Iron deficiency

What is iron deficiency?

• Royal College of pathologists of Australasia definition of iron deficiency is serum ferritin level of < 30 for an adult 

Who gets iron deficiency?

• Basically everyone 
• Pre-menopausal and pregnant women are at higher risk
• Vegetarian with a balanced diet should not have iron deficiency

What causes iron deficiency?

• 2 major categories
• Not taking in enough iron such as coeliac disease, poor diet etc
• Loosing iron such as blood loss

What are the clinical features of iron deficiency?

• No clinical features in many cases and found out from routine blood test
• Clinical features include: fatigue

How is it diagnosed?

• It is diagnosed via iron studies, not as straight forward as it sounds 
• Ferritin is the most reliable indicator of iron level but it elevates with acute inflammation so a CRP is recommended to order with ferritin together 
• Transferrin saturation levels reflecting transport iron, if it is less than 20% indicate an iron supply that is insufficient to support normal erythropoiesis
• Total iron binding capacity increases in iron deficiency in an attempt to increase iron uptake 

What is the treatment for iron deficency?

• Dietary modification is inadequate to treat iron deficiency, only enough to prevent 
• treatment is around 100 - 200 mg elemental iron daily in divided doses 
• Over the counter product only contains very small amount of iron content
• If iron replenish is required urgently (prior to operation or pre-obstetric delivery), IV iron can be used. (Usually ferronjet 1000 mg can be given over 15 minutes)
• There are quite many iron oral formulas available: Here

What is the outcome?

• Variable depends on the cause
• takes 3 to 4 weeks to have a clinical significant impact
• Hb level should increase by approximately 20 g/L every 3 weeks

References:

• RACGP check program 2016 Blood disorder 
• South Australia health. Blood safe iron deficiency anaemia resources

Approach to Dyspnoea

Murtagh's diagnostic model 

Probability diagnosis 

• Bronchial asthma 
• Bronchiolitis 
• COPD 
• Lack of fitness
• Left heart failure
• Obesity 

Serious disorders not to be missed

• cardiovascular:
• acute heart failure (e.g. AMI)
• Arrhythmia 
• Pulmonary embolism 
• Pulmonary hypertension 
• Dissecting aneurysm 
• Cardiomyopathy
• Pericardial tamponade
• Anaphylaxis
• Neoplasia
• Bronchial carcinoma
• Severe infections
• SARS
• avian influenza
• penumonia 
• acute epiglottis (children)
• Respiratory disorders
• inhaled foreign body 
• upper airways obstruction 
• pneumothorax
• atelectasis 
• pleural effusion 
• tuberculosis 
• Acute respiratory distress syndrome
• infective polyneuritis
• poliomeylitis 

Pitfalls 

• Interstital lung disorder:
• fibrosing alveolitis
• extrinsic allergic alveolitis
• Sarcoidosis
• Chemical pneumonitis
• Metabolic acidosis 
• Radiotherapy 
• Kidney failure 
• Multiple smal pulmonary emboli 

Heart Failure

Condition

• Heart failure 

Definitions

• Occurs when the heart is unable to maintain sufficient cardiac output to meet the demands of the body 

Main features

• increasing dyspnoea progressing to (in order):
• fatigue, especially exertion fatigue
• paroxysmal nocturnal dyspnoea 
• weight change : gain or loss 
• Dizzy spells/syncope
• Palpitations 
• Ankle oedema
• Signs
• left heart failure
• tachycardia
• low volume pulse
• tachypnoea
• laterally displaced apex heart 
• bilateral basal crackles
• Gallop rhythm 
• Pleural effusion 
• Poor peripheral perfusion 
• Right heart failure 
• elevated jugular venous pressur e
• right ventricular heave
• peripheral/ankle oedema 
• hepatomegaly 
• ascites
• Causes of heart failure
• Systolic heart failure 
• The most common cause: myocardial infarction 
• valvular heart disease, mainly aortic and mitral incompetence
• high output states (e.g. anaemia. hyperthyroidism, paget disease)
• Non-ischaemic idiopathic dilated cardiomyopathy
• Viral cardiomyopathy 
• ETOH cardiomyopathy
• Other cardiomyopathies - diabetic, familial
• persistent arrhythmias, especially atrial fibrillation 
• other systemic illness (e.g. sarcoidosis, scleroderma, myxoedema)
• Diastolic heart failure
• ischaemic heart disease
• systemic hypertension 
• aortic stenosis 
• atrial fibrillation 
• hypertrophic cardiomyopathy 
• idiopathic 
• pericardial disease

Investigation 

• Office test: ECG 
• Blood test: FBE, UEC, TFT, LFT, B type natriuretic Peptide (in uncertain cases)
• Imaging
• Chest x-ray 
• Echocardiography

Management

• Prevention is the key. Approximately 50% of patients with heart failure die within 5 years of diagnosis
• Treat or remove precipitating factors
• General non-pharmacological management
• education and support
• smoking: encourage no smoking 
• refer for a rehabilitation program with interdisciplinary care
• Encourage physical activity especially when symptoms absent or mild 
• Rest if symptoms are severe 
• Weight reduction if obese
• salt restriction: advice < 2g salt per day  
• Water restriction 
• Limit caffeine to 1-2 cups coffee/tea a day
• Limit alcohol to 1 SD a day 
• Fluid aspiration if pleural effusion or pericardial effusion if present 
• Daily weighing - check significant weight gain or loss
• Other general measures: optimise cardiovascular risk factors, monitor emotional factors including depression, regular review, vaccination (annual influenza, 5 yearly pneumococcus), 2 yearly echocardiography
• Drug therapy
• Please refer to Heart Failure Medication Titration Plan from Queensland Government. It provides excellent guidance on how to titrate ACE inhibitor, beta blocker and mineralocorticoid receptor antagonist. link
• Digoxin can also be used in controlling rapid AF 
• Device-based heart failure treatments : implantable cardiac defibrillators, biventricular pacemakers and left ventricular assist devices 

Reference

- John Murtagh's General Practice 5th edition 

- RACGP Check Program: Heart failure 

Cardiovascular Examination

What would you do when you have only 10 minutes per patient? GPs are often accused for not examining patients and expose patients properly. What would you do if you have 10 minutes per patient?

This 10 minutes include: history, examination, diagnosis, management, educate patient and follow up planning, and also documentation. GPs are supposed to do selective examination. It takes fair a bit of experience in order to do that.

Anyway, the following is the standard approach to a cardiovascular examination. It is what is expected for RACGP exam.

The following notes are from Talley and O'Connor. It is an Australian textbook and it is mainly written for physician trainees. It is a bit too much for a GP but it is what it is needed for the exam. I was once told by a medical registrar, he watched one of Talley and O'Connor's videos every night when he was preparing for the physician exam. That is how he fit his study around his family life and work.

Cardiovascular examination step by step as per Clinical Examination by Talley and O'Connor:

• General inspection (lying at 45 degrees)
• Dyspnoea
• Cyanosis
• Marfan's, Turner's Down syndromes
• Rheumatological disorders e.g. ankylosing spondylitis (aortic regurgitation)
• Acromegaly 
• Hands
• Clubbing 
• Stigmata of endocarditis
• Peripheral cyanosis 
• Pulses
• Rate and rhythm
• radial radial 
• radiofemoral delay (if there is a history of hypertension)
• Measurement of BP 
• estimating BP first by palpating radial pulse 
• Face
• Sclerae - pallor (anaemia), jaundice
• Xanthelasma
• Malar flush (mitral stenosis, pulmonary stenosis)
• Mouth
• Cyanosis 
• Palate (high arched - Marfan's)
• Dentition (risk of endocarditis)
• Neck 
• Jugular venous pressure 
• Central venous pressure height 
• Wave form (especially large V waves)
• Abdominojugular reflux test 
• Carotids - pulse character 
• precordium 
• Inspect
• Scars- whole chest, back 
• Deformity
• Apex beat - position, character
• Abnormal pulsations
• Palpate
• Apex beat 
• Character 
• Thrill or parastenal impulse 
• Auscultate
• Heart sounds
• Murmurs
• Position patient 
• Left lateral position 
• Sitting forward (forced expiratory apnoea)
• NB: palpate for thrills again after positioning
• Dynamic auscultation may be indicated (no GPs will do this)
• Respiratory phases 
• Valsalva
• Exercise (isometric e.g. hand grip)
• Standing 
• Squatting 
• Back (sitting forward)
• Scars, deformity 
• Sacral oedema 
• Pleural effusion (percuss)
• Left ventricular failure (auscultate)
• Abdomen (lying flat - 1 pillow only)
• palpate liver (pulsatile etc), spleen, aorta
• Percuss for ascites (right heart failure)
• Femoral arteries - palpate , auscultate
• Legs 
• Peripheral pulses
• Cyanosis, cold limbs, trophic changes, ulceration (peripheral vascular disease)
• Oedema
• Xanthomata
• Calf tenderness
• Clubbing of toes

Here you go. If you have 10 - 15 minutes to study, consider watching one of the examination videos. I always pick up a few things every time I watch it. 

https://youtu.be/Gi0FzMzyJbA?list=PLD30A9F834AD276C9

Reference:

Clinical examination by Talley and O'Connor