Module 7 Cold Feet • Revisit Structure And

Session 2012-2013 Grad Year 1 Semester 1

STRUCTURE & FUNCTION  Revisit structure and function of the heart and circulatory system  Discuss the control of blood pressure  Discuss the mechanisms involved in tissue perfusion, including the related role of aspirin  Define mechanisms of pain and principles of its control  Outline lipid metabolism

INDIVIDUALS, GROUPS, & SOCIETY  Define stress and discuss its presentation in vascular disease  Define types of personality in relation to lifestyle and response to stress  Discuss psychosocial factors in patient compliance  Discuss the psychosocial effects of vascular disease

POPULATION PERSPECTIVE  Illustrate the social class determinants of health and relate these to health inequalities in health determinants or outcomes in populations and implications for health promotion strategies  Outline the hierarchy of evidence from epidemiological study designs (for critical appraisal) outlining the key features of a randomised controlled trial related to the classification of descriptive, observational/analytical intervention studies and types of bias  Define case-fatality rate; cause; relative risk and absolute risk (e.g. incidence) and relate risk to probability: health protection; health education and primary disease prevention (as elements of health promotion); Bradford Hill criteria for assessing causal association in clinico-epidemiological studies  Define prevention paradox (related to population and individual approaches to hypertension)  Discuss the potential and limitations of data devised for death certificates

PROFESSIONAL & PERSONAL DEVELOPMENT  Discuss the impact of professional attitudes on life-style related disease  Reflect on the nature of rights and their importance (e.g. provide protective boundaries, security of expectations, indicate minimal standards).  To reflect on the correlative notion of duty  Discuss GMC “Duties of a Doctor” and attitudes to patients who do not follow advice  Discuss the Human Rights Act 1998 –and its implications for health care workers

Session 2012-2013 Grad Year 1 Semester 1

HARC  Revise anatomy of heart  Anatomy of peripheral vascular system  Discuss the names of the major arteries and veins of the body and their clinical importance  Revise structure of the heart  Examine appropriate images of the vascular system

CLINICAL SKILLS  Sphygmomanometry  Examination peripheral vascular system

Session 2012-2013 Grad Year 1 Semester 1

SCENARIO – Module 7: Cold Feet

Frank is a 55year old unemployed docker who rows with his wife Betty most days over their shortage of money. Both smoke heavily and Frank takes longer to get cigarettes from the local shop because of cramp in his right calf which comes on after 20 yards walking and is only relieved when he stops to rest. Betty complains about this and about his legs being cold in bed. She persuades Frank to go to see the doctor.

The general practitioner, Dr Long, asks Frank about his leg pain and whether he has had any chest pain following his heart attack last year. He asks about his exercise, his efforts to stop smoking and how he is coping with his tablets. Frank admits not taking Aspirin regularly because he thought it was a pain killer and it did nothing for his leg pain.

Asked about his family history, Frank remembered his mother having a special diet to control the fats in her blood before she died after a stroke in her 50’s. His brother has pills to control his blood pressure but doesn’t like taking them as he thinks they make his cough worse.

Dr Long then checks Franks pulses and blood pressure in both arms before listening to his chest and checking for foot pulses, which he notes are absent on the right side.

He asks Frank to make an appointment with the nurse before breakfast one day to recheck his blood pressure which was high on this visit, and to check some blood tests. He explains why Frank gets leg pain and how stopping smoking may help. ‘Weight loss and exercise will also help you know’. He prescribes a statin and encourages Frank to take his aspirin regularly. Frank replies ‘you always tell it to me straight doc – I respect you for that’

Later that week , after checking Franks blood pressure and taking blood for fasting lipids and glucose, the practice nurse records an ECG. She tells him he needs to cut out the beer and chips and gives him a diet sheet. Before leaving, Frank asks if he can see his medical records to see how he is getting on.

Dr Long discusses Frank’s problems at the practise meeting. They discuss the evidence behind the advice given to frank and whether it meets the Bradford – Hill criteria as they are concerned he will be unlikely to follow the advice he has been given. It was suggested that Frank was at higher risk of heart disease that the more affluent patients from the private houses in the dock redevelopment so a recent case controlled study was reviewed. This study looked at the effect of social class and psychological risk factors on outcome in serious heart disease with a high fatality rate. They consider the hierarchy

Session 2012-2013 Grad Year 1 Semester 1 of evidence from epidemiological studies and clarify the terms case-fatality rate, relative and absolute risk and relate risk to probability to help interpret the findings. They realised that information from death certificates was far from accurate. Dr Long muses on the cost of heart disease and the implications for the primary care trust health promotion strategy.

When Frank tells Betty about the advice from the health centre, she says’ smoking’s one of our few pleasures in life and you know my nerves are bad without ciggies. Giving up would be a nightmare – I don’t know how we would cope! Think of the stress Frank – I thought stress caused heart attacks! And I don’t like salad – even if we could afford it.