Category: Diagnosis

Posted in Cardiovascular system, Chronic disease management, Diagnosis, Heart Failure, Uncategorized

Heart Failure – the need to knows

Posted on by Emma

Heart failure is a condition we are increasingly seeing as the population ages. According to figures there are approximately 900,000 people in the UK with a diagnosis of heart failure. It is likely many more remain undiagnosed.

Why is it important to a GP? Because it is often our doors that patients arrive at with symptoms of undiagnosed heart failure, or for management of their already diagnosed heart failure. So we need to remember to consider it as a diagnosis, know what other points in their medical history are relevant, how to investigate and how to manage heart failure.

An important learning point – from prior experience – keep heart failure as a differential diagnosis in all patients presenting with symptoms of breathlessness, regardless of age or lack of other risk factors. It is not difficult to include it in your investigations so keep it on the list until you’ve excluded it via tests.

Firstly, we need to think of the way people might present with heart failure. I am not going to cover an exhaustive list of all of the symptoms because you should know this by now. But people often come to see their GP with symptoms of breathlessness ( to differing degrees), fatigue, or very commonly – ankle swelling. All of these symptoms have multiple potential diagnoses, and it is through further questioning and consideration that you are going to consider whether heart failure is on your list of differentials. If it is then your first step is going to be the trusty BNP or NTproBNP blood test.

BNP/ NTproBNP

These peptides are sensitive enough to use as a diagnostic tool for detecting heart failure. But they are not quite as specific. Carrying out a blood test to check the levels of either of these peptides is going to help you both diagnose or exclude heart failure.

But what other factors or conditions can affect the BNP result?

Falsely lower Falsely higher
Obesity Tachycardia
Diuretics LVH
ACE Inhibitors Hypoxaemia
ARBs eGFR < 60
Beta- blockers COPD
Diabetes
> 70 years
Cirrhosis

Note the above features – this is going to influence the other elements of your assessment. In order to help you interpret the result you need further information. You need their medical history, medication list and some examination findings.

Notably you might need to weigh your patient to look for their BMI. You need to know what their pulse is and the regularity of it. In addition, an ECG isn’t going to go amiss. From that you can look for SVTs, LV strain and signs suggestive of ischaemia.

In addition to the BNP you want to get some additional blood results:

  • Renal function
  • Liver function
  • Thyroid function
  • Lipids
  • HbA1c

*An off-track learning point – I am pretty tough on trainees at times when it comes to requesting bloods and tests. Why? Because they are expensive and you need to interpret them! When I undertook my emergency medicine rotation I worked in a hospital where the pathology lab was off site. During the induction they told us that we shouldn’t be ordering bloods unless we were planning to admit the patient, because the chances were that the results would not be available before the 4 hour see and treat time was up. Unless you’ve experienced this you will not appreciate how liberating it is to go back to using a history and examination to diagnose a patient. General practice has very much the same ethos. It can be really tempting when requesting a blood test to tick a load of other boxes ‘whilst we are at it’. Don’t. Have a rationale for each test you undertake – what are you looking for and why is it relevant. I’m not going to spell it out for you for the above tests but have a think why they might be relevant!

Interpreting the result

We now have a patient with some symptoms suggestive of heart failure and a positive BNP. What do we do now?

Well we need to look for the cause, unless it is glaringly obvious. The chances are we need an ECHO to help us with this. But how urgently do we need an ECHO? We are going to split our patients into three different categories (as suggested by NICE guidance), and this is going to help us treat our patient within an appropriate time frame:

  1. A very raised BNP (> 400pg/ml) or NTpro BNP (>2000pg/ml) – levels like this carry a poor prognosis so refer urgently to the heart failure clinic for further assessment.
  2. A past medical history of a myocardial infarction (MI) – refer for an ECHO and specialist assessment within two weeks.
  3. Other patients – need an ECHO within 6 weeks of the abnormal BNP result.

The result of the ECHO is going to split our treat versus refer patients even further. Who will we refer?

  • Patients with a preserved ejection fraction
  • Valve disease – I think there is some scope to be rational with this group of patients. Read the ECHO report and refer sensibly. A very mild aortic stenosis in an 80 something year old may not necessarily require immediate referral.

So the other patients, i.e. those with left ventricular systolic dysfunction, are the ones we are going to get on and treat.

Mangement principles

  • Effective communication regarding the diagnosis
  • Lifestyle measures
  • Drug treatment
  • Consider the psychological impact of the disease

Communication – You need to explain the diagnosis clearly and carefully. Heart failure is probably a scary diagnosis to a patient. They are being told their heart is failing. We need a heart to live, and theirs is failing! You need to turn this into a less scary situation with a very good explanation and reassurance that there are ways of helping them. Think about how you might explain this diagnosis, and perhaps try your explanation out in a role play setting.

Lifestyle measures – There are a number of changes patients can make that could help to improve their symptoms and outcomes. Increasing exercise as best they can, stopping smoking, reducing alcohol intake and receiving their annual influenza vaccine.

Drug treatments – Keep this simple in your mind.

  • First line:
    • ACE Inhibitors & Beta-blockers – titrate your ACE inhibitors every two weeks (keeping an eye on the renal function) and start with a low dose and gradually increase (perhaps alongside the ACE inhibitor). Make sure you keep an eye on the heart rate when titrating the beta-blocker. If your patient has a home BP monitor then it is worth suggesting the patient check their blood pressure and pulse if they are feeling dizzy or unwell. An ARB is a suitable alternative if the ACE inhibitor is not tolerated.
  • Second line:
    • At this stage you might wish to consider seeking specialist advice but the following medications can be used in the management of heart failure:
      • Aldosterone antagonist (Spironolactone) – for moderate to severe heart failure, or oedema in congestive heart failure.
      • ARB (Candesartan and Valsartan) – mild to moderate heart failure.
      • Hydralazine + Isosorbide dinitrate – moderate – severe heart failure.
      • Digoxin – will improve the symptoms but will not improve mortality. Use in worsening or severe heart failure where patients are already taking maximal treatment with the above mentioned medications.
  • Diuretics:
    • Use for the relief of congestive symptoms and fluid overload.
    • They can be titrated up and down as required.
    • If a patient is requiring greater than 80mg Furosemide daily then you should refer them onwards.
    • Whilst using diuretics you should monitor every six months via a blood test and medication review.

As with all chronic diseases it is important to consider the psychological impact upon the patient. You should address this at their reviews, and manage as required. Locally in Peterborough the psychological wellbeing service has capacity to provide support to individuals who are suffering from chronic disease such as COPD and heart failure. This part of the management shouldn’t be under-estimated. You can spend your days treating disease and illness, but you can’t lose sight of your patient as a whole.

I hope this has been a helpful summary of how to work up a patient for heart failure, and the basic management approach.

Posted in Consultation skills, Diagnosis, Men's health, Uncategorized

Male lower urinary tract symptoms (LUTS)

Posted on by Emma

This topic seems to crop up fairly regularly as a tutorial request. It’s funny because whenever we go through it I think it actually seems very straightforward. Yet there seems to be this tendency to over think the subject. So I have put together my approach to the male LUTS consultation. My suggested reading for this topic is the hyperlinked BMJ article and the NICE guidance.

A good way to approach male LUTS are to consider the symptoms as storage versus voiding symptoms. Having this in the back of your mind is helpful for data gathering but also gives you information from which to consider the most appropriate management options.

  Storage Voiding
Symptoms Frequency

Urgency (and urge incontinence)

Nocturia

 Hesitancy

Poor stream

Terminal dribbling

Double voiding
Causes Overactive bladder (if isolated) Benign prostatic hypertrophy

Urethral stricture

Meatal stenosis

Phimosis
Management options Anticholinergics Alpha blockers

5-alpha reductase inhibitors

A mixed picture of symptoms would suggest bladder outlet obstruction, most commonly cause by benign prostatic hypertrophy (BPH).

I take a history of the above symptoms in a systematic manner. I go through all the steps of passing urine to clarify what symptoms they have. It is also important to consider the duration of these symptoms. If these symptoms are acute then you should be considering whether this might be a urine infection, or potentially a bladder cancer.

The other important information you need to know are whether they have (or could have) any other medical conditions that may be causing their symptoms. E.g. is this a presentation of diabetes if they have increased frequency of micturition. Also, the medications that they take for other medical conditions could cause side effects that mimic LUTS. So check with them and check their medication list. You also need to consider taking a sexual history if they have any dysuria or penile discharge.

One of the important questions to ask, as with all consultations:

Why is this man presenting now? What are his concerns?

This is the golden question because it is going to guide your management plan. I often see men who wish to discuss their urinary symptoms because they are concerned about the possibility of prostate cancer. But once this is discussed and investigated they don’t feel the need to take medication for their symptoms. So ask them about expectations – it might save an unwanted prescription!

You need to examine your patient:

  • Abdominal examination
  • Genital examination
  • Digital rectal examination (DRE)
  • Look for peripheral oedema
  • Neurological examination – if there is anything in the history that creates suspicion

A note about DRE and Prostate specific antigen (PSA). You need to undertake a DRE at some point during your assessment of the patient presenting with LUTS. Unless the patient is having their blood test very soon after the DRE it is unlikely to impact upon the PSA results. However, you could undertake the PSA testing, advise them they will need this examination at their follow up consultation and then perform it at the review. That is down to your preference. As long as it is completed in good time.

Investigations:

  • Urinalysis – can look for infection, diabetes, or possibility of malignancy.
  • An input/output diary – if they have storage symptoms or nocturia. Make sure they note caffeine intake.
  • PSA – You need to counsel the patient prior to offering a PSA test. I really like this website for providing a man with information about PSA testing.

It is also very helpful to ask the man to complete the international prostate symptom score (IPSS) questionnaire. The man’s scoring on this questionnaire can direct the management plan put in place.

Management:

First line should be information. About their condition and the lifestyle measures they can make that may improve their symptoms e.g. fluid modification. I really like this patient information leaflet from BAUS

Drug treatments. This is where the IPSS can be helpful.

Mild LUTS (IPSS <8)

Enlarged prostate

 5 Alpha reductase inhibitor
Moderate – Severe LUTS (IPSS >7)

Normal sized prostate

 Alpha blocker
Moderate – Severe LUTS (IPSS >7)

Enlarged prostate

 Alpha blocker +

5 Aplha reductase inhibitor
Overactive bladder (isolated storage symptoms) Anticholinergics

(if fails or not tolerated Beta 3 agonist)

Consider the common side-effects of these medications when explaining them to patients:

  • Alpha blockers (e.g. Tamsulosin) – reduced ejaculation, postural hypotension (it is advisable to suggest the patient takes these last thing at night)
  • 5 Alpha reductase inhibitors (e.g. Finasteride or Duasteride) – Reduced libido, Erectile dysfunction, gynaecomastia. With this treatment it may take several months for it’s benefit is seen. It is worth explaining this to the patient up front.
  • Anticholinergics (e.g. Oxybutynin) – dry eyes, dry mouth, constipation, confusion (in the elderly).
  • Beta 3 agonist (e.g. Mirabegron) – Tachycardia

Organise follow-up:

It is useful to review they patient at 4-6 weeks post initiation of treatment. They you can review at 6-12 month intervals. If it is Finasteride only that you have initiated then you may wish to lengthen the first review to around 3-6 months to allow time for it’s effects to have been seen.

Who to refer?

  • Failure of medical treatment after a couple of reviews
  • Severe LUTS (IPSS 20+)
  • DRE suggests malignancy
  • Elevated age-specific PSA
  • Recurrent UTIs
  • Persistent non-visible haematuria or any visible haematuria
  • Urinary retention

This is the British Association of Urological Surgeons (BAUS) age adjusted PSA guide:

Age Maximum PSA (ng/ml)
40-49 years 2.7
50-59 years 3.9
60 – 69 years 5.0
70-79 years 7.2
80-84 years 10
85+ years 20

If your patient has a raised PSA then this is a really nice web page to direct them to or print off to explain what this means and what might happen next.

I really hope this has shown you how straightforward a male LUTS consultation can be. If you have any questions then just as and I will answer as best I can.

Posted in Consultation skills, Diagnosis, Malignant disease, Uncategorized

Referring for suspected cancer

Posted on by Emma

This is written following some CSA preparation with a trainee. Let me start with a usual disclaimer – I am no expert in breaking bad news or discussing this topic! I have spent a number of years trialling different methods of approaching this with patients. I’m still not sure I have it right but I wanted to share some thoughts to help you build on your skills.

I don’t know if there are many people out there who do not know of cancer. I would say the vast majority, if not all, have heard of the word. It may be that they don’t fully understand what that means though. But how good are you at using the word in your consultations and saying it with ease? It’s an easy word to stumble over and turn in to the most awkward conversation you’ve had that day. Even with those patients who have a diagnosis of cancer. So practice saying it aloud regularly. Normalise the word.

Here’s where I think the problem lies. Most of us are all a bit too nervous to say the word aloud to someone who doesn’t already have a diagnosis. So when we sit there worried that their symptoms suggest cancer, and we want to refer them, we try to think of every other way of saying it without using the word. We talk about the need to exclude serious, sinister or worrying causes. But none of these words define cancer. They could define any illness that may be more than something minor, or something that someone may have to live with or need an operation for. Some people may not even be sure what sinister means. So here’s the issue – we tell someone we need to refer them to clinic to rule out something serious (or sinister; or worrying) but we don’t tell them we need to exclude cancer. We then send them via a clinic that is specifically to exclude this, where there’s a reasonable chance someone else is going to use this word. Imagine being the patient at this point in time. You’ve trundled along to the hospital, on your own having taken the bus, thinking you might have something wrong that that the GP can’t quite sort out. You’re then faced with someone telling you that you’re in this clinic to look for cancer. Yep, I’d feel pretty stressed too. What if I’ve got cancer? Am I going to have to get home by myself and hold it together? Especially, if they decide you need further investigations to rule it out.

So this is what we need to do – we need to find a clear, yet sensitive, way of breaking this news to the patient. I would like to hope that somewhere along the way in your medical training you’ve been given some guidance on breaking bad news, and had the opportunity to practice this. (I wish someone would have given some guidance in medical school on how to tell a relative their loved one is dying or has already passed away – it would have made my days a junior doctor a little less painful).

We need to model this explanation and planning upon the breaking bad news methods. Because that’s what we are kind of doing. We are introducing the possibility of cancer to a patient, who may not have even considered this as the cause for their symptoms.

Firstly – have you gathered the patient’s ICE (ideas, concerns and expectations)? If you have then you may have already garnered that they are a) worried they have cancer or b) have a completely different agenda. A good example is the consultation regarding a breast lump. On the whole a woman thinks a breast lump = cancer. They want you to tell them it’s not. So they are still a little surprised when you explain you’d like to refer them onwards, but they understand why from the get go. The opposite is bowel or urinary symptoms I find. They think there’s probably something wrong but they haven’t often considered it might be cancer. They just want you to stop them from opening their bowels several times per day for example. So ICE is your starting point for knowing what your opener needs to be.

Use the above knowledge to start the explanation. Here’s the important part – I really think you need to use the word cancer at some point during this stage of the consultation. How you do it is something to work out for yourself, via practice. If I am not truly convinced it’s cancer but they sit within the criteria for a two week referral I usually say something along these lines:

” From everything you’ve told me I think you fit within the criteria for us to refer you urgently to rule out cancer as a cause. I’m not entirely convinced this is the case, however I think it would be wrong not to consider this”

Or if you’re really nervous about telling them you could try:

“For each area of the body there are set symptoms and time frames that have been listed as a reason to refer someone to rule out cancer. From what you have told be you fit into one of these categories so I really think it would be a good idea to send you to the hospital clinic”

If you’ve examined them and you are really worried because you’ve found a mass for example then tell them:

“When I examined your tummy I could feel a lump there. There are many causes for feeling a lump in the tummy. However, when taking the symptoms you told me you have into consideration, I’m worried this could be a cancer. So I think we need to get this looked at urgently”

The same goes for discussing a result that is highly suggestive, or confirmatory for cancer. Speak the whole truth.

Whichever way you decide to drop the word cancer in. Follow it up with a ‘would that be ok?’ and a ‘do you understand?’ or a how do you feel about that?’ You know roughly the answers to these questions but asking them out loud rather than assuming allows you to open up the discussion about how they are feeling and to do some (metaphorical) hand holding. Acknowledge that you understand this may be worrying, stressful, etc.

Discuss the next steps. Confirm that two week wait means they will be seen within the next fortnight. If it’s such they may have investigations first then explain this. If they’re going to the breast clinic or neck lump clinic then tell them it might be a long day and they might want to take a book. Suggest they may wish to go along with someone for company.

When closing the consultation and planning suggest some follow up so they know they can come back to you. If they don’t have cancer then they will still have the symptoms that need to be managed, and if they do then they might want to talk to you about it. In addition, if appropriate, make sure you offer some management for the symptoms they have in the meantime.

You might have noticed that I have dropped the word cancer into this narrative many time – because it’s an actual word with a definition and we shouldn’t be afraid of it.

It’d be great if anyone else has any good tips to share on how they broach the subject of a two week wait referral.

Posted in Consultation skills, CSA, Diagnosis, MRCGP

CSA – What’s clinical management all about?

Posted on by Emma

I went to the autumn seminar at the end of September, and I saw a session on clinical management in the CSA. So I circled it and made sure to attend. Having sat the CSA myself I really couldn’t say with certainty exactly what they were looking for. I have also found this with trainees I have helped prepare since. I think the data gathering section is obvious (because you need to take a thorough yet relevant history), and interpersonal skills are also pretty straightforward. But with the clinical management it’s hard to be sure whether we are supposed to have a clear diagnosis, whether we need to show the examiner we know everything there is to know about a topic, give 10 options to the patient, or completely cure them in one consultation!

In addition, the commonest CSA feedback statements are related to clinical management, and this is where trainees are most likely to lose marks.

This session was, by far, the most useful I have attended to date. So I thought I would share some of my learning from it. It was led by Dr Roger Tisi, who is the Associate Postgraduate Dean for Health Education East of England. All credit is to him for making things clearer, and being a great presenter! In addition, this information is from his session so I must also credit him for the knowledge I pass on.

The first point that was made clear is that we should consider that we aren’t just getting 3 marks for the clinical management section. We should assume that half the marks for each station are related to clinical management since interpersonal skills run throughout, and are linked in with a good management plan.

The commonest pitfalls in the CSA are what we all know they are – running out of time, missing the point and managing a condition but not managing the patient who has the condition.

A lot of people in this session noted they would see a clear drop in energy levels as a trainee reaches the second half of the consultation. So you need to think about how you might keep that energy up, and provide a great management plan. Some suggestions included repositioning yourself and straightening your posture, taking a deep breath, etc. The clinical management section begins at the time that you put a possible diagnosis on the table. One possible way to ease in to the clinical management section is to repeat their ideas, concerns and expectations back to them. You might want to think about how you phrase this, but if you can achieve this then you know that you’ve got to the bottom of this consultations, and are on the right tracks. In addition, it means you are more likely to manage the patient and the psychosocial context rather than just the condition in general.

What I took away that is very important is that the CSA doesn’t require you to have a diagnosis in every case. You may be creating a differential diagnosis, or dealing with a dilemma, or providing something else such as advice or support. Remember this – how many times per session do you sit and listen to a history and make a definitive diagnosis at the first appointment? I know that I often come up with some differentials, and have to undertake some further investigations to create a diagnosis and an appropriate management plan. So if it’s ok in real life, it’s ok in the CSA!

You need to provide your explanations in such a way that both the patient and the examiner can understand. You may wish to refer back to any concerns the patient has raised here. Something I like to do, and that we discussed in this session, is thinking out loud (We’ll call it the Em Sheerham technique). Sometimes you have a lot of thought running through your head ‘it could be this or it could be that’, ‘to decided I think I need to do this or that’, ‘normally we’d do this but this patient is that’. If you sit in silence having those thoughts it looks awkward, and also no-one knows why you then come up with the plan you have made. In addition, if you’ve thought it all through in your head then there’s a good chance that when you verbalise it you do it in such a way that you don’t give the full information. Instead, say it out loud – confidently. If you do this then both the examiner and patient see where you’re coming from and understand your rationale. They are more likely to get on board if you make it clear what your thinking is.

Just to reiterate – you must put it into the context of the patient you have sat in front of you. E.g. the lady that’s had a funny turn (possible seizure) who drives for a living, the contraceptive advice for the 15 year old who’s boyfriend is 19. It might be when doing this that you realise you’ve missed a crucial piece of information. If you have then signpost that you hadn’t asked a question that may be of relevance and then ask it. The examiner might realise for the first time that you’ve missed something here so be careful!

Options, options, options! Guess what – sometimes it’s ok to give few or non-options. On the basis that you keep it patient centred, and explain your rationale. E.g. the patient who is worried he may have cancer, and you’re worried he has cancer. The only real option is 2WW referral – so that’s what you’re going to offer – just explain why! You need to inform the patient to allow them to be involved in the decision process, whether there are lots of options or none. Again, this is whether thinking aloud helps, and remembering that the consultation is a dialogue or a conversation – not a presentation!

But whatever you do – do something! A really good point that Dr Tisi made was that the examiner might ask himself at the end of the consultation ‘Is this patient better off for having seen this doctor today?’ They want to be able to say yes, and if you do nothing at all then the answer will be no. So make a plan that the patient is happy with and go with it. Do not run out of time before you’ve done this.

Make sure the patient knows what the plan is, agrees with it, knows how it is to be executed, and there is follow up to ensure patient safety. Be clear on it. E.g. if you say you’ll get in touch with them then tell them how e.g. telephone, writing to them or face to face.

Last crucial point – DO NOT AVOID THE ELEPHANT IN THE ROOM! It is in the CSA for a reason. However painful you might think it will be to address the 14 year old with the 20 year old boyfriend, the drug addict, the patient with back pain who probably has bone metastases, etc. You must address this, otherwise chances are you will fail!

Few little pointers:

  • Video consultations – watch some of your own and check whether you are a serial word user. This can be annoying to an observer so just be careful! I remember I used to say ‘I think’ a lot, and my supervisor pointed out that I sound unconfident, even when I knew I was doing the right thing.
  • Stock phrases such as ‘what were you hoping I could do for you today?’ need to be used carefully, and in the appropriate context. Otherwise they just sound wrong, patronising, ridiculous. If a phrase is completely out of your comfort zone then don’t bother with it.
  • Patient preference doesn’t always take preference. It’s Ok if you don’t give the drug addict more fentanyl patches.
  • Consultations don’t necessarily have to end on a positive note – e.g. as with the above scenario. But this shouldn’t be due to an inappropriate management plan or lack of consultation skills!

You just need to practice all of this, and with time it will just flow. Remember if you need to practice explaining diagnoses or treatments then the best person you can find is a non medical friend or relative. You can easily work on a jargon free explanation with said individual!

 

Posted in Consultation skills, Depression, Diagnosis, Mental health

Consultation skills – Tackling low mood and depression

Posted on by Emma

One of the commonest consultations we have in primary care is for low mood and depression. It’s also picked up during consultations where a patient may not have come specifically regarding their mood. As such it’s really important that we have the skills required to tackle this type of consultation.

With experience each of you will develop your own way of working your way through this type of consultation, and setting up your own schedule for reviewing, and providing ongoing care to this cohort of patients. But in the early days of training it can be helpful to hear about how others undertake such consultations, and shape this to fit your own style.

So I will talk through how I approach this type of consultation. I’m not planning to cover all the detail regarding diagnosing depression, and specific management protocols. You can find the most recent NICE guidance on the recognition and management of depression here

NICE uses the DSM-IV criteria for diagnosis of depression. It’s important to know this since this is how you are going to diagnose someone with depression, and recognise the different grades of depression from ‘sub-threshold’ to severe. By understanding the diagnostic criteria you will a) know what you need to ask your patient and b) be able to ascertain what type of treatment you may wish to offer to your patient.

DSM-IV criteria for major depression:

5 or more symptoms

  • Depressed mood for more than 2 weeks
  • Anhedonia
  • Poor appetite/ Weight loss > 5%
  • Insomnia/ Hypersomnia
  • Agitation / Psychomotor retardation
  • Reduced Libido
  • Loss of energy
  • Poor concentration
  • Thoughts of life not worth living / Suicidal ideation

Categorisation of depression:

  • Sub-threshold = < 5 of the above symptoms
  • Mild = only 5 (or not many more) of the above symptoms, resulting in only minor functional impairment
  • Moderate = Symptoms or functional impairment is between mild and severe
  • Severe = Most symptoms, and they have left a major functional impairment.

With the above knowledge we should be able to come up with a diagnosis, and a severity, of depression. However, the important part is how to gather that information. Sure, we could go through each of these symptoms very robotically, but is the person sat in front of us going to open up and be honest if you are undertaking a tick-box exercise? The answer is no!

It is this type of consultation where I find that a golden minute, or possibly two, is the most useful of any type of consultation. Because in that time you can get an idea of what’s going on, to what extent, and you get to look for all the verbal, and non-verbal cues, that will help you interpret what they are saying, and give you ideas of further questions you need to ask. I’m not going to teach you to undertake a mental state examination (I found a really nice summary here if you need to brush up on your skills), but during this opening minute or two you can start to cover some of the areas of the mental state examination. This is really important for considering the impact of symptoms upon the persons level of functioning.

I like to try and gather information regarding their other symptoms by turning the consultation into more of a ‘chat’ than an ‘interview’. I find this makes it more personal, and tends to develop a greater rapport with the patient.

In my head I am trying to be as nosy as possible, and painting a picture of this person’s life. By doing this I can work out what’s going on, why they might be in this position and the amount of support they have. In turn, this is going to help me offer them the best options for management.

What do I tend to ask about?

  • One of the big questions I ask is what triggered them to come and see me today in particular – this gives a really useful insight in to their situation.
  • I want to know when they last remember being themselves/happy/’normal’
  • Have they ever felt like this before? If so what happened at that time
  • Can they put a finger on what triggered this episode? Is that ‘something’ still happening?
  • Whats their home set up like – Who do they live with? Do they have children? Is home happy or are there stresses? Are their financial or marital concerns?
  • What do they do for work? How is their mood impacting upon work, and how does work impact upon their mood? Have they had any time off recently? If so, did things improve?
  • What makes them happy normally – Do they have any interests? Do they get time for themselves? Are they still enjoying those things they used to?
  • How is their sleep? If they are not sleeping well is it because they struggle to get to sleep, or are they waking. If they struggle to get to sleep – why? What are they thinking/worrying about?
  • Are they eating? Do they enjoy mealtimes as before?
  • Do they smoke, drink, take drugs?
  • Who is in their support network locally – do they have one? Have they got family and good friends locally? Have they talked to any of these people about how they are feeling? Is there any history in the family of low mood/depression/other psychiatric illness?
  • Have they got to the point where they’ve felt so low that they have thought about harming themselves in any way? Or thought about ending their own life? If they answer yes to these questions then I am going to ask for more information (I will chat about this more below)
  • In anticipation of this appointment, have they thought about what might help them get better? Are there any specific treatments they wanted to talk about? What are their views on taking tablets? Have they taken any medications for mood in the past, or undergone any psychological therapies?

By the end of this questioning I feel like I have a really good grip of whats going on, what it might be sensible to offer, and what my follow up plan will be.

If they answered yes to the question regarding self harm and/or suicidal ideation then I need to talk about this in a bit more depth. I acknowledge that this might be difficult for them to talk about, but that it’s important for them to be as open as they can so that I can help to the best of my ability.

If they express that they have thought about taking their life I ask about what those thoughts have involved? How often they’ve occurred? Do they have any intention of acting upon them? What would stop them from doing so? Have they ever had thoughts like this in the past and have they ever attempted suicide in the past?

Asking these questions allows me to generate a degree of risk. Again, this will alter my management plan. Someone who has clear plans, and no clear support or inhibitive factors is going to make me question whether I ought to make a same day referral to the crisis team. Those with thoughts but no active intention I am going to follow up sooner than those with no thoughts of self harm. At this point I also take into account the demographics of the person sat before me. Male suicides are more common than female, and middle-aged males more likely to commit suicide than anyone else.

Only you can decide what your follow-up consultation interval will be for each patient. You are making your own risk assessment, and often this is affected by our personal level of risk. For me, it might be between 2 days to 4 weeks. I might even follow someone up by telephone the following day if I’m particularly worried, but I don’t feel there’s anything specific that warrants a crisis team referral. Bear in mind that some crisis team referrals are bounced back pretty quickly so even if you do refer, you need to continue with your own follow up plans.

What are the management options?

This will be tailored to the patient in front of you but can range from no treatment if they have sub-threshold depression, or there’s a specific incident driving their mood that they just need to be supported through. It may require low intensity psychological therapies such as self guided or computerised CBT, or medications.

Medication ought to be reserved for those with moderate or severe depression, or where they have a past history of moderate or severe depression. It may be considered if they have had sub-clinical or mild depression that has persisted for a couple of years, or where low intensity psychological therapy has failed.

It is important to consider patients ideas and choice. However, I often make it clear that medication may help the symptoms, but if there is a clear trigger then it is most helpful to address this. Hence why psychological therapies can be very useful. Sometimes it’s the conversation you have that breaks down their barriers and opens them up to trying such therapies. If they are not keen initially I will ask them to think about it and discuss it more next time.

LOCAL TO PETERBOROUGH

  1. Patients can self – refer for psychological therapies. In those who I  feel a re low risk with sub-clinical and mild depression I advocate this. It gives the patient some ownership of their symptoms, and there is less likely to be a non-adherence to treatment if they have chosen to refer themselves.
  2. We have 111 option 2. By calling 111 and selection option 2 they are put through to a first responder from the mental health trust. They are trained to talk to patients over the phone, with the aim of avoiding A+E attendances. They are also working with Mind (a mental health charity) to provide ‘safe havens’ where people can go out of hours if they are experiencing a crisis.

Please feel free to use the comments section to share your ideas, or ask questions related to the above. Also, would it be helpful for me to post a video of a simulated consultation for this topic?

Posted in Cardiovascular system, Chronic disease management, Consultation skills, Diagnosis, Hypertension, Uncategorized

Hypertension – the diagnosis

Posted on by Emma

I’m covering this as it’s a common reason for consulting in primary care. What do you do when you pick up a high blood pressure as part of an examination for another presenting complaint? The answer should not be ‘ignore it and hope it goes away’!

As always, you can read the NICE guidance for all the ins and outs of hypertension diagnosis and management. What I’m going to do is give you some tips on what might be helpful during a consultation where someone has a raised blood pressure but no diagnosis of hypertension.

What I will say (and I can imagine this will become a familiar phrase) is that it is not easy to complete all of this in one 10 minute consultation. So it’s worth planning how to tackle this over a couple of consultations.

Most importantly, you need to know what raised blood pressure is. Here are the definitions to guide you:

  • Stage 1 Hypertension – clinic BP 140/90mmHg or higher AND subsequent 24h BP or home monitoring BP 135/85mmHg or higher
  • Stage 2 Hypertension – clinic BP 160/100mmHg or higher AND subsequent 24h BP or home monitoring BP 150/95mmHg or higher
  • Severe Hypertension – clinic systolic BP 180mmHg or higher OR clinic diastolic BP 110mmHg or higher

I think it’s fair to consider their reason for attendance, and whether this may be impacting upon their BP reading. The other important point is that your patient should be relaxed and quiet whilst the measurement is being taken. It’s a good time for you to complete your documentation. It can be hard to convince a patient to sit and say nothing! Also – make sure you’re using the correct cuff size – this really does impact upon the measurement.

If the BP is high on the first reading then measure it on the other arm also. You should have at least two measurements of BP if the initial one is >140/90. You may take a third if there is a significant difference between the first two. Document the lowest reading taken.

Your first consultation is likely to go as follows if you note a raised BP:

  • You will need to organise 24 hour (ambulatory – ABPM) BP monitoring OR home BP monitoring (HBPM). You might want to discuss these options with your patient. The ideal is ABPM.
  • You can also introduce the idea of hypertension and the lifestyle factors that might impact upon the patient’s BP. It gives them a bit of information to digest in the meantime, and it may allow them to consider how they can alter their lifestyle to make improvements.
  • You can also organise further investigations required to assess for target organ damage (kidneys, heart, eyes), and perform a cardiovascular risk assessment:
    • Bloods – renal function, lipids, HbA1c, liver function (if considering statin)
    • ECG – look for LVH, and REALLY helpful to have a baseline ECG
    • Urine – for albumin: creatinine ratio
    • Fundoscopy – you can look yourself but signposting them to an optician for a detailed check is helpful.
  • To complete a CVD risk assessment (a Q-risk in our case) we will need some information regarding family history of CVD, their height and weight (to calculate BMI), their smoking status, and checking their pulse for AF (which should ideally have been done prior to BP measurement since it can affect electronic BP recording)

You can see that after you’ve taken a history and reached the point of diagnosing a raised blood pressure (which may not have been their reason for attendance) there is quite a lot of explanation and planning to get on with! Don’t forget to address their actual reason for attendance if it wasn’t related to blood pressure.

NOTE – If you diagnose someone with severe hypertension, you need to consider starting an anti-hypertensive there and then. You should probably get on and get some bloods taken on the day to facilitate appropriate monitoring of the medications you have started (e.g. unless you have a recent renal function it is good to get one taken prior to starting an ACE inhibitor, since we need to monitor renal function after initiating said medication). You must also consider referral for same day specialist input if they have signs of papilloedema and/or retinal haemorrhage, or if they have symptoms to suggest an underlying cause e.g. phaeochromocytoma, or referral for investigation if this is possibly secondary hypertension.

The follow-up consultation is hopefully going to be straightforward if you have completed all of the above.

You are going to have the BP monitoring results and be able to diagnose hypertension, and which stage. You will also have the investigation results. This, in turn, allows you to manage the condition appropriately.

What are the lifestyle measures patients’ can take to reduce blood pressure? Did they have a think about these after the last consultation? Are there any changes they think they can realistically make?

  • Diet and exercise (including reducing salt intake, and reducing caffeine intake)
  • Quitting smoking
  • Reducing alcohol intake
  • Relaxation therapies

Who are we giving drug treatment to?

  • Stage 1 hypertension and < 80 years old with:
    • target organ damage
    • established CVD
    • 10-year CVD risk > 20%
    • Diabetes
    • Renal impairment
  • All stage 2 hypertension

Consider referral if < 40 years old with stage 1 hypertension and nil other risk factors, since CVD risk may be underestimated in this population. We need to be looking for a secondary cause in these individuals and offering detailed assessment.

Hypertension should be monitored through clinic readings (unless they have white coat hypertension, in which case home monitoring can be used).

Target BP in clinic is <140/90 if <80 years old or <150/90 if 80 year or older. (home monitoring is <135/85 for < 80years and <145/85 if 80 years or older).

I’m going to stop here.

Do you know which antihypertensives should be used in which groups?

Do you know the stepwise treatment for hypertension?

Do you know how different drugs should be monitored, and what common side effects you might experience with the different medications?

Please use the comments section to try answering some of these questions, or if you have any questions regarding what has been discussed above!