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Annual Reviews Flashcards

1
Q

What is the order of the asthma annual review?

A

Check diagnosis + method
ICE
Symptom review + triggers
Exacerbations
Inhaler Use
Vaccines
Atopies
Social Hx
PEFR + height/weight
Management + book follow-up

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2
Q

Give 3 diagnostic criteria for asthma

A

PEFR showing reversibility, 7
FeNO,
spirometry

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3
Q

What are the 3 key symptoms to ask for in the asthma review?

What else do you ask here?

A

1) In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?

2) In the last month, have you had any of your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?

3) In the last month, has your asthma interfered with your usual activities (e.g., housework, work, school, etc.)?

What triggers your asthma? Anything that triggers your asthma the most?

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4
Q

How do you ask about exacerbations in the asthma review

A

Have you had any asthma exacerbations requiring oral steroids in the last 12 months?

Have you attended A&E with asthma in the last 12 months?

Ask about emergency signs

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5
Q

How do you Check knowledge of emergency signs during asthma review?

4 emergency signs

A

□ Difficulty breathing/Rapid worsening of SOB
□ Inhaler not effective
□ If difficulty speaking – Call 999 if this occurs
□ Peak flow <50%

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6
Q

What do you ask about inhalers during the asthma review?

A

“Which inhalers do you use?” – Blue or brown
How often do you use your reliever inhaler (Ventolin/Blue)?
How often do you use your preventer inhaler (Brown)

Check technique and Signposts to Asthma UK website

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7
Q

What are the 9 steps to correctly use the metered dose inhaler

A
  1. Shake the device.
  2. Remove the cover.
  3. Check there is nothing in the inhaler mouthpiece.
  4. Breathe out completely.
  5. Place your lips around the inhaler mouthpiece.
  6. Press the trigger to release the spray.
  7. Inhale gently and as slowly and smoothly as you possibly can, as if you are sucking on a long straw of thick milkshake.
  8. Hold your breath for 10 seconds.
  9. Rinse your mouth.
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8
Q

What should you ask after asking about inhalers in the asthma review?

A

Vaccines (flu+COVID)
Atopies

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9
Q

What do you ask about after medications/vaccines in asthma review?

A

Social history ->
- Occupation
- Smoking
- Smoke exposure
- MOOD

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10
Q

What do you do after social history in asthma review?

A

Take height and weight
Measure PEFR

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11
Q

How do you measure PEFR?

A

Weight + Height

Measuring PEFR:
1. Ensure the peak flow meter is set to zero.
2. Position yourself sitting up straight or standing.
3. Take the deepest breath you are capable of.
4. Hold the peak flow meter parallel to the floor and position your mouth around the mouthpiece of the peak flow meter, creating a tight seal with your lips.
5. Exhale as hard and fast as you can
6. Note the reading on the peak flow meter, which is measured in liters per
minute.
7. Repeat steps 1–6 twice more.
8. The highest reading of the three attempts should be used as the final result

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12
Q

What is the management ladder for asthma?

A
  1. SABA
  2. SABA + low-dose ICS
  3. SABA + low-dose ICS + LTRA
  4. SABA + low-dose ICS + LABA +/- LTRA (if responsive to it)
  5. SABA +/- LTRA + low-dose ICS MART
  6. SABA +/- LTRA + medium-dose ICS MART (OR consider changing back to separate moderate-dose ICS + LABA)
  7. SABA +/- LTRA and one of the following options:
    - Increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART)
    - A trial of an additional drug (e.g. LAMA or theophylline)
    - Referral to asthma specialist
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13
Q

How should you conclude the asthma review

A

Book follow up (soon if meds changed etc, otherwise for next review)

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14
Q

What is the structure of the COPD annual review?

A

Diagnosis
Disease Impact and Severity (MRC)
Pulmonary Rehab
Exacerbations
Drug Hx + vaccines
Social hx (smoking cessation; MOOD)
Examine (FEV1/FVC; O2%; BMI)
Management

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15
Q

What should be covered in the diagnosis section of the COPD review?

A

Baseline
Spirometry
Smoking status

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16
Q

What 3 questions should you ask to assess the impact of COPD in the last month

A

1) In the last month has your COPD interfered with your usual activities (e.g., housework, work/school)? (ADLs)
2) In the last month have you had difficulty sleeping because of your COPD symptoms?
3) In the last month have you had your usual COPD symptoms during the day (cough (productive), wheeze, chest tightness, or breathlessness)?

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17
Q

What are the 2 most important questions to ask in the COPD review to assess severity using the MRC?

A

“How far can you walk before resting?”

“Do you get breathless getting dressed?”

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18
Q

What are the 5 stages of the MRC dyspnoea scale?

A
  1. Not troubled by breathlessness except on strenuous exercise.
  2. SOB when hurrying or walking up a slight hill.
  3. Walks slower than contemporaries on level ground or has to stop for breath when walking at own pace.
  4. Stops for breath after walking about 100m or after a few mins on level ground.
  5. Too breathless to leave the house, or breathlessness when dressing or undressing

Compare this to previous score

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19
Q

How does the MRC dyspnoea score guide management?

A

All patients with MRC >= 3 à eligible for referral to pulmonary rehabilitation

3 = “Walks slower than contemporaries on level ground or has to stop for breath when walking at own pace.”

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20
Q

What does pulmonary rehab involve?

A

2 or more group sessions a week for at least 6 weeks.

A typical programme includes:
* physical exercise training tailored to your needs and ability – such as walking, cycling and strength exercises
* education about your condition for you and your family
* dietary advice
* psychological and emotional support

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21
Q

What do you do after the MRC score in the COPD review

A

Assess exacerbations

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22
Q

How do you assess exacerbations in the COPD review? (4)

A

1) attended A&E (if yes, what happened)
2) needed abx or steroids
3) awareness of signs of exacerbation
4) check exacerbation management plan

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23
Q

What are the 5 signs of a COPD exacerbation?

A
  • Increased breathlessness (more than usual)
  • Increase in coughing
  • Changes in the amount/colour/thickness of phlegm
  • Chest feeling tight
  • New or increased wheeze
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24
Q

What should a patient do during a COPD exacerbation?

A
  • Increase reliever (blue) frequency – Max: (1–2 puffs) up to four times daily.
  • Continue with other inhalers as normal
  • Rest and keep indoors
  • If symptoms persist over 24h despite using reliver start your exacerbation rescue pack
  • If unsuccessful and/or they develop severe breathlessness, chest pain, incomplete sentences, worsening leg swelling, call GP/999
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25
What should you ask in the drug hx of a COPD review? (4)
- Inhalers (which, how often, spacer) - Inhaler technique (Signposts to Asthma UK website/ pharmacy/ surgery to be taught.) - Mucolytics for chronic cough - Vaccines
26
What vaccines should COPD patients have? (3)
flu single dose of pneumococcal COVID
27
What do you do in the social hx of a COPD review?
Smoking (status and recommend cessation) Mood
28
What do you do after social hx in COPD review?
Examination
29
What does the examination in COPD review involve
FEV1/FVC □ O2 sats □ BMI
30
What symptoms might prompt a drug change in COPD review?
Increasing symptoms = Commence LABA or LAMA Frequent (≥ 2) exacerbations in a year especially if FEV1 < 50% = Commence ICS and LABA
31
What is the structure of the diabetes review?
Background Monitoring Control (ie exacerbation) Past Medical Hx Drug Hx + vaccines Social Hx + MOOD Examination (BP, BMI, urine, foot, eye, skin)
32
What do you need to establish in the introduction/background section of diabetes review?
Type of diabetes How has it been (Current health, medication, and compliance)
33
What monitoring parameters should you check with a diabetes patient? (4)
Capillary glucose HbA1c BP Weight
34
What do you need to assess about someone's diabetes control in the annual review?
Admissions Hypos - any? awareness? Check understanding sick day rules Compliance/coping
35
What medical problems should you screen for in the diabetes review? (7)
* MI * Recurrent infections/abscesses? * Stroke/TIA * Feet/Neuropathy – Change in sensation in feet? * Eyes – Any changes to vision * Claudication * Kidneys – Blood in urine? Change in urinary patterns MRS. FECK
36
What medications should you screen for in diabetes review DHx after an open question?
Hypoglycaemics Anti-hypertensives Statins Vaccines
37
What are important social history questions for diabetes review/
Smoking Alcohol Mood!
38
What vaccines should diabetics get?
Flu Pneumococcal (If you’ve diabetes and use insulin or anti-diabetic medication, you’re eligible for extra pneumococcal vaccinations.) COVID
39
Are diabetics at higher risk from flu?
“People with diabetes are at increased risk of developing severe complications from influenza virus infection, with 3 times the likelihood of hospitalization and four times the risk of intensive care admission once hospitalized”
40
What objective measures should be assessed at the end of the diabetic review?
BMI (weight+height) BP Radial pulse Urinalysis
41
What examinations should take place at the end of the diabetic review?
Foot Eye Skin Objective measures
42
What should you examine in the feet in diabetes review (6)
- Soft touch (Microfilament test) - Leg swelling - Vibration sense - Back of leg - Foot pulses - Interdigital areas
43
What should you examine in the eyes in diabetes review (4)
Xanthelasma/cataract/ophthalmoplegia (check this) Ophthalmoscopy (check this) Visual acuity Inform about annual eye reviews
44
Why check the skin in the diabetic review?
Check injection sites for formation of lypohypertrophy
45
What tests should be sent after diabetic review? (8)
HbA1C U&Es Albumin–creatinine ratio (urine) Lipid profile - Total cholesterol/HDL/LDL/Triglycerides FBC liver, thyroid B12 if on metformin
46
HbA1c targets
aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support them to aim for an HbA1c level of 53 mmol/mol (7.0%). 58 or higher -> add drug
47
What are the key areas of management to address after a diabetic review?
Meds Kidneys Cholesterol BP Lifestyle -> DRIVING Mood
48
How should you treat kidneys in a diabetic review?
CKD stage ≥ 3 and/or confirmed positive urine microalbumin: offer a statin (without need for a QRISK2 assessment), ACEI or ARB. Dapagliflozin improves outcomes for CKD and CVD
49
What are important driving rules for diabetics?
Five to drive – your blood sugars have to be 5mmol/l or above before you drive. If they’re between 4mmol/l and 5mmol/l, eat some carbs before heading out. If they’re under 4mmol/l – treat your hypo and check your levels again before driving. Always keep hypo treatments where you can easily reach them in the car.
50
Who should get an immediate referral to a podiatrist in a diabetes review?
Those with infection, active ulceration, or suspected Charcot foot.
51
What are 3 educational courses you can recommend to diabetic patients
DAFNE: Dose adjustment for normal eating DESMOND: Diabetes education and self–management for ongoing and newly diagnosed X–PERT: prevention and lifestyle advice.
52
How to remember sick day rules
SICK: Sugar Insulin Carbs Ketones
53
What are the sick day rules for SUGAR
Blood glucose levels can rise during illness even if not eating Increase blood glucose monitoring if you have access to it – 4 hourly or more frequently Anti-diabetics may need to be increased temporarily to manage raised glucose
54
What are the sick day rules for INSULIN
NEVER stop insulin If you are taking any of the following diabetes medications, you need to stop them when you are sick: Sulfonylureas, ACEIs, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors SAD MANS Insulin doses may need to be increased during illness, especially if ketones are present
55
What are the sick day rules for CARBS
Maintain hydration – at least 3L in 24h If not able to eat or are vomiting – replace meals with sugary fluids If blood glucose is high, maintain fluid intake with sugar–free fluids. If blood glucose is low, regularly take sugary fluids
56
What are the sick day rules for KETONES
In T1DM, check for ketones every 4–6 hours. If present, check every 2 hours. Give extra rapid–acting insulin doses (in addition to regular doses) based on total daily insulin if ketones are present Drink plenty of water to maintain hydration and flush through ketones
57
What is the structure of the heart failure annual review?
WIPERQ Baseline/background Overview since last review (symptoms, NYHA, Mood) Drug hx + vaccines Social hx (rehab, smoking, alcohol) Examination
58
What are the key things to establish in the baseline section of the heart failure annual review
□ On register. □ Type of HF. □ Date of diagnosis. □ Date of most recent echocardiogram □ Evidence of left ventricular systolic dysfunction (LVSD)
59
What symptoms are most important to ask about in the heart failure annual review?
Start with open question Are your symptoms stable? □ Are you becoming fluid overloaded (e.g., leg swelling) or dehydrated? Orthopnea: “are you able to lie flat without being breathless?” “How many pillows do you sleep with at night? □ PND: “Do you ever wake up in the middle of the night gasping for air?”
60
How do you assess a patients NYHA HF score?
How much effect is your heart failure having on your daily activities? I NO limitation on physical activity. Ordinary physical activity does not cause undue fatigue, palpitation and dyspnoea. II SLIGHT limitation of physical activity. Comfortable at rest. Ordinary activity results in fatigue, palpitation and dyspnoea. III MARKED limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation and dyspnoea. IV Unable to carry out any physical activity without discomfort. Symptoms of heart failure at rest - undue fatigue, palpitation and dyspnoea
61
How do you differentiate between NYHA categories II and III?
II - Can complete any activity requiring ≤ 5 MET: * Sexual intercourse without stopping * Garden * Roller skate * Walk 7 km/hour on level ground * Climb one flight of stairs at a normal pace without symptoms III - Can complete any activity requiring ≤ 2 MET: * Shower or dress without stopping * Strip and make a bed * Clean windows * Play golf * Walk 4 km/hour
62
What other symptoms are important to screen for after classic heart failure symptoms in the annual review?
Living with HF can sometimes be tough. There may be many problems and hassles concerning HF and they can vary greatly in severity: □ Do you ever feel overwhelmed by the demands of living with HF? □ How is your mood?
63
What do you ask about after symptoms in HF annual review?
Drug history including devices and adherence + vaccines
64
What are the steps of medical management of heart failure?
1.ACE-i and beta-blocker 2. aldosterone antagonist e.g. spironolactone and eplerenone AND/OR SGLT-2 inhibitors in patients with HF-rEF e.g. dapagliflozin 3. ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin, or cardiac resynchronisation therapy
65
What are ARNIs? What is the NICE indications in HF?
ARB and a neprilysin inhibitor. ONLY Sacubitril/valsartan available For patients with: - (NYHA) class 2 to 4 symptoms and - with a left ventricular ejection fraction of 35% or less and - who are already taking a stable dose of ACEi or ARBs.
66
What devices are important to ask about in the HF review?
ICD cardiac resynchronization therapy (CRT)
67
What should be established when asking about adherence in the HF annual review? (4)
Taking as directed? Understand purpose? Effectiveness at controlling symptoms? Do you buy Aspirin and take daily?
68
What should you cover after drug history in the annual review?
Social history
69
What does the social history in the annual review for HF include? (4)
Rehab Vaccines (flu+covid) Smoking Alcohol (how much + interventions + Dysdiadochokinesis)
70
What do you do in the examination section of the HF review? (4)
Full set of obs Radial pulse – rate and rhythm Lying standing BP or ABPM BMI
71
What should you do if a patient has an irregular rhythm upon examination? (3)
□ If not known AF and pulse irregular or unsure, perform an ECG. □ If known AF, check if patient is anticoagulated with correct dosing. □ CHA2DS2–VASc and HAS–BLED scores
72
What bloods should be ordered after HF annual review? (7)
FBC U&Es LFTs TFT eGFR Lipid profile HbA1c
73
What are likely comorbidities a HF patient may need managing? (4)
□ HTN □ DM □ AF □ Cognitive and nutritional deficit
74
What parts of the MDT may be helpful in HF management?
□ Community nursing team. □ Community matrons. □ Frailty team. □ Lives in care home. □ Carers at home
75
How does Sacubitril work? What is it combined with and why?
Blocks the angiotensin II type 1 receptor (AT1), preventing: - Vasoconstriction - Aldosterone release (thus less salt/water retention) - Sympathetic activation - Myocardial fibrosis ---Further reduces afterload, preload, and cardiac remodeling. Combined with valsartan because neprilysin also breaks down angiotensin II. If you just inhibit neprilysin (without an ARB), angiotensin II levels would rise — bad for heart failure!
76

Medical Examinations (18 decks)

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