in the abdomen, and his heart rate is high with low blood pressure. YOUR NAME INTRO YOUR GRADE & DEPARTMENT CLARIFY NAME & GRADE OF PERSON YOU ARE CALLING REASON FOR CONCERN AND CALL PATIENT DETAILS S PATIENT CURRENT LOCATION SITUATIONOST PERTINENT PROBLEM THE ADMISSION DETAILS (IF APPLICABLE) SUMMARISE CLINICAL PRESENTATION & WORKING DIAGNOSIS RELEVANT MEDICATIONSL HISTORY, RISK FACTORS AND RED FLAGS SBAR B RELEVANT INVESTIGATION RESULTS BACKGROUNDLLERGIES APPRO A CH NEWS SCORE: STATE BP, P& TEMPERATURE. EXAMINATION FINDINGS 2 A PENDING INVESTIGATIONS MANAGEMENT SO FAR ASSESSMENTERALL CLINICAL IMPRESSION SUSPECTED DIAGNOSIS +/ - DIFFERENTIALS WHAT NEEDS TO HAPPEN AND WHEN IT NEEDS TO HAPPEN R IS THERE ANYTHING ELSE I SHOULD DO? RECOMMENDATIONLD THIS PATIENT BE TRANSFERRED TO ANOTHER PLACE? Hello, my name is Rohan, the FY1 doctor on call in the emergency department. INTRO Is this the medical registrar I am speaking to? The reason for my call today is to request your reviewal of a patient who has present unwell. The patient’s name is Mr Steve Rogers, a 67 year old man who S concerned that he may have a ruptured abdominal aortic aneurysm.n. I am SITUATION THE pain and slowly developed shortness of breath. He has several cardiac risk factors with a history of smoking, hypertension and increasing aortic aneurysmal size. A SBAR B thorough vascular examinations showed an expansile mass in the abdomen, along with hypotension and tachycardia, showing signs of shock. BACKGROUND APPRO A CH The patient currently has a high risk NEWS score due to being tachycardic His respiratory rate is 27, and he-repbreatherarted on 15L nonaline bolus. A mask. He is starting to feel faint, but is afebrile. ASSESSMENT Due to his part medical history and through the examination signs showing that the patient is haemodynamically unstable, I believe that the patient should be R transferred for vascular surgery rather than requesting a CT scan. Would you be RECOMMENDATION to come and review this patient as soon as possible. Thank you. TIPS FOR ALL PHYSICAL EXAMINA TIONS! • For general inspectionLOOK at the patient and around the bed for a good few moments • When talking in between the examination, say ‘’there is no evidence of….’’ rather than ‘’I am looking for …’ • Always perform WIPE • Examine from the patients right side • BE SYSTEMATIC and try to look slick • PUT ON A SHOW! PLEASE FILL OUT THE FEEDBA CK FORM FOLLOW OUR SOCIALS TO Y UP TO DATE WITH ALL EVENTS @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@outlook.com