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on the eye. So I'm holding you to beat this session around 1.5 hours. Not too long just to make sure everyone gets the most adequate amount of information. But what they don't get completely bought out by me is well, throughout the session moving on. So what? I would like to cover some of the key things that I want to focus on today are the basket history. Um, some ky um, we'll keep a college is not come up in on the station show. DVT's back is a pro for vascular disease. Domino aortic aneurysm is and finally the basket examination should do right? The end. I think the main aim off Osteo series is to tackle different basket based pathologies in an office setting. So what we would do is we'll go over some of the key off skills such a history taking a B, c D management Um, estar reporting, you know, So the examination on but also look at presenting histories back as well, but I think another bite apart, boss keys also is the knowledge on. You need to know the higher your knowledge to find your differential diagnosis to make a good management plan and also do the pattern investigations. Um, yeah. This is why we kind of run through the pathology. Um, so moving on, I was, but he station, um, Mr Can present with pain in his legs. You're required to take a focus history and initiative management plan, including percent investigations. So before we move on to what we kind of doing the station. We love to do a spot diagnosis, and so we'll monitor a few of these based on leg pain. And the first one 62 year old be swollen presents electing on examination. Dilated veins in the legs with X man hyperpigmentation of the skin. They just put a chart. What? You might think this is, um, in terms off a differential diagnosis D v d. Okay. Okay. Um yeah, no baths. Um, so mostly, um yeah, most see on the right side. So we have a market event. I think the key things to pick out here is first dilated brain. The left on also the eczema on hyperpigmentation of skin. You don't really get that that indignity, but you get very prominent dilated veins in Barca's markers. Vents on also the skin changes are hormone sensitive off the varicose veins. All right, good stuff moving on to the next one. Um, that's for your pregnant woman. Presents the emergency department with pain in the legs. She has been spending frequent time on her couch on examination. Just warm. Controlling. Now she's struggling. Okay. Okay, good. Yeah. So we have DVD. That's correct. Um, any risk factors? Perfectly. That points out DVT in this. And this one. Yeah, I've been see on the mobility. Good. Yeah, those two. All right. Next one six year old man presents Be much department today. Pain in his legs. Yeah. History of heavy smoking and based E on examination, if you're know positive and it's okay. Yeah. Okay. Good. Um, yeah. Most of your crack term, of course, is peripheral arterial disease. The more statistically it's keeping them threatening ischemia. Um, and the main thing to point now is the pulse is is the lack of pulses in the feet on also the pain. So we got two of the six cube, which will go the later anyway. Yeah, those are the key things pointing out towards cute. All right. Um, next one, so 62 year old man presents be mostly department with significant episodes of pain with legs while taking history. You mentioned that the pain because the 50 when walking down there but improved form fitting made ST quite a few mix of answer there. Yeah, okay, good. It's a mix of We got performed arterial disease. People think intermittent claudication on spinal stenosis sports. So the both good friendships, but assisted me this point towards fine Oster notice. Um, why? Because, um well, we haven't really brought in the history that there's any past history of smoking or hypertension. Your risk factors. So peripheral arterial disease firstly, exactly the way the pain occurs. So it's only one walking downhill, he said. I'm also improved upon sitting know on rest, um, intimate support occassion. It's when you're walking like, anyway, especially uphill. The pain is worse. Where spinal stenosis when you walk downhill, that's the key sort of provocation. You get spinal stenosis. Not when you're walking up hill or just normal walking on the only approved one sitting really no money just standing and rested. Um, but yeah, good. Okay, last one. Put your put a year old Women present with swelling and redness in the legs alongside several accidents. Fever, both. Like since he writes and swollen on examination with the pain on ships. Yeah, very good. Um um, mostly go on this one cellulitis. Um, I think, uh, that one's not too bad, because, um made it quite well. Be said, because of the pain on the shins, Um, on day one of the fever, which are the symptoms of cellulitis. All right, good stuff. So moving on to introductions in the history patient section section off his taking session, so And first thing that you introduce yourself so time my name's you're on and fourth year medical student apart. So something simple similar to that. Then you won't identify the patient so often. Name on date of birth. Moving on. Explain what you're doing. So explain what you're gonna do on why you're there. So something simple as I'm just gonna ask you a few questions about your condition and your lifestyle. This is only a couple of minutes. Um, off that after about confidentiality, This is saying I lost it in forget. And I think it's good to show this just to show you got the structure and you show me? Examine. That you're aware about confidentiality is well, just saying something like this, this information I gained from you will only be kept within the medical team. Teo Battery. Okay? Yeah, just something like that. Just that the patient also knows that the information only being shared with the breast medical team. You know, one up. I'm finally get consent to just awesome. Please. Okay with you. Okay. So moving on to, um the history and focus questions. So I think a good thing about hits you taking section is, um the main thing you need to do is just outside the station. You want to start thinking about your differentials? Um, otherwise, that history taking history taking off ization is quite similar, depending on be differentials. The main thing you have to do it. He just think about the French. Something about focus questions. You're gonna have to relate this. So so really history of present complaint. The best thing first off the presenting simply something like Tell me what? What government be the moving on to Socrates? I think even if you can rethink differentials at that stage, um, folksy is a very good way to kind of get past that and start asking questions. I will slowly start bringing you toward the differential diagnosis to the other stuff like, where is the pain? What causes the pain? And obviously questions like this will start giving you onto like, Oh, it it comes, well, exercising or it's come on suddenly that don't make start thinking about maybe acutely make Sr if it's a sudden or if it it comes on exercising made the compartment syndrome. So you need to start thinking off. The French is like that. Um, that's the pain go anywhere else is in both legs. That's really like this. More commonly, both legs raise other leg pathology is usually in one leg. Do you get any other symptoms? Any other associated symptoms? So if, for example, back pain was in there, we could start thinking about spinal stenosis. Um, how long does the pain last? And what relieves the pain is well, so again, this will stop coming towards perfect here with these as well. So stop. It is a very good baseline to use if you can take with friends for a straight away. But then moving on. Think about, um the other friendships. We had enough spot diagnosis, for example, protruding Russell vessels. That's related because we're into that. Something you could ask about. Or if they've noticed any swelling thinking about DVT, um, or lymphedema hold still alive. Any skin changes and colorage is again, which is associate varicose of the incidental, chronic venous insufficiency. So stuff like that is really important. Also, that I would move on to the review of systems. Um, again, Review systems is a good way of kind of narrowing down to six system so hardy, logically, or, um, some sort of respiratory issues, like some sort systems you want to think about. So the main four questions I always ask are the unexplained weight loss, night sweats, loss of appetite and fever. Always touch up upon those fevers, a good ones off in this case as well as physically, because it's very like this, um, syncope on dizziness as well, just to think about cardiological causing cardio for related issues. Um, chest pain, shortness of breath, back pain. Think my spinal stenosis again on any joint pain or decreased mobility. Because this could be trauma, for example, Compartment syndrome is up past medical and surgical history. So you want to start thinking about specific conditions in history that they may have that may be related to our friendship. So diabetes, for example, because this could be a diabetic. Leg pain is Well, um, muscular or nerve issues. Um, hypertension, cholesterol, previous DVT, um, any vascular disease that they may have, um, any recent or previous surgeries, because then we start thinking about disability on DVD, um, and then moving on to your social family and drug history on Never forget Isis. Um, I think this part off the history is pretty straight forward. It's very similar in most countries, you know, with the questions. It's all very similar. So in terms of so she lost about family history in terms of smoking alcohol, recreational drugs and over counter over the counter medications, family with the family history off any diseases or arterial disease or diabetes intended drug history with allergies. Try not to forget that, because, um can be a common place where people fail stations. So please be careful on that one. Um, on in terms of social issue, always think about how independent they are. If they've had any psychological impact is, we'll step making your services. Um, plenty. I said the end. If you have time, it's good to put that in. Just a you thinking about the patient and the incorporating every member. So these are some of the friendship that could have been in this, um, in this station, for example. For activities, of course. The spectrum that So we will talk about this later on. Um, but these are some of the, um, symptoms you would have or some of the things you take out the history related peripherals. Artery disease to maybe like, 10 that goes with breast neurological problems. For example, have sensory issues in your legs. History of smoking, which the big factor in for for the same with chronic venous insufficiency off the least of our kids are. Well, um, I think with some of these symptoms as well, um, and like swelling, of course. Uh, compartments injury. Um, but oven emergency situation. Um, this would be something where a person probably hasn't had much of a history of, So they come in with sudden pain. Um, it could be seven pain after exercise. So two things I would think about enough exercise or trauma. It is that compartment syndrome on so that you have to initiate straight the CT. What? We'll move on to, um, methods of management after beauties. Well, so we want to think about other respect Is that we mentioned that is, that is the mobility also swelling? Um, consider previous history as well. So you want to think about DVT lymphedema as well. So lymphedema is usually just very, very large swelling. So you want to think about 20 that actually non pitting as well. Um, skin thickening is another thing. I think that cancer is treatment. So if they're having some sort of chemotherapy already of therapy, uh, back in commonly to lymphedema as well, Onda usually have lost flexibilities. Or besides, in that there's also non vascular don't think about, which is why I put some of these in the spot diagnosis. It's really important to kind of think about all these defenses on there slowly move on to questions based on just a big French. Isn't that route in the mouth? Um, just Africa. Muscle cramps, tendonitis for my All of these are not mask it down, but that could be in part of history. So, um, how do we presented the history on? So I'm just gonna okay patient details and key complaints. So he think about this. If you don't wanna You don't want to, um, go through what? You just hide from the patient. You want to summarize it on, Say, the key, relevant things have come up. Um, and you don't want to just repeat back with regard to say, Well, you got it from the patient on including the pasta Medical. In pleasure. Get so you don't want to talk about, um, unrelated medical history or unrelated testicle history as well. So something you just say, um, for the patient. So Mr Can a 55 year old came in to the motion department with pain in the legs. Um, on at this point, I just probably moved to stop it eases not talking about history of present in a plane. So you say he had, um, pain in his legs. Hey, said that it improves with breast. Um, it's primarily in his right leg in the cough region. Um, Andi. He can usually walk around the 200 m on off to enter me to start treating the pain in his legs. So that's another thing to ask him. Perform out here with these, for example, how far they walk on when this war, when the pain comes up. And that would be good to mention in. This represents a plain as well. And then you mentioned stuff like, uh, this pain Now, at now. This time, just pain is not improving on these. Come in with very severe pain in the legs. Uh, this time is not improving dressed. So this is pointing towards the cube them directly and skinnier. It doesn't relevant. Negative. So what, What would be irrelevant? Negative or what would be mean by something at such a relevant negative? Can anyone put that in the chart Would what would be about 11 negatives? But what do you mean by yet? Yeah. Yeah. So yeah, that's right. So, statistic with factors or Simpson on that they don't have. That would help. Um, I guess No gait. Some differential. So, for example, noticed of the mobility or surgery like some of that in the chart yet exclude DVT or saying stuff like no rashes or know protruding days thinking about Baracus vent. So what relevant Negative do is just stating some symptoms that they don't have, which therefore negates the depression's A. Now is your friendship down something? Um, so, for example, you could even say there's no fever, so no cellulitis stuff like that. Then you keep going back through prosthetic a history on just a relevant stuff. Like there are a smoker. They have a history or hypertension and hyperlipidemia. Um, drug street on, um, housing channel Block is for hypertension on. There's no relevant drug allergies. Um, so drug allergies. We'll get to mention at this point, then move onto. I talk about patient's ideas, contents, expectations, to buy a top differential on Why, um on. Then rule out your the French is and just mention them is Well, what other differentials? It could be the most like it. That's how we would present our history. So leg pain investigations. So how we look at our investigation just kind of break it down into that side blood on them, like specific tests or imaging tests that we'd like to do for, like general leg pain. Some sort of bedside examination that we may do is a B C. D. You said that may be more specific for, for example, like compartment syndrome or acute lymphocytic leukemia from basic observation alone, um, exam just to look at any joint issues or mobility issues as well. On the basket examination, which will look at later blood so glucose just to pull out a better pain, a full blood count as well after and creatine kinase to the muscle break down. So that might be causing the muscle pain. If you have high See, can you bud and use the knees as well. So considering things that says hypocalcemia and hyponatremia that lead Teo muscle pain as well on on MRI scan and exercise would be good with star your leg pain investigations just to look at traumatic corners. Um, at least are narrowing down to the French use. Um, you reduce it stick investigations. So, um, both of purple arterial disease and chronic venous insufficiency. They very much over that. So what you want to do for chronic venous insufficiency is kind of ruled out purple heart disease. And so the investigation to do will be both of them. So our best had you would do an a d t. I. Does anyone know what um, a D P I means, But then the job. Yes, it's the ankle brachial index. Um, moving on blood. Have a little profile talking screen on each A one c uh, so these again are very important just to look out. Firstly, the past medical history in this case, it also any talking issues that may be causing either of these pathologies. Okay, um, imaging tests. So duplex ultrasound on magnet to MRI. MRI, a memory is more done. Would, um when you're thinking about treatment and the duplex ultrasound would be first night. Um, if you want next apartment syndrome, you want to look at into compartmentalize pressures, that's nothing you mentioned. If you're looking at a bedside extra investigation, select apartments into a plastic friendship, um, for DVT calculating a well school, um, again, that's, I think, one of the key things to mention if you have a DVD DVT diagnosis in inside your head, um, someone just asked in 80 CD approach Acute, um, ischemia with your for a CT A or M R A s. O in an 80 CD approach. It depends on how severe is it is. I think in that case, you would probably do an MRI of the commute. Wanna do a bone? And we want an intervention. Show it. So you probably do an MRI. Um, also for DVT, um, looking at blood going to do the d dimer, uh, proximal leg, then ultrasound. The DVT is the main imaging and special test that you wanted to, um and for lymphedema A, um, if it's in regards. All right, so, um, moving onto DVT causes This is a good way of thinking about questions you may wanna off in, um, your history that may lead to a diagnosis of DVT thrombosis. A good way of remembering some of these causes of DVT. Um, any other. Any other message of remembering? The UTI causes very common triad. What might not be. Yeah, but how about the cattle, but just tried? You want to say it? Um, So, making out either Stasis That's the war injury or hybrid car. Regular bility. So some of these doing things you can just kind of kept it dries. Um, some of these causes into those, and remember, just like I'm trying to find it. Friendship. Okay, um, now, looking at DVT and the pathways on um, what we would do? It's a DVT suspected on what we would say. It's an examiner after doing about school. So, um, dvt likely, um, if it's two points more, what would we do? Um, in terms of dvt you didn't mention earlier. Okay, so some of your CPK doctor. So according to guidelines, it would be a proximal leg ultrasound. Um, so that's the first thing you want to do it within four hours. So if you well score you, you would say to examine her if the world because two or more, I would prefer them for a proximal segment, Understand? Within four hours. Um, that's a key thing to do. Um, if it's positive, that's any side anticoagulation. If it's negative, you want to do a d dimer. Um, but if the, um if if you're staying off sound is delayed, um, you want to do a, um, a dime a test? But in between I did. I'm a being done. You want to get into, um, a combination? In case they do have a DVT on or start in 24 hours, the duties unlikely. Um, instead of approximately a grain of sand you want to do a d dimer. Um, and if you can't do that within four hours again in terms of triangulation, so probably very similar on very used to remember. So if it's likely you do you approximately they're not sound within four hours. It's not likely due did I'ma and same thing if you don't have time in between you for possible, like there's no sign of time. Do the time a dementia can collect on, um, came to the other other way. If you don't have time, give him interesting combination. Uh huh. Um so best way to look at, um, DVT management is usually conservative on medical. Um, especially if you think, um, conservative treatment is mainly dependent on the well school pathways. Which is why I said that first, um, so pretty, pretty much you would give them anticoagulation or weight, depending on what the investigation shows Now, full medical management. Um, some of you said in the child extrication and wh things like that, um, nowadays, um, are the key things give of stuff like a tick span and rivaroxaban. Um, but that depends on, um, the patient's history as well. Um, but I don't think That would be a big thing to mention our ski. But just remember that if it's unprovoked, attack the cancer. You want to get the foundation for 3 to 6 months, Otherwise, three months. Um, it is a massive dvt gonna have to do surgery, so percutaneously can icals from back to me. Um, if you want to prevent, um, pulmonary embolism because I'm anticoagulations are contra indicated. And I did see filters be just put this in for extra information and revision too. So I think it's good to just consider the the progression. In case you actually say which one to give. Um, for example, you might want to get the active someone has for you to give him wh and warfarin. Um, but it's just something to keep in mind. On most cases, he would get to go act so I don't think to ban or a box. Um, but just consider I started it. The singer on green open. It's either of them. Um, Adam wh and well for So since we're talking about DVT, I thought add insufficient number of itises. Well, um so definition Houston affirmative itis and that off defense from bursting in the deep end to Fisher number phlebitis is in the superficial way on. It's basically information, YouTube or both, um, associations. So it's very much associated with underlying DVT. Also associate it to chronic venous insufficiency. I may progress to DVTs is well, ah, in terms of management, uh, again, consider the A Colbert your pressure. And Dex, if you gonna get compression stockings because you don't want to get compression stocking, it's the ankle, but brutal pressure in that very low, you're going to completely destroy the pressure of the legs, um, pain management and say can collaboration. Of course, it's a drum bracelets on, but I can't Teo concurrent DVT. So it's a complication. I'm thinking a very Christian. So not a differential. Yeah, to do some of the key risk factors on aged female pregnancy. Um, was a compression of the pelvic pain. Pregnancy is what causes very close. Also, Beastie, I've got one last ammonic. It's symptoms, eh? I owe you. The valves are taking ex mama itching the demon fluctuation. I'm good way to remember the symptoms of Parkinson's. Um Always remember, the presentation is also the protruding day and markets and mark complications so indeed in a market center time, the DVT and superficial thrombophlebitis competitions. Um, also venous ulcers, bleeding and skin changes. That's, um, a big ones. Well, um, management. Um, so it's usually not that necessary unless you have pain or some of the complications. Um, so if you know against months when you just got conservative management. So, um, elevated legs, exercise and weight. Uh, but other medications? Oh, other methods off management, Uh, co just being by sclerotherapy. Um, more surgery when legation surgery by ligation or being stripping. I'm cool, bird. Just tell me how we, um Okay, the very ankle vertical pressure index. This gets commonly people get comedy confused by this one. How would we calculate the PPI? Yes. Yeah, it did. You know, we go back down to that. So what you want to do is you measure, um, both be Syria to do. I'm doing solids, Pettus pulses. Um, but the pressures in the ankle right, um and which ever one is higher? I'll those two. You divide that by and the higher BP. So, for example, if I'm looking at the right leg, I'm gonna work out the right ATP. I, um I would see which of the two ankle pressure. The higher. So either, um, because your table does Does all this medicine on whichever is higher between the right and left arm, the BP. You divide by that, Okay? There's not right divided by right. It could be right there right by less, depending on which pressure is higher. Just dying mind. Okay. So, yeah, it's a race. Just got it. But pressure, lower leg arm. What? The clinical correlation off the following a t t. I've al you. So for more than 1.2, what would that show? Technically, yes. You got diabetes. Anything else? Yeah, Pressure is diabetic. Or if you're elderly, those the tubing that cost five vessels on go to those would be does. All right, what about between 1.0 to 1.2, But with the clinical correlation for that be Yeah, normal. Um, your clinic to their 0.9. Yeah. My lip. 80 into medical occasion. That's that's fine. That's correct. Um, joke. When? 3 to 6. Yeah, It's more like 80. And you have course, rest pain or you take critical limits. Kenya, I'm less in there. Open three would be to, um, ischemia. Um, so, yeah, those values there, Um, just those are kind of correlation there, so they know exactly so whatever. Yes, that it might not necessarily be the case. On most, most occasions, correlation is pretty, um, so in intimate cortication symptoms, Right? So we already covered if it's pain, legs off with no exercise, relieved by rest as pain is, um, going on at rest. You don't have the pain at rest on diagnostic. How would we How we go about diagnosing and this or so of diagnostics, would you want to say? Yeah. Good? Yep. But I got quite a few good ones that, um uh, some of your going very well saying step by step is off show. Yeah, um, I would start by first things. So basket examination, assessment, bedside, things like the PPI, um, and then duplex ultrasound on. I'm all right. Um, only do MRI if the force that interventions decided. So that's keeping to remember critical limits. Kenya. Um, so we kind of touched upon that ATP? I said, usually when it's less than 0.5. Um, but diagnosis is basically do these medical methods, so it will be either a recipe in for more than two weeks. Um, also language in your tissues on the systolic. Ankle pressure. Let's see. Um, so looking at the shooting threatening senior 60 to that, the best way to remember your symptoms if you kind of see this whole picture, you're pale. Painful partner pulses seizure, uh, prizes, person code. Um, that would be a diagnosis for colon practicing esquina if you see more for clinical diagnosis. Um, but most likely, most cases, you've all the investigations. Well, it's not like a TPI again 100 handheld arterial Doppler. Um, so yeah, Buffalo sent it. I'm very happy confusion. You want to treat this soon as possible? Um, during a CT testament, Um, I know. Geez, uh, on different surgical methods, such a strong glasses and let me and there's really as such conservative, um, method of this is well on. And you also want to think about causes. Well, so it could be the acute, um, scheme. It could be caused by pre existing medication. All part of the least. You want to think about some embolus that my course this could even be secondary to something like a s or am I? Um it's just pull it into my mind to acute management. I thought this point another good often skill Teo Burbur is our ABCDE. Um, running through a b c d e a way what sorts of things we look at. So that pain management or acute um, maquina this will be general things. All they look at their work. Yes, it is. The patient talking. So the airway patient do you think else Foreign bodies, Shuxian? Yeah. Yeah, Well, good stuff. So checking patient talking. It's a airways, Peyton, especially the voice. It's no wonder you had still into this, um, and to the breath sounds as well. So if you can feel any breaths Okay. Um, breathing. Yeah. Um right looking there that we can do, um, say every spiritually symmetry. Just just expansion auscultation, that's all. That's all pretty much cracked and look in the chest wall. Movement on extra ky essential. All of these things, Counter executive. In what sort of things will be due to circulation. So you would want a color skin, Hillary, refill time, BP. You see GI because off the other causes we feel about on also this point I want to start considering the management is also did the IV access Think about, you know, some subtle from both this treatment. So happen infusion or IV nausea. Um, and then moving on to be your disability. Check it after you levels. Um, check if people's equal reactive to light. Um, check your CVG like the keto levels when it's like one of these bility on everything else. Start thinking about, um, you'll management plan now. So instead of the different times of vascular disease to re basket examination temperature check on urine analysis, Um, you also wanna inside capital as well. Uh, this point in case a good measure, um, ATP, I don't plan and you're back to your first message off investigations on Professor Basket says that would be a key thing to do for you in the skin up. I think these was put in the past. Septation is, uh, give you split into your different carts is the last one passed away to be in past three. That's also good for, um, thinking about your examination. Um, it says you know, for example, sensory impairment. We checked that, um, it can be gone or is there? Yes, some sensory impairment. You know, it's important. Think about that. And then you can start thinking about it. Passes and what needs to be done, Um, for your treatment. And, of course, your own doctors and most impairments. Well, I'm thinking about all these things. Meeting examination. Um, so purple are here with these key risk factors here. A second for history. What? What would they be? Yeah, and shop. Yep. Yeah, most of them on the right line. Onda. So think thinking off these following one. So, for example, and, uh, smoking, hypertension, obesity, um, diet and alcohol. Um, diabetes, the all of these, Um, I must've respective smoking is one of the most strongly linked profile two of these. So really important to take that in the history is Well, um, when giving out magin can You had mentioned some of these if they were there, and you would say you want to treat these, um, respective. Um, Andi. Also consider other conductive method, so, you know, except programs, um, refined in two different tracks, which is the chest circulation foundation. Um, the the other message. So the medical therapies roll. Think, start thinking about you taking the therapy? Um, liquid lowering therapy is we'll start into the muscle hypertension management. Better control on. There are some statistic medications you could give, like surveys dilated, um, which we used to just treat the pain. Mostly, um, that's usually given if excess terrible isn't working for patients on before surgery. So thinking about endovascularly Vasculera at the end of last year of vascular is a shin for short notice. Um, but it's longer. You want to do something by part because it's been more serious on, um, force if it gets very serious in a job, you know, lots of gangrenous issue you might even think about invitation. Um, so So moving on some leg pain. Another box killer differential is abdominal aortic aneurysm. Um, so it's very useful, Teo. Kind of think about this is all the good parts of vascular. Um, exam is also looking at, um, with allergies. Such abdominal your general. Um, so, considering a ruptured a, um how How would it for them? What would you see in a ruptured of dominated? Yes. The key thing is shock. Shock is very good. Back pain. Yeah. I don't know. Pain can't be so very good. Yeah. And shortness of breath, Of course. Said those are the key. Asking if you would see tearing pain would know Really? The brush It don't matter what kind of That's something. You get more in that section. Tear in. Central Trustee. Um so ruptured. I don't know. Your cancer is, um um more like, um, look, about paid, um, abdominal pain. Yeah. Single piece and shock that some of those I mentioned there. Um, so in this case, yeah, um, this was a case. How would be manage it? What would we say? Examine how we manage. This patient is coming. Um, And you found this? Yeah. You want to you A B C D. Um, that's correct. Onda. You want to send it straight off these on that Straight to ask your view on a CT scan and soon as possible. Um, but it's a hemodynamically stable. But if there is a shot, um, that would be a straight clinical diagnosis. He taking All right. Very good. Okay. So what is normal? Your exercise. Um, but with our normal able to exercise be, I don't know on yours. And so for less often do we quit trying to do here. So it was a bite and usually would say, less than three centimeters. So Okay, um, what would be our range for a small aneurysm? Small aneurysm. Nobody here? Yeah, about 3 to 4.44 point five. That's cracked on. So if someone does have a small domino the Canasa how often would you screen them? Uh, what would you do? Skips here says, arched down Can, um really good cook, Um, for medium, um, a meeting place on what? What's our range? Yeah, well, I tried to my point for you. All right? Yeah. Good stuff on for that hour. Abdominal ultrasounds kind of be able to three months. Um, And what's our standard and screening for dominant or two generations? How do we screen? Yeah, single sounds gone. Um, yes. It's single of sons gone. Um hum, um, aged five or bus. So those are the key things you want to do for ruptured? Don't really kind of Yeah. Looking at, um, unwrapped it. I don't know. Anderson always wanna stick them into low risk and high risk on stuff in terms of lowest. Um, those were the ones that are asymptomatic, but it will take time is 5.5. Um, you just carry out the recommended screening on Condemned to management driver, um, to lifestyle issues, um, and other things risk factors. Just hypertension, smoking alcohol, um, and then for high with, um, it was either symptomatic lows in the old ones with above 5.5 on with those. You wonder if I want to vascular surgery within two weeks on Juicy and EADiaz done. Okay, Um, another very obscure basket. A condition that could come up. Um uh, to be honest, common trying to get this confused by the way a good test is. Well, this is very different. Blake is test breaking through. These is completely different in Vegas. Test. There's no pass. A vagus disease. Um, so can you tell me what, um, weight is is destruction of what it might be? Um, what's your vaccination? Is it? Yeah, that's just so just more and medium vasculitis. And this Lisa trumpets formations. So symptoms of these are similar that we have stuff like, um intimate cortication in preference on. That would be without a history of this. If you don't have a history of Katie This might be another thing you're thinking about. Um can also be superficial from the phlebitis on skim it. Ulcers and gangrene on key risk factors are heavy smokers, Middle Asian being male. So investigations. One of the key things is just extremely other differentials. First, because those are more likely. Of course. Um, your doctor confirmed the presence of pulses again. This will be excluding PT. Um, but the key thing you see in a duplex, um, would be the corkscrew. Uh, shit. The lateral wrestles. That's a key thing to just look out for on a management plan. So course smoking cessation as that's one of the key risk factors. Um, and, uh, he, um which he was given presently, you wouldn't get appropriate or the other one died of time because they are contra indication pregnancy. Um, hum days, acting medication. So fed again, for example, on department gang on this issue of, that's a very common complication in Vegas. Okay, I just mentioned rain or phenomenon. Can anyone mention what that is? I can actually help with the difference between disease. Phenomenon was different. Raynaud's phenomenon Andre, not disease. Yes, he has become cold. That's good. what else happens? Yes. Instance. So you get a change in color? Yeah, and it's because the base constriction inside your purpose. So you get a change in color you get on either pink or pill changing color. Um, hear those. The key things on between Raynaud's phenomenon and renal disease. Key thing is that on right now, the the juicy, um, like a primary disease, I would kind of think it is the underlying cause. Um, whereas in the rain off phenomenon, there's an underlying cause. Structures of vasculitis as Reagan disease. Okay, just this kind of summarizes that what we were talking about. So I know he's been, um, mouth competitive nominal, But it's also symmetric on. There's no on smoking females on with Raynaud's phenomenon. It's more common in the elderly. Just bad I in mind, and that's something to keep an eye out for. You'll ask you a combination is Well, all right, So, um, this Now we'll move on to the vascular part, the vascular examination part off the session. So we just have a short break, maybe like, 2 to 5 minutes, max. Um, and then we'll come back on, um, carry on with the examination hour off. He, um So, Mister Rogers, present with the mild chest and domino pay and shortness of breath carry out spoken fashion examination present. You're finding just reputation. Next. Measure that scenario. Okay, um, so let's move on to quick spot diagnosis again. Based on this off setting. So, uh, 66 2 year old man presented care intestine has a history of hypertension smoking basket examination finds week, possibly for freeze. No change in the X rays. What might speak? Yeah. So this time we have a little section and little tearing chest pain mentioned earlier. That would be a key thing to look out for. All right, um, since you since year old man presents with some chest pain. Abdominal pain ready the back point examination. Find a mask in the abdomen. Percent of time. Show up. This should be easy. Yes. Yeah, but that's okay. Stay through your present. Woman presents with chest pain, chest pain, westerns doing breathing in history of lotion that she had violated. Yeah. Good. Yeah. So, yeah, pee pees. Want stuff? Okay. On last 1, 70 year old women presented to the chest a an extra bills smoking. I potential and happened Epidemiology, she says the pain inside aspect to a neck shoulder. My sneezy one. Yeah, And my knife And keep a C s is what we could say that one Cool. Is that chest pain? Abdominal pain both in that one I thought would be useful to put in some of these diagnosis. Just think about cool. So, um, moving onto our initial introduction off a basket examination our wiper on. So first thing is, first you wanna wash your hands doing PT nowadays that's very important and makes you show also steps of hand washing job. Um, because that's very important for washing hands is keeping to do. Don't do it. You could tell the station is also always wash your hands. Introduction. Um, same with full. Hello. My name is behind on a 40 medical student. Um, at this university introduces So mentioned, what you'll be doing is well, at this point to your patient, details explain confidentiality and consent, saying before they confirmed the name of dated, Uh uh, tell them a little bit about what you'll be doing. Just a small examination of the blood vessels on what this involves is examine your arms. Legs on the pulse is check the blood flow and your body. Any information again will be strictly confidential within the medical team. It's okay with you again. Talk about confidentiality and getting the consent. Very important. I'm exposed for this station. Um, you want to expose the torso, arms and legs, Aziz, the areas we will be examining on before you begin. Always ask. Are you any pain at the moment? Okay. Very important to do on finally recondition the bed. You were reposition it later on in the examination that you start coughing that the agreement. Yeah. So, um, first thing was the first thing we will do in a basket examination. Also, we've done this introduction. He done the introduction. You got to contend what would be And here any other? Yeah. Perfect. General. Expect infection. As with any salt examination, Always start with the general instruction. Okay. And so, like, scars, limbs, medication personally, and the patients self so doing its detail about some of these things scars. Want to look for stuff like bypass surgery. Oh, sit looking at the limbs. You wanna look stuff like amputation? Palestine nose distinct by French rolls for arterial disease. Um, medications looking for oxygen GT n paraphernalia as well. The secret mobilities things like that, of course. Look, a patient in general. The house patient seems Are they comfortable at rest All of these things? Ankles in two point Island just mentioned, um, while you're doing the general inspection after general inspection and what would be our next step in a vascular examination? What part of the body would you want to? Yeah, great hands. And so, yes, moving on to the arms on hand. So that's correct. So again, we'll start with the inspection. Uh, part of that water. Look. A temperature pill every time after delivery. Full time. Sorry. And pulse is on BP. So inspection off the gland on this close inspection of the, uh, cleanse itself, right? You don't your general instructions. Then you move on to the arm. Hands do closer inspection. So you look at things like tussin in your digits. Have Santa Marta for hyperlipidemia. Palance. I notice is so if you have specific diagnosis again, that's why I really notice. A big difference is to think about purple Paulo's well, thinking about putting a fusion and Nina on brand name on this issue. Yeah, Same old thing. Basically look out for and they think back to all the differentials that we kind of spoke about. So, Temperature, you want to use the dorsum of your hands? He's has a fuel symmetrically on both arms. Move up. Just looked different. Um, And if you have a lack of warm, you know, you've got poor profusion against, um, soft clitoral evacuation. A capillary refill time. How do we test for that On What would we do support, then? The job. Yeah. So you want a personal thing? That it for five seconds? Um, on how many seconds should it take for the color to return? Yeah, about 1 to 2 seconds. I wouldn't Not. Right. Um, so that was important to check. And because we're full time to go. So, um, these some of the images off things we mentioned. So what's the first image showing on the hand? Did That was tomato exact. Correct? Yes, Marta. All right. What about the next one second? One little Yes. So that's fading. Yeah. So you see, on the fingertips, you can see the back. Same. Um, that's more statistically shown. Passed any could be coming, but we can't really check clubbing without being up. Having test is all right, so it's more specifically and tossing. All right, Onda. Last one. Yeah. Midline. Not God. Uh, which should most likely indicator my pasta. Cool. All right, I'm with this. Now, that's a mindful. Yeah, right. Get stuff, guys. All right, So, um, the next part of the abdomen that you mentioned the pulses. Um So what would be the anatomical landmark replication of the radio post? Late. Raynaud's would be bilateral. Only if it's raining on the beach. It is. Raynaud's phenomenon will be asymmetrical, so Yeah. So for radio post, you wanna feel just rest between the tendon tendon off the brachioradialis on the Celexa. Copy. Radiologist doesn't case. If that's what you want, she'll be ready. Opposed. Um, you just want to palpate birthstones and do one first, um, common and rate and rhythm. And then move on to the other one, uh, corn and rain rhythm and do them together on why we do them together is to check for radio radio label and what that means. What is radio right here today? Mean on what might it show if there is radio. I do that. Yeah. Delay. Um, in the past between both radio cost is basically that's correct. On your occupation of the is a good one. Um, able to that section is a good one. Um, also paving artery stenosis would be another one radio. It was good. Cool. On what would be next off the radio person. What possibly go next? Yeah. Break you. So it just means systematically up to the break your pulse on. Where would we feel for the brutal pulse? Yeah. Medium biceps tendon. No. So, what, you want to do this externally, rotate the arm a little bit? Palpated on Coumadin. The volume, obviously. Probably one and the other come comment on you off the post. Okay. Okay. On the BP. Want to measure it in both arms? Uh, forced in an office setting. Very might be difficult to see that you mentioned at this point, I would measure BP in both arms. Um, why is it important to consider the difference between dystonic on diastolic pressure? Wise it in going to consider the pulse pressure. Well, my, um indicate if it, um very high or anything a wide pulse pressure. What does that indicate? Yeah, Yeah. Good. You don't think we've met? And yeah, the infection on granted. Er and the BP differences in both arms. What? What? My, That's good. Different in that question about Bones already said it. That section? Yeah. Connotations. Well, yeah, a section. Cool. Get stuff. All right, that's your arms Done. Right. You've done inspection, and you've done the capillary time. You've done your pulses study, but actually done all of that. What heart off the body wouldn't we want to now? Or which there would be going to feel the neck pulses? Think systematically where we go? Yeah, good stuff. Eso moving Want to cost it right? So get do inspection a lot of that stuff. And then you do your auscultate and then palpate So why It's important off school. Take first on, then palpated the court ibs. Why would you also take fast? Exactly. Uh, so if you pop a first you might remember on, um I need to that many complications and sure that we don't want to do that right? You always one a, um auscultate first thing. That's kind of worry about there. Yeah, um, So you want to check the breathing and socket indicated with explosives? And if it dislodges, maybe destruction. Be careful about that. Once you use I am auscultated. Then you palpate all right. Um, patient must be arrest on. Of course. Don't palpate. Both started at the same time. Why? Must be not do that exactly. Yeah, in my, um, cause today's a vehicle. Think the exit, This stuff. Um, I had, um, an atomical location to the crafted post. That would be feel. So it's just Yep. And terry booted again. I'm between the larynx. Is okay on terrible. Off on America. Yeah. Okay. So you're going to face quoted what would be would be the next thing we would do another examination. You kind of moved up the arms up the pace that would you know, Actually, um, we were talking about, um, the abdomen pathology. Such a little scanner is, um so yeah. You want to do your inspection Outpatient off rotation again. Right. So, um, for the abdomen. Do you are stable inspection? You want to start? I'm looking for a domino pulsation just of the examination and see if there's any position looking abdominal scars, uh, moving. Want to help patients? Uh, you want to use both hands to palpate. Right. So here is the umbilicus on just along the midline. Right. Um, and what you want to do is say, if it expansile on pasta. Right. So what do I mean by expansive? What would you have that c o What is it called me? Yeah, your fingers move apart when you think they're just moving apart When you're, uh, palpating on post houses means that the pulse is very strong. They could really feel a strong dominant or post on that. Basically, you checking full. And I don't know what kind of, um and then auscultation, um, just auscultated of the auto in the same place where you probably just security ability. It's 10 midline, um, and also the renal arteries. Just lateral to the midline. Um, it doesn't take breathe. Um, that may also suggested aneurysm. Um, on breo. Breathe. May suggest down. Okay, so now that's your abdomen. Done. What would we do next? Yes, I'm moving on to the lower lengthy. A human jumps up here that's not too low. And the first day is always inflection. Okay, then temperature really returned. Then you did your part. Okay. On it makes you go in a systematic order. So very similarly again in the low. Then you look for the very similar thing that you look for the upper limit. So again, just moving on the lower limbs and saying, Hey, look of inspection. Look, be talking common and only thing you see, right? So again, um, beauticians, gangrene, hair loss, All of these different things could be seen on just common on them And indicate what? Being my show. So, for example, um, also, um, look at the difference between Alter and Venus. Um, think about what? The course I'd be performed. Terrible disease. I'm a diabetic. Also. So these inspections points a very important turn. A little, um, inspection temperature earlier. The same thing. There was a part time we've of symmetrically. There are differences on call themselves. Just important fusion. And same with the capillary refill time. The same way we did your hand. You just get on the toast and it's basically the same medication as you have. Yeah, the little impulsive. So what are the four pulse is that we want to feel was the first one we do was fast. Pulse would be okay. Yeah, again, in a system that will start from top to bottom. So you got a straight and does that that with the moral first and cognitive? Yeah, moved out just magically. All right, um, so there's the four will be wanted you to start with him. All started pocket. You sure it's a bill and dose on the pet is right. So the femoral pulse whereabouts. Do you want to see what you can see in the image over there? Slightly. But what kind of the anatomical location when you're feeling for what would you say? Well, I would be. Yeah. Yeah, between a six and six. And factors in the midpoint off the basis and pedic and prices is where you just feel for the moral pulse. Popliteal you can see over there just in the public. Foster, You want to push beeps with tibia on, feel the popliteal pulse. Syria tibial pulse. You can see it's just inferior on posterior to the media. Millions. Many of us. Um, your Sinus medicine pulse. Where where would be feel for that? And topically. What would it be? Okay, there's two ways. You can think that for the dose on this pet its right. So, yeah, simply simply you could say and the the first metatarsal stuff like that. But in atomic, there will be a natural weeks. They're extended release. It's long, It's right. Or you could say medial to the extent extended digitorum longest endeavor. Get either one of those is where you wanna feel the dose. I don't penetrate. Same thing coming on. Talked. Uh, I mean, body and start there. Right? And you don't really common on rate. Maybe you want to see if you can feel them on. Um, what the bottom is like of the key things you wanna that mentioned. I'm in sensation, simple. And for vascular, you don't need to. Um you know, the different observations amazing you to do is just down like touch. Um, So you'd want a full kind of perform your feet. You to, uh, peripheral vascular disease. A little diabetic disease. Um, So the main way to do this is provide example of light touch. So on the sternum, Uh, make sure you guys the coast, um, and then do it on the feet and sodium move up systematically, Uh, on compare both sides is also one is worse than the other. And now did the good image. What? The pathology might be a swell. Um, that's how we do it on the image on the let's kind of shows we might expect. And, um, for example, diabetic disease or, um, perform. Ask a disease. You might get the government stocking distribution on strike Woman. There'll be less sedentary in the distal. Yeah. Okay. Um, so we've got some inspection, um, Things with the first one with the first image show. What is it? Shrank? Might be hard one. Yes. By the vein, um, called varicose veins. They're enough. Um, I wouldn't really say varicose veins. What about second? And this was your second? Yeah. Second image is more prominent right on the vein. The way most official on gets Pretty much you can tell. It's because names, right. Uh, where's the first image? You can see you go, but readiness give you the swollen seem to bit red Inflamed. Right. So that is kind of showing image off. Yeah. Second one's varicose veins on the last one. A lighted Dema swelling. Yeah. Yeah. Um, yes. In this case is an image of lymphedema because the swelling is so massive. Um, so this would be left Cool. Good stuff. Um, changes show. And in the first image what my happy won't might cause that. Yeah. Yeah, Kitty, these changes we see in purple to on the middle image. What are we seeing that? Yeah. So it's also, um yeah, more specifically, be a tear. Also. Yes. Um, the last image. Yeah. Younger, maybe. See tissue like that that's going dark. Um, that would be getting rid of tissue. All right. Okay. On now, living on to, uh, wages test on. So this is, um, again. No, it, um, to make the disease. Um, it's more kind of test. How bad? Peripheral artery the deed is. So this point now, your condition a patient in that surprising, um, we have to do is raise one of legs to make sure the leg straight and keep it raised for that amount of time. Well, let's lose What's the color? So if you see pallor that indicates a pool of sterile pressure, right? In a normal patient, if you lift the leg up even completely upright, you wouldn't get any changes. Um, where is it? Preferable up here would meet you to get those changes. Okay, um, if that doesn't, uh, if you do see college dangers, you just help patient and sit up on leave their legs hanging by the side of the bed. But this also restored blood flow meter gravity by the same time. You see another thing which you see on the second image. I was just reactive. Truly me. A. There's some influence of the blood flow to that area. My platter vessels. Um, which quote that pinkish red color is one c reactive hyperemia. As this kind of just shows the president of perform a terrible disease. If the angle so great is ankle, she just a little bit, um, and the, um kind of the Palo on. But she was smaller Vegas angle, and that shows that pretty much worse off. Okay, so too small vial, the worst of the leaves. And in a normal patient, you wouldn't get any changes on our final step. Just finishing off the examination. Just want to thank the patient, and we still clothing. All right, um, so, in terms of concluding the examination, so I think the patient office. Help Get dressed. Wash your hand. You don't forget to do that. And it requires in your feet station somebody finding, um, we'll call back on, um, the summer. Further assessment you could think about, depending on what the issue might be or what sort of times you picked up. I'm from your station. So you make it to the cardiovascular exam. You may consider a joint and your examination of the leg up a limb on a lower than your examinations. A PPI on unfairly examination. For example, if we were fired, eight passed on experimental mashing the dominant abdomen. Um, and his heart rate is high. I would live with a low BP. We've got shocked until you start thinking about your ruptured A on if it's very bad. Um, then he'd be straight furrow to surgery to do a CT scan. So in this case, if you were reporting back something like an examination, as if there was something that, uh, gyn the best approach, you did the FDA approach another skill that's quite useful. Skis. Um, so yeah, ready to district forward the way you lay out, you just do your intra you start your name? Um, you're great. And department. Clarify everything. And how far do you want to talk to? So let a situation to tell the patient on where the patient is right now. What? The key issue is the background that you've done, um, any extra 30 so background because we've seen an examination district. I mean, you do any tests? You don't know, um, on in terms of, um, recommendations on, Just think about, you know, like the diagnosis and friend shoes. Um, what would need to happen and what needs to be done? So get transferred or, um, and asking is picking up that we need to do the time that it takes the, um, personally call for help. Go. All right. So kind of got, like, an example one here, but for what you would do for an FDA approved, uh, for example, and money's for, um, that's why one doctor, one imaginary in the mostly department off the medical registrar. Talk about, um, your picture in jury is presented. Very unbearable. Domino pain. Um, name age on talk about the key Key symptoms. Keep sending something that you see on this one. You mentioned keep French is low. I'm concerned that you may have a ruptured, uh, plate and then talk about the background just on the examination. You can talk about the symptoms. He's presented it on any thing you picked up from examination, so collect some nationally. Dominant, um, in the abdomen story. Um, talk about past history. If you mentioned in your station, it most likely will be, um, Andi. Um, any other signs? You seen the patient? Any other examination times? Well, just kind of the way to go back assessment on. So the patient party has higher rest New school d to be intact. Ptotic Um just by being given this treatment the saline polish, um, mention spiritually and it stopped it on. I'm often as well. Uh, he started to feel it. A brother. That's your assessment. Kind of summarize. Uh, possibly information on on any recommendations that you want to be tract like vascular surgery because he Madonna the unstable on. Just confirm that you want the rest of you this patient as well. That's the FBI approach they could use to ah report back as well. After examinations, both courses. It must have said take with more information? No. So keep it for the examination. Uh, general for the general section inspection makes you cramp. Probably give it a few moments. But when saying stuff to say stuff like, uh, I'm looking for is in that because it's just kind of fill it. It's like there's no evidence off this this, um, you know, you're making it sound better. Um, always perform your white. Never forget that our introduction before we start examining and doing visional inspection examine for the patients. Right side on the systematic on. Try to Looks like I think it's all about being confident in Austin combinations. Just try and show. Um, constant. See clearly, because that's the main thing. That will look good. Okay, that's it for the, um that concludes, uh, the vascular teaching. Um, thank you all for attending and hope that was useful.