The Iceberg

  The Art of the Cardiovascular Exam-Kahmbhati et al-J of Clin Cardiology: 2018, 41:677-684

Like an Iceberg, your existing health risks can be obvious on the surface.

When we see something in front of us that looks like it will do us harm, what do you do?

You can make the decision to steer clear of what can obviously may hurt us.

But are you really in the clear if you make that evasive manuever?

Sometimes but not always.

What health risks that my lurk may not be as obvious,  but can be equally or even more so a threat to your present and future health quality and longevity.

What is the biggest health threat below the surface?

CARDIOMETABOLIC disorders-which include in the largest sphere the no. 1 and 2 killers on planet earth.

Circulatory and metabolic disorders, namely heart disease, stroke and prediabetes and diabetes.

70% of us have these issues now.  Some less advanced, some more advanced.

Some of our newer research indicates that

  1. inflammation is a key factor in development of many of these disorders
  2. 90 million of us have prediabetes (which is whopping 1 in 4 of us and more kids now) and a staggering 90% don’t even know they have it!
  3. Plaque build up in our arteries has been documented as early as age 10?

Just to name a few..

As primary care physicians, we must drill down deeper, earlier and more often,  if if we are going to detect health risk of our patients that are asymptomatic


Avoid things that can hurt you that will accelerate what science knows is bad stuff even though you can’t see it.

I want you to do three things:

A. Practice daily healthy lifestyle cornerstones which are good nutrition, adequate exercise and stress management

To that end, follow this mantra:

Modern version of this poem..with my italics


“The best six doctors anywhere
And no one can deny it are


(we won’t get enough in Michigan, check your Vitamin D3 levels please)


(our body is 90% of this don’t shortchange y0urself, if your urine is clear, you are good, very yellow during the day, you need more)


(6-8 hours of sleep-if you snore tell your doctor)




(150 a week of Cardio and 60 min of stretching/strength training)



(maintain ideal body weight and fat at 25% or less, BMI only tells part of the story)

These six will gladly you attend
If only you are willing
Your mind they’ll ease
Your will they’ll mend
And charge you not a shilling.

(unless you smoke, may cost you more than that)

— Nursery rhyme quoted by Wayne Fields, What the River Knows, 1990”

     -Adapted in italics 2021-Paul Ehrmann, D.O. -30 years later-

B. Aside from the standard blood work, ask for additional cardiometabolic screening blood tests:

  1. Apo B and LDL particle size not just a standard panel
  2. Lp (a) also known as lipoprotein a-cheap and should have once in your life you need it.
  3. Do a microalbumin test in the urine since a normal kidney flow rate may not mean normal kidney function.
  4. Vitamin D3 level-almost epidemic at least in my experience it is.
  5. Do you snore? Tell your doc, could be sleep apnea, which could aggravate this…40% have this and don’t know it
  6. If you have at least two risk factors for heart disease -consider getting a calcium scoring test at the very least.

C.Make sure you kids follow better nutrition and exercise regimens and get some blood tests

-1 of 3 of our kids born after the year 2000 will not outlive their parents on the present trajectory.  

-40% are overweight or obese

-Much higher incidence now of fatty liver which can go on to cirrhosis, diabetes and heart disease among many other bad things

I know it hurts out kifd to get blood work done but It hurts more to see our kids get sick or have the quality and longevity of their

lives potentially threatened by not knowing the dangers that may lurk of undetected health risks.

A  lot of work to do. 

The good news….most of these maladies are preventable and reversible, however our present research tells us if we are going to positively impact these problem, we need to pick these problems up early.

Better and more widespread health screening to detect below the surface issues that most of have that if detected early, can prevent , delay or even reverse

ongoing acquired disease.

Remember, don’t be like the Captain of the Titanic ,look below the surface…..

  The Art of the Cardiovascular Exam-Kahmbhati et al-J of Clin Cardiology: 2018, 41:677-684

Speak up… Expect more…Now let’s get to work!

References:Partnership for Chronic disease-

American Diabetes Association-

American Heart Association-

Kids and early heart disease…… College of Sports Medicine-

Getting started with exercise safely-

 Common lab information-

General Nutrition.-

How to read a food label-

Letter to our patients-How to have a great Televisit

Posted on  by docpaul

*Disclosure Statement: I have no financial interest in any of the products discussed above and I recommend before you try any of these recommendations or tools, you consult with your own primary care physician.

In March, April and May of this year, I performed hundreds of televisits many of which were due to concerns pertaining to the Covid-19 pandemic. Our office had been perfoming televisits to a smaller degree in the past , but dramatically ramped up when the demand increased exponentially during this time.  With this article, I want to lend my experience in hopes of having potential patients prepare for the probability of utilizing televisits over the coming months and having their experience be a meaningful one by helping your provider with additional basic and advanced data if needed at the time of your visit.

I anticipate many more televisits done by primary care providers over the coming months due to the advent of seasonal flu and Covid-19 and because of this most outpatient medical offices wanting to keep sick patients away from the office for fear of spread to other patients or office staff.

Here is what I think you need to not only prepare but to execute your next televisit in order to give your primary care provider the data he/she needs in order to have the best chance of helping you stay healthy and away from urgent care and the emergency room. I include this short list (some with links* and estimated cost) You can get most of these at local drugs stores or often online.

Pre-visit Prep

These measurements are best done BEFORE the start of the tele-visit to help your health care provider factor in that data as they move through the visit with you which often takes only 10 minutes or so:

1.    Find a comfortable place-best in a chair in front of your device-larger device the better if possible

2.    No bright lights behind where you set up to improve receivers contrast

3.    Near your flashing box for the best internet connection on whatever device you want to use

4.    No other ambient noise.

5.    If use advanced tools ear and stethoscope send before-See Televisit tools 2.0 below

6.    Consent forms done and sent if your provider offers them and make sure they receive back before your visit.

7.    Make sure HIPPA compliant (early on, this was not a requirement).

8.    See if your insurance still pays..some pay all, some do not pay co-pay.

9.    Assemble your tools and take measurements 30 min before your visit and have ready-your physician will usually enter this data into your electronic chart.

Your visit and tools you will need-help us-help you:)

Televisit Tools 1.0

I like tools since it establishes subtle trends and because some illnesses are sometimes unpredictable and follow different courses…subtle findings are important. I often will touch base with my patients daily for Covid for example in high risk patients. I am sure I was able to help those patients during the initial pandemic in April and May of this year because of this.

You may want to consider owning these now ahead of the Flu season so when you need it, you are ready…and demand will probably go up creating supply issues.

-Blood Pressure monitor (BPM)

a.        Standard deskop BPM**-can get arm or wrist (more convenient and do not need to worry about the hassle..I like Omron trade name or the like with memory-30 dollars

b.        Wireless BPM-50-85 dollars-Expandable and contractable size so do not have to take measurements to make sure the size is correct. Read the reviews if you get online. I like these because patients can email me their results and can take multiple times

** make sure you have the right size for you arm (mid upper arm)..I like the pharmacists to help with this one or you can do self-measurement if you have a tape measure.   

Small adult or possibly child cuff-7-9 inches-mid bicep measure

Standard adult cuff-9 to 13 mid bicep

Large adult cuff-13-17 inches md bicep

 -Pulse Oximetry on finger…measures oxygen level-15 dollars

Make sure at rest and walk around for two minutes and report result to provider

-Thermometer-Infrared no touch is best if available (forehead)-20 dollars w link example

-Peak flow spirometer-good for initial and trend-15 dollars with link example-Do three times and report to provider

-Maglight Flashlight-5 dollars or can use your smartphone if light source-with link example-In case it is needed

Televisit tools 2.0

1.      Blu tooth paired devices

a.    Sound- Stethoscope-can hear your lung and heart sounds and can send to your doctor the sound file before the visit- 50 dollars

b.    Video-Pictures of ears-can take a digital and send before the visit-30 dollars

Finally, Televisits are not perfect and can be challenging. If you anticipate using this way of communicating with us more than just a little, this investment in equipment and time ahead of your visit, will allow me to do the best job I can to help you.


Dr. Paul

My perpetual health and wellness digital health library for patients

Image result for image teaching to fish

I have found this extremely helpful for patients over the years….as the saying goes….by teaching them how to fish, it lasts for a lifetime

1.Health library- and use search for any disorder

2.Animation of disorders-

(go to search and put in “your disorder animation” i.e. smoking)

3. Getting started with exercise safely-

4. Very reliable easy bp cuff-

5. Everything Covid


b. Long Haul Covid-you had Covid and do not feel right yet-

6. Common lab information-

7.>>search>>”vis (then name of vaccine).

8.  Nice Cardiovascular Risk tools-

9. Great dietary documentaries-“Defense of Food”-

10. Nice overview of foundation of nutrition-

11. National Osteoporosis foundation-

12. General Nutrition.- about your lipids-

13. Know about your lipids-

14. How to read a food label-