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 

Fitness to drive assessment

Fitness to drive assessment is always difficult. Patients usually walk in with a smile asking you for a fitness to drive assessment. If you fail them, they become very angry and you and your patient's relationship can turn 360 just in 5 minutes. 

However, we do have the obligation to protect the community against incompetent drivers. There is a check program in 2012 dedicated to fitness to drive.

Should you allow a person with dementia to drive?

The diagnosis of dementia does not equal to a immediate ban to driving. It will depend on the severity of dementia. Most of them will have to give up driving in the near future. For those who are still at the very early stage, careful physical examination and referral to a fitness to drive by an OT is required. 

How about people with mental health illness?

People with mental health illness (especially schizophrenia, bipolar, depression and substance abuse) are at higher risks of involving in car accidents compared to the normal population. People with bipolar may not be suitable to drive a commercial vehicle and requires careful assessment before granting the permission to drive a private vehicle. 

How often do you need to review diabetics in regards to fitness to drive assessment?

Diabetics who are on diet alone treatment may be eligible for an unrestricted licence. 

Diabetics who are on oral hypoglycaemic agents may require 5 yearly review with a notification to DLA. 

Diabetics who are on insulin may require 2 yearly review with a notification to DLA. 

What should you do after a hypoglycaemic event?

The person should not drive for 6 weeks and may require a specialist opinion. 

Why is assessing elderly people for fitness to drive is difficult and how would you tackle those difficulties ?

Multiple medical co-morbidities, aged related changes leading to slow reaction time, poor mobility, hearing impairment and impaired vision. 

In country area, they often rely on their licence to shop and visit friends. Removing their licences may increase their social isolation. As pedestrians, they also have at high risks of getting hit by cars. 

Other management options: taxi card, get family members to drive them and conditional licence to drive within 5km radius. 

Here is the summary key points to help GPs in assessing patients fitness to drive:

References:

1. RACGP Check program 2012 fitness to drive. 

What does it actually feel like being a GP registrar?

The longer you are in medicine, the more you realise that the most important thing is not patient care. Good patient care in Australia is not going to get you anywhere in life.

First of all, medicare is not going to reward you by providing good quality care. They reward you by the number of patients you see and the number of procedures you do.

Secondly, no one cares about the quality of care you provide. They worry about what is actually being written down - aka your CV. You can spend a lot of time doing what is deemed good patient care but at the end of the day, in order to enter training program, you really need a good CV. You can't spend most of your energy and time just looking after patients, the focus needs to be on building your CV and getting to know the bosses. As I observe frequently, doctors who don't put their CVs as priority, they often fall behind.

Enough of my whinge. If you want to be ahead, don't put too much focus on treating patients and shift your focus on your CV and exam.

Approach to deafness and hearing loss

Key points:

- Deafness may be conductive, sensorineural or a combination of both (mixed).

- deafness occurs at all ages but is more common in the elderly. Fifty per cent of people over 80 years have deafness severe enough to be helped by a hearing aid.

- The threshold o normal hearing is from 0 to 20 decibels, about the loudness of a soft whisper.

- One in seven of the adult population suffers from some degree of significant hearing impairment

- One child in every 1000 is born with a significant hearing loss

- Degrees of hearing impairment:
--- mild = loss of 20-40 dB (20 dB is soft-spoken voice)
--- moderate = loss of 40 - 70 dB (40 dB is normal spoken voice)
--- severe = loss of 70-90 dB (shout)
--- profound = loss of over 90 dB

- More women than men have a hearing loss

- People who have worked in a high-noise levels (>85dB) are more than twice as likely to be deaf

- There is a related incidence of tinnitus with deafness

- It is useful to consider the causes of deafness in terms of pathophysiology (conductive or sensorineural hearing loss) and anatomical sites

- Diagnostic strategy model

• Probability diagnosis 
• Impacted cerumen
• Serous otitis media 
• Otitis externa
• Congenital 
• Presbyacusis 
• Serious disorders not to be missed
• Neoplasia
• acoustic neuroma
• temporal lobe tumours (bilateral)
• otic tumours
• Severe infections
• generalised infections (e.g. mumps, measles)
• meningitis
• syphilis
• perforated tympanic membrane
• cholesteatoma
• Perilymphatic fistula 
• Meniere syndrome
• Pitfalls (often missed)
• Foreign body
• Temporal bone fracture
• Otosclerosis
• Barotrauma
• Noise-induced deafness
• Rarities
• paget disease of bone 
• multiple sclerosis 
• osteogenesis imperfecta 

- When to refer 

• sudden deafness
• any child with suspected deafness, including poor speech and learning problems, should be referred to an audiology centre
• Any child with middle-ear pathology and hearing loss should be referred to a specialist
• Unexplained deafness

Reference:

John Murtagh General practice 5th edition 

Dermatoscopy

Key points:

- Skin cancer is common in Australia and GPs need to be competent in assessing skin lesions.

- The use of a dermatosope in clinical practice has been shown to increase diagnostic accuracy and is considered the standard of care in assessing patients with pigmented skin lesions.

- All visible lesions that cannot be confidently diagnosed should be examined with a dermatoscope.

- Dermatoscope is more than a magnifying lens and light source. By eliminating reflection from the skin surface, the dermatoscope allows better visualisation of the patterns formed by pigment and blood vessels - critical features in the diagnosis of skin lesions. (Try to get one if you don't have one already)

- There are many different methods in analysing a pigmented lesions. (CASH, the ABCD method of dermatoscopy, the 7-point checklist, the Menzies method, the 3 point checklist, the revised pattern analysis and a short modification of revised pattern analysis called 'chaos and clues'.

- The method I learned is called Chaos and Clues.

- First, we need to learn how to describe pigmented structures, which are objectively defined using the following geometric terms:

• Line: a two dimensional continuous object with length greatly exceeding with 
• Pseudopod: a line with a bulbous end
• Circle: a curved line equidistant from a central point
• Clod: any well circumscribed, solid object larger than a dot; clods may take any shape
• Dot: an object too small to have a discernible shape 
• Lines are further classified into 5 types: reticular, branched, parallel, radial and curved, as these have diagnostic significance

- Blood vessels can be described the same way:

- Colour has great diagnostic significance in dermatoscopy. The main pigments are melanin and haemoglobin, and the colours produced are shown :

- The chaos and clues algorithm:

• The first step is to dermatoscopically assess the pigmented lesion for 'chaos', defined as asymmetry of structure or colour'. Chaos is assessed by pattern not shape. As perfect symmetry is biologically rare, some deviation from geometrical symmetry must be expected. It is helpful to imagine a piece of carpet that can be cut in any shape but which maintains uniform pattern.  It would be regarded as having no chaos regardless of how irregular the shape was and regardless of the presence of a little dust on one part. 
• If chaos are identified, look for clues. 
• As for all the algorithms, there are always exceptions: beware of dermatoscopic grey on head or neck, pigmented nodular lesions, parallel ridge pattern (palms or soles)

- As with many things in life, they don't come easily. It takes a lot of time to practice, practice and practice. If in doubt, do a biopsy. (Spoke to a surgeon in the past, he told me that he has never regretted taken out a normal appendix but he always regret on the ones which he didn't. Biopsy rarely results in major harms but melanoma kills.)

Reference:

1. Dermatoscopy in routine practice 'Chaos and Clues'. Australian Family Physician. 2012. 

Gout

Key points:

1. Gout is the most common inflammatory arthritis with a prevalence of about 2% in Australasia.
2. Key steps in the development of gout are 1)chronic hyperuricemia 2) monosodium rate monohydrate 3)interaction between the crystals and the inflammatory system, which is primarily responsible for the clinical features. 
3. Definition of hyperuricemia: serum rate level > 0.42
4. Hyperuricemia is caused by medications and genetic predisposition
5. Only 20% of patients with hyperuricemia develop gout 
6. Definite diagnosis can only be achieved via synovial fluid analysis. This needs to be done before recommending hypouricemic drug therapy.
7. Management of acute gout:
   
   8. There is an increase risk of gout when the patient is started on rate lowering therapy. Patients can be started on low dose colchicine 0.5 mg daily or daily NSAID or 5mg prednisolone. Usually prophylaxis is required for around 3-6 months.
   
   
   9. Serum rate target is less than 0.36 mmol/L, however for patients with a large rate crystal load (as reflected by the presence of tophi) erosions or chronic joint deformity due to gout, the target is a serum rate of less than 0.3 mol/L
   
   
   10. Diet and lifestyle modification alone usually is inadequate to lower serum urate level.
   
   
   11. Allopurinal hypersensitivity syndrome occurs with greater frequency in the setting of renal insufficiency, advanced age, HLA B58:01 positivity and higher initial doses but can occur in their absence. The syndrome usually occurs in the first 12 weeks of exposure, and thus the development of rash during this period should prompt immediate cessation of allopurinol, assessment of liver and renal function, and for the possibility of hypersensitivity. 
   
   
   12.Probenecid is another agent which can be used as rate lowering agent. But the patient needs to have renal function > 30-40ml/min. Because of the marked increase in urinary uric acid in the early phase of treatment, good hydration and urinary alkalisation are appropriate. 
   
   
   
   
   
   
   

Osteoporosis

Key points:

- Osteoporosis is under-recognised and under-treated, even in people who present with a minimal trauma fracture.

- A minimal trauma fracture is sufficient for a presumptive diagnosis of osteoporosis medicines can start prior to obtaining BMD results with dual energy x-ray absorptiometry (DXA).

- Guidelines recommend risk factor assessment and that modifiable risk factors be addressed in all postmenopausal women aged >45 years and men aged > 50 years.

- A full diagnostic investigation is indicated for:

• women> 50 YEARS and men> 60 years with other clinical risk factors 
• Patients > 45 years with a minimal trauma fracture or suspected vertebral fracture 
• patients who have causes of secondary osteoporosis (medical conditions or medicines such as long-term, high-dose corticosteroids)
• adults aged over 70 years 

- Clinical risk factors (CRFs), use the mneumonic of shattered 

Previous minimal trauma fracture, family history 

• S: steroid use (oral corticosteroid use > 5mg/day)
• H: hyperthyroidism, hyper parathyroidism and hypercalciuria 
• A: Alcohol and tobacco use 
• T: Thin (BMI < 22)
• T: Testosteron decrease (e.g. anti androgen ca, prostate Rx)
• E: Early menopause 
• R: renal or liver failure 
• E: Erosive/inflammatory bone disease (e.g. myeloma or rheumatoid arthritis)
• D: Dietary Calcium decrease/malabsorption , DM1 

- The strongest risk factor is age > 70. Peak bone mass is achieved by age 30. Bone loss occurs steadily from the age of about 40, with accelerated loss in perimenopausal period (4-6%) before slowing again after the age of 70 (1-2% per year).

- Basic investigations: DEXA, Ca, PO, ALP, FBE, UEC, LFT, myeloma screen if indicated

• Hip bone mineral density best predictor for hip fracture
• Lumbar spine bone mineral density best for monitoring treatment effect
• 
  

- Management:

• lifestyle measures
• quit smoking and reduce ETOH consumption 
• Weight bearing exercise may increase bone mineral density 
• Balance exercises such as tai chi reduce risk of falls 
• Calcium and vitamin D supplements 
• recommended dietary intake of calcium is between 1000 and 1300 mg per day, depending on age and sex
• Most Australians do not reach the recommended dietary intake so daily supplements of 500-600 mg of calcium are sometimes needed
• Safety of calcium is still a controversial topic as there is evidence that it may increase risks of MI
• Home based fall prevention program, with visual assessment and a home visit
• Medications 
• Bisphosphonates and Denosumab
• Criteria: minimal trauma fracture or age > 70 with T score <=-2.5
• Bisphosphonates: well tolerated, some significant side effects: oesophageal cancer? (not proven), osteonecrosis of the jaw (see dentist prior to commence treatment) and do not use with the other antiresorptive or anabolic agents
•  Denosumab: use with caution in patients with severely impaired kidney function as denosumab may exacerbate hypocalcaemia 
• Raloxifene 
• postmenopausal woman with a minimal trauma fracture and risk of vertebral fractures predominatly
• reduces vertebral fracture but not non vertebral fractures in postmenopausal women
• Reduces risk of breast cancer so suitable for women at high breast cancer risk
• Associated with increased risk of DVT or pulmonary embolism in meta-analyses
• Strontium ranelate
• Criteria: unable to tolerate other medications or contraindicated to other medications
• assess patient risk of developing CVD before treatment due to safety concerns in patients with history of CVD, embolism or stroke 
• Teriparatide 
• Reduces vertebral and non - vertebral fractures in postmenopausal women 
• limited evidence in men
• must be initiated by a consultant physician
• Vitamin D deficiency
• 600 IU per day for people under 70
• 800 IU per day of people over 70 
• 1000-2000 IU per day may be required for sun avoiders or those at high risk of deficiency
• Monitor treatment response and review therapy to encourage adherence
• BMD measurements 2 years after the commencement of therapy or 1-2 years after therapy changes significantly