December 30, 2023

Dear Sir/Madam:

I am writing this letter to explain why I am unable to present an Income Tax Return (ITR) for my
visa application.

For your reference, I included my bank certificate in this application to show the steady income
that I am receiving.

As a nurse with a freelance setup, I have made it a lifestyle to travel. Just for the year 2023, I
have been to countries such as Malaysia, Singapore, Taiwan, Vietnam, Cambodia, Thailand, and
Hongkong. This year, I hope to explore one of my dream countries, Japan, if given a Japan
multiple tourist visa.

Thank you for reviewing my application.

Health Promotion and

Counseling: Evidence and
Recommendations
Important Topics for Health Promotion
and Counseling
● Screening for lower-extremity peripheral artery disease
● The ankle–brachial index
● Screening for renal artery disease
● Screening for abdominal aortic aneurysm
Risk Factors for Lower-Extremity Peripheral
Arterial Disease
● Age ≥65 years
● Age ≥50 years with a history of diabetes or smoking
● Leg symptoms with exertion
● Nonhealing wounds
Source: Rooke TW, Hirsch AT, Misra S, et al. Management of patients with peripheral artery
disease
(compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the
American
College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
American College of Cardiology Foundation Task Force, American Heart Association Task Force.
J Am Coll Cardiol. 2013;61:1555.
The Ankle–Brachial Index. PAD can be diagnosed noninvasively using
the ABI. The ABI is the ratio of blood pressure measurements in the foot and arm;
values <0.9 are considered abnormal. However, the U.S. Preventive Services Task
Force (USPSTF) does not advocate PAD screening due to insufficient evidence
for estimating the relative benefits and harms of ABI testing (I statement).30
Nonetheless, the American College of Cardiology Foundation/American Heart
Association (ACCF/AHA) practice guidelines recommend measuring ABI in those
at risk, as detailed in the box below, in order to offer therapeutic interventions to
reduce the risk of cardiovascular events.5520 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N
ATIONANDHISTORYTAKING
HEALTH PROMOTION AND COUNSELING
Learn to use the ABI, which is reliable, reproducible, and easy to perform in the
office. Although the sensitivity of an abnormal ABI is low (15% to 20%), the
specificity is 99%, and the test has high positive and negative predictive values
(both >80%).1 Clinicians or office staff can easily measure systolic blood pressure
in the arms using a sphygmomanometer and the pedal pulses using Doppler
ultrasound. These values can be entered into calculators available at selected
websites (see American College of Physicians, at http://www.sononet.us/abiscore/
abiscore.htm).
For patients with PAD and intermittent claudication, the ACCF/AHA guidelines strongly
recommend supervised exercise programs as the initial treatment.5 Randomized clinical trials
have shown significantly increased
pain-free walking distances with supervised exercise programs compared to
nonsupervised programs.31 Other recommendations for managing PAD
include: tobacco cessation; treatment of hyperlipidemia; optimal control of
diabetes and hypertension; use of antiplatelet agents; meticulous foot care
and well-fitting shoes, particularly for diabetic patients; and, in selected
cases, revascularization.
Screening for Renal Artery Disease. Atherosclerotic renal artery
stenosis (RAS) is present in substantial proportions of patients with end-stage
renal disease, congestive heart failure, co-occurring diabetes and hypertension,
and other atherosclerotic diseases.32 Atherosclerotic RAS is associated with
markedly increased risks for cardiovascular events.33 RAS is less commonly
caused by fibromuscular dysplasia, usually in women younger than age 40 years.
The ACCF/AHA guidelines recommend screening for RAS with either duplex
ultrasonography, magnetic resonance angiography, or computed tomographic
angiography in patients with the conditions listed in the box below.5
See Table 12-3, Using the Ankle–
Brachial Index, p. 536.
Conditions Suspicious for Renal Artery Disease
● Onset of hypertension at age ≤30 years
● Onset of severe hypertension at age ≥55 years
● Accelerated (sudden and persistent worsening of previously controlled hypertension),
resistant (not controlled with three drugs), or malignant hypertension (evidence of acute end-
organ damage)
● New worsening of renal function or worsening function after use of an
angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocking agent
● An unexplained small kidney or size discrepancy of >1.5 cm between the two
kidneys
● Sudden unexplained pulmonary edema, especially in the setting of worsening
renal function
See Chapter 9, pp. 365–367, for
guidelines for assessing blood pressure.
The frequency of hypertension arising
from RAS is unknown.
Screening for Abdominal Aortic Aneurysm. AAA is defined as an
infrarenal aortic diameter ≥3 cm. The population prevalence of AAA in adults
older than age 50 years ranges from 3.9% to 7.2% in men and from 1% to 1.3%
in women.34,35 The dreaded consequence of AAA is rupture, which is often
EXAMPLES OF ABNORMALITIESC H A P T E R 12 | The Peripheral Vascular System 521
TECHNIQUES OF EXAMINATION
fatal—most patients die before reaching a hospital. The chances of rupture and
mortality increase dramatically when the aortic diameter exceeds 5.5 cm. The
strongest risk factors for AAA are older age, male sex, smoking, and family history;
other potential risk factors include history of other vascular aneurysms, taller height,
coronary artery disease, cerebrovascular disease, atherosclerosis, hypertension, and
hyperlipidemia.34
Because symptoms are uncommon and screening can reduce AAA-related mortality by about
50% over 13 to 15 years, the USPSTF makes a grade B recommendation for one-time ultrasound
screening of men aged 65 to 75 years who
have smoked more than 100 cigarettes in a lifetime.36 Clinicians can selectively
offer screening to men in this age range who have never smoked (grade C); evidence is
insufficient regarding screening women in this age range who have ever
smoked (I statement). However, the USPSTF recommends against screening
women who have never smoked (grade D). Ultrasound is a noninvasive, inexpensive, and
accurate (sensitivity 94% to 100%; specificity 98% to 100%)
screening test for diagnosing AAA. Palpation is not sensitive enough to be recommended for
screening.
Techniques of Examination
As you intensify your focus on the peripheral vascular system, recall that peripheral arterial
disease is often asymptomatic and underdiagnosed, leading to significant morbidity and
mortality. Review the techniques for assessing blood
pressure, the carotid artery, the aorta, and the renal and femoral arteries on the
pages indicated below, which reflect current guidelines.
Important Areas of Examination
Arms Abdomen Legs
Size, symmetry,
skin color
Radial pulse,
brachial pulse
Epitrochlear lymph
nodes
Aortic width and
pulsation
Inguinal lymph nodes
Size, symmetry, skin color
Femoral, popliteal,
dorsalis pedis, and
posterior tibial pulses
Thighs, calves, and
ankles for swelling and
peripheral edema522 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O
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TECHNIQUES OF EXAMINATION
There are several recommended systems for grading the amplitude of arterial
pulses. One system uses a scale of 0 to 3, as shown in the box below.25 Use the
scale adopted by your institution.
Summary: Key Components of the Peripheral
Arterial Examination
● Measure the blood pressure in both arms (see Chapter 4, p. 130).
● Palpate the carotid upstroke, auscultate for bruits (see Chapter 9, pp. 381–
382).
● Auscultate for aortic, renal, and femoral bruits; palpate the aorta and assess
its maximal diameter (see Chapter 11, pp. 472, 483).
● Palpate the pulses of the brachial, radial, ulnar, femoral, popliteal, DP, and PT
arteries.
● Inspect the ankles and feet for color, temperature, and skin integrity; note any
ulcerations; inspect for hair loss, trophic skin changes, hypertrophic nails.
Source: Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the
management of patients with peripheral arterial disease (lower extremity, renal, mesenteric,
and abdominal
aortic): a collaborative report from the American Association for Vascular Surgery/Society for
Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular
Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on
Practice
Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With
Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and
Pulmonary
Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing;
TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol.
2006;47:1239.
If an artery is widely dilated, it is
aneurysmal.
Recommended Grading of Pulses
3+
2+
1+
0
Bounding
Brisk, expected (normal)
Diminished, weaker than expected
Absent, unable to palpate
Arms
Inspection. Inspect both arms from the fingertips to the shoulders. Note:
■ Their size, symmetry, and any swelling
■ The venous pattern
■ The color of the skin and nail beds and the texture of the skin
Bounding carotid, radial, and femoral
pulses are present in aortic regurgitation; asymmetric diminished pulses
point to arterial occlusion from atherosclerosis or embolism.
Swelling from lymphedema of the
arm and hand may follow axillary
node dissection and radiation
therapy.
Visible venous collaterals, swelling,
edema, and discoloration signal
upper extremity DVT.