Cardiovascular Flashcards
Your next patient is a 45 year old man who has booked a consultation at your general practice. He wants to discuss his concerns with you as his brother has recently had a coronary bypass surgery.
Tasks:
Take history
Counsel regarding his cardiovascular risk
Explain your management plan
Open-ended Question
D: Hi, my name is ___. I’ll be taking care of you today. How can I help you?
Address Concern
D: I understand your concern, but let me ask you a few questions, let us calculate the risk of heart disease for you and we’ll make the best management plan together.
Cardiovascular Symptoms
D: Do you have chest pain on exercise?
D: Do you have shortness of breath on exercise?
D: Do you experience pain in your legs while walking, especially on uphill?
Cardiovascular Risk Factors (ABCDEFS)
D: Do you drink alcohol? (Alcohol)
D: How much do you drink?
D: How often do you drink?
D: Have you ever been told that you have a high blood pressure? (BP)
D: How is your weight currently? (BMI)
D: Have you ever been told that you have high fat levels in your blood? (cholesterol)
D: Have you ever been told that you have a kidney disease? (CKD)
D: Can you describe your diet for me?
D: Can you tell me if you take enough vegetables and fruits?
D: Do you take lots of red meat?
D: Have you ever been told that you have a high blood sugar level in your blood? (Diabetes)
D: How much exercise do you do in a week? (Exercise and lifestyle)
D: May I know your occupation?
D: Do you sit for long hours in a day?
D: For the calculation of the CV risk, may I know your ethnic background and the postcode of your residence?
D: Any family history in any other member of heart disease, heart attack, or strokes? (Family history)
D: At what age were they diagnosed? (<55 years old: premature heart disease)
D: Any family history of a high blood pressure, diabetes, and high fats in blood?
D: Do you smoke?
D: How long have you been smoking?
D: How much do you smoke?
D: Any stresses at home or at work?
Positive Findings in History
Drinks 4 beers/day
No veggies, eats a lot of takeaway, loves fatty food
Only walks on the weekends
Chronic smoker
Mother has heart disease
Never checked the BP
Physical Examination from Examiner (needs to be time efficient and SPECIFIC)
General Appearance: BMI & Waist circumference
Vital Signs: Blood pressure
CVS Exam:
Inspection: raised JVP, visible apex beat
Palpation: displaced apex beat
Auscultation: S1 and S2 if normal, murmurs/gallop rhythm
Lower limb: pulses in the lower limb
Office test: BSL, urine dipstick
*no need for ECG for asymptomatic patient
Counselling
Thank you for seeking help and coming in today. Having a family history of heart disease increases the risk of you having a heart disease in the future.
We will use an Australian cardiovascular risk calculator to calculate the risk of you developing a heart attack or stroke in the next 5 years. For this calculation, I need a few extra things: I will arrange for a blood test to check your sugar levels and the fats in your blood, specifically the total cholesterol:HDL ratio. These numbers will help me calculate the risk.
Once we calculate the risk, if your risk is above 10%, it means you have a high risk of developing cardiovascular disease, if it’s 5-10% you have intermediate risk, and if it’s less than 5%, it is low risk. These categories will help us decide if we need to start you on medications.
I want you to aim for a healthy lifestyle by doing these few steps:
I need you to stop smoking because smoking increases the risk of heart disease. I will arrange another consultation for you to discuss further how I can help you stop smoking. We have a Quitline that can support you to stop smoking and we can also give you medications like nicotine replacement therapy to help you.
I want you to have a healthy diet. I want you to take more vegetable, more fruit, wholegrains, fish and unsaturated fat like olive oil. Cut down on fatty food, junk food, takeaways, red meat. Cut down your salt intake, and use of saturated fat like butter. I will refer you to a dietician for a Mediterranean diet.
I want you to cut down on your alcohol intake. There is no safe level of drinking. To minimize the risk of alcohol, drink less than 10 standard drinks/week, at least 2 alcohol free days, and never go beyond 4 standard drinks/day.
I want you to do at least 150 minutes of moderate to high intensity exercise per week. I will refer you to an exercise physiologist to help you make a plan for your exercise.
I need you to aim to lose weight, and aim for a BMI of less than 25 and a waist circumference of less than 94cm (man)
I will give you some reading materials about cardiovascular disease, a healthy diet, the risks of smoking and alcohol from the Heart foundation. Once your results are back, we will calculate the cardiovascular risk using the calculator.
*NO need for Stress test for asymptomatic patient
Your next patient is a 38 year old man who has come to your general practice for a check-up. The nurse informs you that his blood pressure is high and is 150/100. You are considering initiating antihypertensive medication and have asked him to record his blood pressure at home.
Tasks:
Explain how to measure his blood pressure on an automated device
Educate him on schedule of measurements before his next review
Discuss specific measures for a more reliable result
Open-ended Question
D: Hi, my name is ___, I’ll be taking care of you today. How may I help you?
Address Concern
D: I understand this is concerning, but let me tell you what we’re going to do for you and how we plan to follow you up.
Explain What has Happened
D: Today we recorded a high blood pressure in the clinic, but we never make a diagnosis of hypertension with a single reading. The reason is, some things like stress of seeing a doctor, coffee, exercise, smoking, can increase your BP.
D: We can check the BP in 3 ways:
In-clinic blood pressure measurement
Blood pressure measurements at home
24-hour blood pressure monitoring
In your case, we have decided to check the blood pressure at home using an automated device. This is more reliable than an in-clinic measurement.
Tasks:
D: You can purchase or rent it from the chemist, an automated blood pressure machine. It is important that the device is validated and checked to make sure we record accurate BP measurements. Preferably if the device has a memory storage, it would be good, but you can also record it yourself in a diary.
D: The cuff size is also important. The pharmacist will help you choose a correct size that has 80% length and 40% width of your arm circumference. Because if the size is too large, it’s going to underestimate the BP, and if it’s too small, it’s going to overestimate the BP.
D: When you’re going to start to take your BP, pull the cuff on your bare arm, place the cuff above the elbow so that the midpoint of the cuff is at the midpoint of your upper arm. Then tighten the cuff in a way that you can squeeze 1 or 2 fingers between the cuff and the arm. Make sure that the tubes fall on the front of your elbow because they have sensors underneath that to take your blood pressure.
D: I want you to place your arm on a desk so the cuff level is at the level of your heart. Turn the device on and press the start button. There is an indicator on most devices to show you if the cuff is tight or it’s okay. The cuff will inflate and deflate and who you 2 numbers. I want you to record these. You need to do this at least twice and record both readings. Be in a seated position after resting for 5 minutes, in a quiet room where you are alone. You should not be distracted and you should not be talking.
D: Do your BP measurement before eating, before vigorous exercise, no coffee or smoking for at least 2 hours, and after emptying bladder. Don’t measure your blood pressure if you are stressed, in pain or in extreme temperature.
D: I would like you to this at least 7 days, at least twice a day, one in the morning before breakfast and one in the evening, and preferable at the same time each day.
D: I want you to make a diary and record any unusual readings, symptoms and reasons that you can think of such as pain, stress, coffee, exercise.
D: if you’re average BP is above 135/85, this will confirm the diagnosis of hypertension.
D: I will give you some reading material from Heart foundation on how to check your blood pressure.
Your next patient is a 50 year old man who has come to your general practice today for his shingles vaccination. The nurse decided to check his blood pressure and it was 160/100. His blood pressure remained elevated on the second measurement. He is a known case of hypertension and was diagnosed 3 years ago. He is on 5mg of amlodipine daily. He did his blood tests 6 months ago and all investigations were normal.
Tasks:
Take history for 4 minutes
Explain your medication-focused management plan
Open-ended Question
D: Hi, my name is ____. I’ll be taking care of you today. How may I help you?
Address Concern
D: I understand your concern. But is it okay if I ask you a few questions so we can figure out what’s happening and make the best management plan for you?
Explore Hypertension
D: When were you diagnosed?
D: What treatment are you taking?
D: Are you compliant with the prescribed dose and frequency of the medication?
D: Are you taking it regularly?
D: Have you noticed any swelling in your ankles? (amlodipine)
D: Has your regular GP explained about the need to take your medications and complications of hypertension?
D: Did you drink coffee or did you smoke before you took your blood pressure?
D: Were you stressed about getting a vaccine?
D: Are you having regular follow-ups with your GP?
D: Do you check your blood pressure at home?
D: Have your blood pressure readings been high?
D: Do you have any blurring of vision?
D: Do you have any chest pain on exercise?
D: Any shortness of breath, especially when lying down?
D: Have you noticed a decrease in the amount of urine that you pass?
D: Do you have any pain in your legs on walking?
Secondary Causes without laboratory investigations
D: Are you taking any illicit drugs?
D: Do you snore at night?
Cardiovascular Risk Factors
D: Do you drink alcohol? (Alcohol)
D: How much do you drink?
D: How often do you drink?
D: Have you ever been told that you have high fat levels in your blood? (cholesterol)
D: Have you ever been told that you have a kidney disease? (CKD)
D: Can you describe your diet for me?
D: Can you tell me if you take enough vegetables and fruits?
D: Do you take lots of red meat?
D: Have you ever been told that you have a high blood sugar level in your blood? (Diabetes)
D: How much exercise do you do in a week? (Exercise and lifestyle)
D: Any family history in any other member of heart disease, heart attack, or strokes? (Family history)
D: At what age were they diagnosed? (<55 years old: premature heart disease)
D: Any family history of a high blood pressure, diabetes, and high fats in blood?
D: Do you smoke?
D: How long have you been smoking?
D: How much do you smoke?
Counselling
Your blood pressure has been higher than the target range today. We usually aim to keep the blood pressure below 140/90 when you are taking medications. As you were supposed to get a vaccine and could have been stressed, I will check your blood pressure one more time to make sure it is consistently high. If you’re blood pressure is still high, the best decision is to add a second medication as this is usually more effective than increasing the dose of the first medication. We have two options:
I can add a medication from a group called ACE inhibitors like perindopril
Another option is I can add another medication from a group called thiazides, which is a water pill
Perindopril might be better as it has protective factors against heart and kidney disease.
However, with ACE inhibitors, it can cause dry cough, and once started I will follow up in 2-weeks’ time to do a blood test for your kidney function and a salt in your blood called potassium. If the potassium stays in the normal range, and if the drop in the kidney function is less than 25%, we will continue this medication.
With thiazides, it can also cause a low potassium in your blood and it can cause a drop in your blood pressure with a sudden change of position.
We will be checking your blood pressure regularly. You can do this at home or you can come to the clinic and the nurse will check your blood pressure.
I will arrange a follow-up in 4 - 6 weeks’ time to check if we have lowered the blood pressure to our goal range. In the meantime, I want to emphasize about the importance of compliance, take your medications at the right dose and schedule. Don’t miss a dose and take it regularly.
I want you to avoid smoking, drinking alcohol, have a healthy diet and do a regular amount of exercise.
our next patient is a 50 year old man who is here to discuss his blood test results. He is a known case of Diabetes and is on 2g of metformin daily. He drinks 2 glasses of wine every night and is a smoker. He exercises twice a week. BMI is 30.
TC: 6.3 (3.5 - 5.5)
LDL: 3.9 (<3.5)
HDL 1.1 (>1.00)
TG 2.9 (<1.5)
TC/HDL ratio 5.7 (<4.5)
HbA1c 6.5%
Tasks:
Explain investigation results to the patient
Discuss your management plan
Open-ended question:
D: Hi, my name is ____. I’ll be taking care of you today. How may I help you?
D: Do you have any concerns before we start?
D: Thank you for coming in and following up on the blood test results.
Explain Investigations
D: We have checked your sugar levels to monitor the control of your diabetes. Your 3-monthly blood sugar level is in the target range (HbA1c <7.%).
D: We have checked the fats in your blood.
Cholesterol is the main type of fat in your blood. Your total cholesterol is high.
LDL is the bad type of cholesterol as it blocks the blood tubes in your heart and causes heart disease. Your LDL is high.
HDL is the good cholesterol since it prevents the blocking in the blood tubes, this is why we like being high and above 1. Your HDL is above 1, and that is good.
Triglyceride is another type of fat in your blood, and your body usually stores extra fat in the form of triglycerides. Your triglycerides is also high.
The TC/HDL ratio shows the overall risk of these numbers causing heart disease. Your ratio is above 4.5 and is high risk profile.
D: The high cholesterol, high LDL, high TG and high TC/HDL ratio all increase the risk of heart attack and strokes.
Counselling
Management
(Key point 1) There are some secondary causes which lead to high fats in the blood
One secondary cause is diabetes, but I can see that your diabetes is well-controlled.
Another cause is hypothyroidism. We can do a blood test called TSH just to make sure this is not the cause of the high fats in your blood
(Key point 2) To decide on management steps, I will need to calculate your cardiovascular disease risk using a calculator. I will be checking your BP, take note of your age, sex, postcode, how long you’ve had diabetes, check your kidney function test, and along with your sugar levels and fat levels, I will input these into the calculator to calculate the risk of you developing a heart disease in the next 5 years
(Key point 3) As you have Diabetes and high fats, you are at a high risk of developing chronic kidney disease. For this purpose, I’m going to arrange for a screening with two tests: eGFR and urine ACR.
I will explain the management plan to you and how we make decisions on our options, at the end I’ll give you some reading materials, and ask you to think about it so we can make a plan together.
When we calculate your CVD risk, if you have a high risk, we need to start medication. We use a group of medications called statins like atorvastatin or rosuvastatin. This medication will lower the fats in your blood and decrease the risk of heart attacks or strokes in the future. This is the most effective medication that we can use for this purpose. In terms of side effects, they can sometimes cause muscle aches and pains or rarely it can cause inflammation and weakness in the muscles.
We aim to lower the fats to the target range:
TC <4.0
LDL and TG < 2.0
HDL > 1.0
Once I’ve started you on medication, I will you follow you up in 6 weeks to 3 months. If we have not reached the target goals, I will increase the dose until we get there.
I want you to aim for a healthy lifestyle by doing these few steps:
I need you to stop smoking because smoking increases the risk of heart disease. I will arrange another consultation for you to discuss further how I can help you stop smoking. We have a Quitline that can support you to stop smoking and we can also give you medications like nicotine replacement therapy to help you.
I want you to have a healthy diet. I want you to take more vegetable, more fruit, wholegrains, fish and unsaturated fat like olive oil. Cut down on fatty food, junk food, takeaways, red meat. Cut down your salt intake, and use of saturated fat like butter. I will refer you to a dietician for a Mediterranean diet.
I want you to cut down on your alcohol intake. There is no safe level of drinking. To minimize the risk of alcohol, drink less than 10 standard drinks/week, at least 2 alcohol free days, and never go beyond 4 standard drinks/day.
I want you to do at least 150 minutes of moderate to high intensity exercise per week. I will refer you to an exercise physiologist to help you make a plan for your exercise.
I need you to aim to lose weight, and aim for a BMI of less than 25 and a waist circumference of less than 94cm (man)
I will refer you to the dietician to help you with your diet and how to lose weight. I will also refer you to an exercise physiologist to help you with exercise. And lastly I will refer you to the diabetic educator. I will give you reading materials about hyperlipidemia from Heart foundation and will review you in 3 months’ time.
Your next patient is a 55 year old man who has come to your general practice for his vaccination. He is a known case of hypertension and hypercholesterolemia and is on perindopril and atorvastatin. He has a family history of ischemic heart disease.
Tasks:
Take history
Counsel regarding his cardiovascular risk and management
Open-ended Question
D: Hi, my name is ___. I’ll be taking care of you today. How can I help you?
D: Do you have any concerns before we start?
Explore the Hypertension & Hyperlipidemia
D: Since when were you diagnosed with hypertension and hyperlipidemia?
D: What treatment are you on? Are you compliant with your medication?
D: Have you been having any cough? Dizziness?
D: Are you having regular follow-ups with your GP/specialist?
D: Are you having your regular blood tests?
D: Have you been having any chest pain?
D: Any shortness of breath on exercise?
D: Any pain on your legs when walking?
D: Any blurring of vision?
Explore the Pain
D: Can you tell me the site of the pain?
D: Is the pain only on one side or both sides?
D: Are the muscles sore or do you have joint pain?
D: Can you describe the quality of the pain? Is it a dull ache, sharp pain?
D: How long after starting the medication did this pain start?
Explore Non-compliance
D: Did your GP explain why you need to use this medication?
D: Have you had any memory problems lately?
D: Have you had any financial issue for getting the medication?
Cardiovascular Risk Factors (ABCDEFS)
D: Do you drink alcohol? (Alcohol)
D: How much do you drink?
D: How often do you drink?
D: Have you ever been told that you have a high blood pressure? (BP)
D: How is your weight currently? (BMI)
D: Have you ever been told that you have high fat levels in your blood? (cholesterol)
D: Have you ever been told that you have a kidney disease? (CKD)
D: Can you describe your diet for me?
D: Can you tell me if you take enough vegetables and fruits?
D: Do you take lots of red meat?
D: Have you ever been told that you have a high blood sugar level in your blood? (Diabetes)
D: How much exercise do you do in a week? (Exercise and lifestyle)
D: May I know your occupation?
D: Do you sit for long hours in a day?
D: For the calculation of the CV risk, may I know your ethnic background and the postcode of your residence?
D: Any family history in any other member of heart disease, heart attack, or strokes? (Family history)
D: At what age were they diagnosed? (<55 years old: premature heart disease)
D: Any family history of a high blood pressure, diabetes, and high fats in blood?
D: Do you smoke?
D: How long have you been smoking?
D: How much do you smoke?
D: Any stresses at home or at work?
Counselling
Thank you for raising this concern about the medication and its side effects. The medication that you are taking is from a group called statins, which is used to lower fats in your blood. High fats in your blood increase the risk of heart attacks, stroke and heart disease. Having a high blood pressure further increases this risk and by controlling your blood pressure and fats, we can lower the risk of you getting a heart attack.
These medications can cause muscle pain, but sometimes the pain can be because of other causes such as joint problems like arthritis, fibromyalgia, tiredness. We need to make sure that the pain is really due to the medication. I want you to restart the medication and if you get muscle aches again, I will check a blood test called creatinine kinase (CK). This will confirm if the pain is because of the medication and will help us decide on further management plans.
If the CK is elevated, at this point, we’ll need to stop the medication for a few weeks. We need to consider the benefits of taking the medication vs its side effects. Benefits are they decrease the risk of developing heart attacks, strokes and other heart disease. The risks are it can cause muscle pain. Overall, the benefits outweighs the risk.
So after stopping it for few weeks, we’ll restart it again with a lower dose, or another medication from the statin group like rosuvastatin. If the muscle aches come back, we’ll check the CK again, and if it’s high, we’ll stop it again for a few weeks, and then we’ll restart with intermittent dosing such as every other day, or twice a week. But if symptoms still happen with intermittent dosing, then we’ll use our second line of medications like ezetimibe (side effect: muscle aches also)
I want you to aim for a healthy lifestyle by doing these few steps:
I need you to stop smoking because smoking increases the risk of heart disease. I will arrange another consultation for you to discuss further how I can help you stop smoking. We have a Quitline that can support you to stop smoking and we can also give you medications like nicotine replacement therapy to help you.
I want you to have a healthy diet. I want you to take more vegetable, more fruit, wholegrains, fish and unsaturated fat like olive oil. Cut down on fatty food, junk food, takeaways, red meat. Cut down your salt intake, and use of saturated fat like butter. I will refer you to a dietician for a Mediterranean diet.
I want you to cut down on your alcohol intake. There is no safe level of drinking. To minimize the risk of alcohol, drink less than 10 standard drinks/week, at least 2 alcohol free days, and never go beyond 4 standard drinks/day.
I want you to do at least 150 minutes of moderate to high intensity exercise per week. I will refer you to an exercise physiologist to help you make a plan for your exercise.
I need you to aim to lose weight, and aim for a BMI of less than 25 and a waist circumference of less than 94cm (man)
I will refer you to the dietician to help you with your diet and how to lose weight. I will also refer you to an exercise physiologist to help you with exercise. And lastly I will refer you to the diabetic educator. I will give you reading materials about hyperlipidemia from Heart foundation and will review you in a few weeks’ time.
50 year old man has presented to your general practice for a consultation after his brother had a CABG.
He is a smoker, BP 160/100, TC 7, HDL 1, LDL 3.5, TG 3.1, FBS is normal. CVS risk assessment has been done using the calculator and his risk is 12%.
Tasks:
Take history
Explain investigations
Explain management plan
Open-ended Question
D: Hi, my name is ___. I’ll be taking care of you today. How can I help you?
Address Concern
D: I understand your concern, but let me ask you a few questions, we’ll take a look at your results, and we’ll make the best management plan together.
Cardiovascular Symptoms
D: Do you have chest pain on exercise?
D: Do you have shortness of breath on exercise?
D: Do you experience pain in your legs while walking, especially on uphill?
Cardiovascular Risk Factors (ABCDEFS)
D: Do you drink alcohol? (Alcohol)
D: How much do you drink?
D: How often do you drink?
D: Have you ever been told that you have a high blood pressure? (BP)
D: How is your weight currently? (BMI)
D: Have you ever been told that you have high fat levels in your blood? (cholesterol)
D: Have you ever been told that you have a kidney disease? (CKD)
D: Can you describe your diet for me?
D: Can you tell me if you take enough vegetables and fruits?
D: Do you take lots of red meat?
D: Have you ever been told that you have a high blood sugar level in your blood? (Diabetes)
D: How much exercise do you do in a week? (Exercise and lifestyle)
D: May I know your occupation?
D: Do you sit for long hours in a day?
D: For the calculation of the CV risk, may I know your ethnic background and the postcode of your residence?
D: Any family history in any other member of heart disease, heart attack, or strokes? (Family history)
D: At what age were they diagnosed? (<55 years old: premature heart disease)
D: Any family history of a high blood pressure, diabetes, and high fats in blood?
D: Do you smoke?
D: How long have you been smoking?
D: How much do you smoke?
D: Any stresses at home or at work?
Explain Investigations
D: We have checked your sugar levels with the fasting blood sugar and this is normal.
D: We have checked the fats in your blood.
Cholesterol is the main type of fat in your blood. Your total cholesterol is high.
LDL is the bad type of cholesterol as it blocks the blood tubes in your heart and causes heart disease. Your LDL is high.
HDL is the good cholesterol since it prevents the blocking in the blood tubes, this is why we like being high and above 1. Your HDL is 1, and that is still good.
Triglyceride is another type of fat in your blood, and your body usually stores extra fat in the form of triglycerides. Your triglycerides is also high.
D: The high cholesterol, high LDL, and high TG all increase the risk of heart attack and strokes.
D: We have calculated the risk of heart attack or strokes in the next 5 years which we call the cardiovascular risk score. Your risk is 12%. This means that if we look at 100 people of the same age, sex, and same circumstances as you, out of these 100, 12 of them will have a heart attack or stroke in the next 5 years. This 12% means that you are in a the high risk group.
Management
Again, thank you for coming in for an assessment so we can talk about the best way we can move forward considering the risk we have calculated. As we’ve found that you’re in a high risk group, we will have you start you on 2 types of medications to lower your risk of cardiovascular disease.
First, we need to start you on BP-lowering medications to control your blood pressure as it is also high. We have 3 options on the group of medications that we can start such as:
ACE inhibitors like perindopril
Calcium channel blockers like amlodipine
Thiazides which is a water pill
Perindopril might be better as it has protective factors against heart and kidney disease.
However, with ACE inhibitors, it can cause dry cough, and once started I will follow up in 2-weeks’ time to do a blood test for your kidney function and a salt in your blood called potassium. If the potassium stays in the normal range, and if the drop in the kidney function is less than 25%, we will continue this medication.
Second is we need to start you on fat-lowering medications. Our preferred medication is from a group called statins like atorvastatin. One side effect of this medication is it can cause some body aches. If this happens, come back so we can check a blood test called creatinine kinase so we can investigate if the muscle aches are caused by the medications or some other causes like arthritis.
I want you to aim for a healthy lifestyle by doing these few steps:
I need you to stop smoking because smoking increases the risk of heart disease. I will arrange another consultation for you to discuss further how I can help you stop smoking. We have a Quitline that can support you to stop smoking and we can also give you medications like nicotine replacement therapy to help you.
I want you to have a healthy diet. I want you to take more vegetable, more fruit, wholegrains, fish and unsaturated fat like olive oil. Cut down on fatty food, junk food, takeaways, red meat. Cut down your salt intake, and use of saturated fat like butter. I will refer you to a dietician for a Mediterranean diet.
I want you to limit your alcohol intake. There is no safe level of drinking. To minimize the risk of alcohol, drink less than 10 standard drinks/week, at least 2 alcohol free days, and never go beyond 4 standard drinks/day.
I want you to do at least 150 minutes of moderate to high intensity exercise per week. I will refer you to an exercise physiologist to help you make a plan for your exercise.
I need you to aim to lose weight, and aim for a BMI of less than 25 and a waist circumference of less than 94cm (man)
I will refer you to the dietician to help you with your diet and how to lose weight. I will also refer you to an exercise physiologist to help you with exercise. I will give you some reading materials about cardiovascular disease, a healthy diet, the risks of smoking and alcohol from the Heart foundation and will review you in a few weeks’ time to check the effect of your medications.
Your next patient is a 40 year old man who has come to your clinic for his influenza vaccination. She was diagnosed with essential hypertension 2 years ago and was prescribed perindopril. She stopped taking her medication recently and her blood pressure today is 165/100.
Her recent blood tests are normal: FBE, UEC, LFT, FBS, lipid profile
Tasks:
Assess patient’s compliance to medication and reasons of non-compliance
Explain complications of hypertension
Counsel regarding management
Open-ended Question
D: Hi, my name is ___. I’ll be taking care of you today. How can I help you?
Address Concern
D: Is there any specific concern that you have about the medication?
*Remember to address the agenda in the management
Explore the hypertension
D: Since when were you diagnosed with hypertension?
D: What treatment were you on?
D: Did the doctor explain why we need to treat a high blood pressure and explained the complications of not treating it?
D: Have you noticed any side effects?
D: Did you have any cough?
D: Did you have dizziness specifically on changing positions?
Compliance reasons:
D: Any financial issues in getting the medication?
D: Are you taking any other medications?
D: How do feel about taking the blood pressure medications?
D: Have you had any memory problems?
D: May I know who you live with?
D: Do you have enough support at home?
D: Have you had any recent significant events in your life?
D: Are you trying any other type of treatment?
Follow-up:
D: Are you having regular follow-ups with your GP/specialist?
D: Are you checking your blood pressure regularly?
D: Are you having regular blood tests for your hypertension?
Complications:
D: Have you had any chest pain?
D: Any shortness of breath on exercise?
D: Any pain on the legs while walking?
D: Any blurring of vision?
D: Any episodes of headaches/dizziness?
AMC cases:
*I forget taking it
*I have financial problems
*No one told me what hypertension is and why I need to take it
*I moved cities, I’ve been so busy that I haven’t been able to take my medication
Counselling
Explain complications of hypertension
I understand your concern about the medication (whatever the reason given), but I appreciate that you are here to talk about it.
Let me explain why we need to treat a high blood pressure. A high blood pressure usually doesn’t cause any symptoms, but over time, it damages your heart, kidneys, eyes and the blood tubes in your legs. These damages are irreversible, which means that once they happen, we cannot fix them, that is why we prefer to prevent them by treating or controlling the blood pressure.
A high blood pressure increases the risk of heart attack and stroke.
Management
Agenda:
Busy: emphasize on importance
Memory: we can do an assessment for your memory. We’ll do a test called mini mental state examination to assess your memory and do some blood tests.
Financial: I can prescribe you with generic brands, they are usually a little bit cheaper. I can also arrange some Centrelink support to help you with procurement of medications.
I will ask the pharmacist to also do a medication-review (DMMR) to help us in educating you and following you up.
I can also ask the Pharmacist to consider a Webster pack
I will refer you to the dietician and the exercise physiologist.
I will give you reading materials from Heart foundation.
I will review you regularly to check your blood pressure and review your medications.
In the meanwhile, non-pharmacological management.
Your next patient is a 54 year old man, who has come to your clinic today. The nurse comes to your room and tells you his first blood pressure reading has been 180/100 and his second reading is 185/120. he is complaining of headache and dizziness. He is a known case of hypertension and has not been taking his medications for 2 months.
Tasks:
Take history
Explain diagnosis
Explain your management
Open-ended Question
D: Hi, my name is ____. I’ll be taking care of you today. How can I help you today?
Address Concern
D: I know this can be distressing. But let me just ask a few questions, do an examination and make the best management plan for you.
Explore Complaint: Headache
D: Where is the site of the pain? Is it on one side or both sides?
D: On a scale of 1 to 10, 10 being the worst pain, how bad is the pain?
D: Can you describe the quality of the pain? Is it a sharp pain, dull ache, throbbing pain?
D: When did this start? Is it on/off or continuous? Is it getting worse?
D: Does the pain radiate to anywhere else?
D: Anything that makes it better or worse?
Explore Complaint: Dizziness
D: Can you describe what you mean by dizziness? Are you lightheaded, about to faint or a spinning sensation?
Hypertensive Encephalopathy & Retinopathy
D: Any blurring of vision?
D: Any weakness or numbness in your body?
D: Any slurring of speech?
D: Any difficulty in walking?
Other Causes of High BP/Headache and Dizziness
D: Any chest pain or shortness of breath? (IHD)
D: Any other pain around the body?
D: Any nausea and vomiting with the headache? (SAH)
D: Any ringing/buzzing sound in your ears?
D: Any recent stressful event?
Hypertension History
D: Since when have you been diagnosed with hypertension?
D: What treatment are you on?
Non-compliance questions
D: Any side effects with the medication?
D: Any financial problems related to procuring the medication?
D: Are you having any memory problems lately?
D: Did your GP explain to you the importance of taking your medications?
D: Are you having regular follow-ups with your GP to check your blood pressure and take blood tests?
Diagnosis
Most likely you’re having a condition called Hypertensive urgency. This is an extremely elevated blood pressure that causes symptoms such as headache, dizziness. I was looking for other causes that increase the blood pressure such as when you’re in pain, when you’re stressed, or when you have problems in your heart such as having a heart attack or problems in your brain such as subarachnoid hemorrhage.
Management
I will call the ambulance and send you to the emergency department. In the ED, they will do some investigations such as ECG, UEC. They will start you on medication, usually we prefer oral amlodipine to lower your blood pressure. They will monitor your BP closely. Once BP is controlled, and symptoms have improved, we’ll restart you on your medications.
It is important to be compliant with your medications. I do understand that a high BP is most often asymptomatic, but we are concerned about the complications to your heart, brain, eyes, kidneys, they are irreversible so we want to prevent them from happening.
Once you’re discharged, I can send you to the pharmacist to do a medication review, and they can also work with you to make sure you’re compliant with your medications.
I can also ask the Pharmacist to consider a Webster pack
I will refer you to the dietician and the exercise physiologist.
I will give you reading materials from Heart foundation.
I will review you regularly to check your blood pressure and review your medications.
If you have more time: explain non-pharmacological management
our next patient is a 23 year old lady who is a regular patient of your GP clinic. You had started her on Microgynon 30 (combined OCPs) 3 months ago and in her follow-up appointment, you recorded a high blood pressure. You ordered regular BP checks at the clinic and at home and the average BP is consistent with hypertension and 160/100. She has been generally healthy and has a healthy diet and regular physical activity. BMI is 23.
Tasks:
Take history for 5 minutes
Explain your most likely diagnosis and differentials to the patient
Initial management
Open-ended question
D: Hi, my name is ___. I’ll be taking care of you today. How may I help you today?
Address concern
D: I understand your concern. But let me just ask a few questions, do an examination and make the best management plan for you.
Explore the Complaint: Hypertension
Symptoms
D: Do you have any headache?
D: Any dizziness?
D: Any chest pain? Racing of your heart?
D: Any past medical history or family history of a high blood pressure?
CVS Risk Factors (whatever you don’t have in the stem)
D: Do you drink alcohol? (Alcohol)
D: How much do you drink?
D: How often do you drink?
D: Have you ever been told that you have a high blood pressure? (BP)
D: How is your weight currently? (BMI)
D: Have you ever been told that you have high fat levels in your blood? (cholesterol)
D: Have you ever been told that you have a kidney disease? (CKD)
D: Can you describe your diet for me?
D: Can you tell me if you take enough vegetables and fruits?
D: Do you take lots of red meat?
D: Have you ever been told that you have a high blood sugar level in your blood? (Diabetes)
D: How much exercise do you do in a week? (Exercise and lifestyle)
D: May I know your occupation?
D: Do you sit for long hours in a day?
D: Any family history in any other member of heart disease, heart attack, or strokes? (Family history)
D: At what age were they diagnosed? (<55 years old: premature heart disease)
D: Any family history of a high blood pressure, diabetes, and high fats in blood?
D: Do you smoke?
D: How long have you been smoking?
D: How much do you smoke?
D: Any stresses at home or at work?
Secondary Causes of Hypertension (TRACKPADS)
Thyroid
Any weather preference? Any heat intolerance?
Any diarrhea?
Renal artery stenosis
Aorta (coarctation of aorta
Cushing disease
Kidney disease
Pheochromocytoma
Aldosterone (hyperaldosteronism)
Drugs, alcohol, smoking, coffee/caffeinated drinks
Sleep apnea
Has anyone told you that you snore and gasp while sleeping?
OCP Use
D: How long have you been using the pills?
D: Any other type of contraception that you have used before this?
Side Effects
D: Have you noticed any swelling in your body?
D: Any breast pain?
D: Any mood swings?
Diagnosis and Differentials
Most likely the reason of your high blood pressure is the contraception pill. Your pills contain a hormone called estrogen which increases the blood pressure. There can other causes such as thyroid disease, kidney problems and renal artery stenosis which is a narrowing in the blood tubes in the kidneys. It can be due to coarctation of aorta which is a narrowing in the main blood tube in your body. It can be due to Cushing’s disease which is due to an excessive amount of a hormone called cortisol. It can be due to pheochromocytoma, hyperaldosteronism, due to drugs, smoking, coffee or caffeine, or sleep apnea.
If we don’t find any causes, we call it essential hypertension.
Initial Management
We will stop the OCPs for now and I will schedule another consultation for alternative options.
I will request some investigations to rule out secondary causes like kidney function tests and thyroid function tests.
As we stopped your OCPs, we will need to follow up and recheck your BP regularly.
