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MBBS 4: Family Medicine > Chronic Care > Flashcards

Chronic Care Flashcards

1
Q

What is chronic care?

A

Care of patients with:
1. Infectious diseases
2. Non communicable diseases
3. Palliative care needs

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2
Q

Conditions considered under chronic care?

A
  1. diabetes
  2. depression
  3. hypertension
  4. HIV
  5. hepatitis
  6. cervical cancer
  7. for some patients, palliative care of disease can become chronic
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3
Q

Whose agenda are we pursuing in chronc care?

A
  1. Patient Agenda: Illness, trying to live normal life with the Disease
  2. Doctor Agenda: Disease
    CHRONIC CARE IS ABOUT PARALLEL AGENDA’S
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4
Q

4 C’s of chrinic care consutations?

A
  1. Complaints : concerns?
  2. Control : is disease controlled?
  3. Compliance : Behaviour
  4. Complications : detect
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5
Q

Complaints?

A

What concerns does the patient have today?

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6
Q

Control?

A

Is the chronic disease being controlled?
What measures (symptoms, signs, labs) help the clinician evaluate disease control?

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7
Q

Compliance?

A

What behaviors are we asking the patient to do or avoid?
How is he/she choosing to follow or not this advice?

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8
Q

Complications?

A

What are the consequences of this chronic illness?
Are there things (exam, history and/or labs) that we can do to detect complications early to see can we treat to slow progression or prevent?

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9
Q

What is hypertension?

A

Definition: BP >140/90 mmHg on at least 3 occasions on different days, by WHO.

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10
Q

Hypertension control?

A

Management goal:
<140/85 in patients without comorbidity
<130/80 in patients with diabetes, renal insufficiency or heart failure

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11
Q

Hypertension compliance?

A
  1. Stop smoking
  2. Reduce/stop alcohol
  3. Restrict salt intake and low fat diet
  4. Weight loss in obese people
  5. Encourage daily exercise
  6. Avoid NSAIDS (brufen and diclofenac)
  7. Take meds daily
  8. Attend clinic regularly
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12
Q

Treatment in hypertension?

A

Mild - start with life style modification only if no treatment then meds
Moderate and Severe - treatment

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13
Q

Why you should avoid NSAIDs in hypertension?

A

NSAID’s can lead to retainment of fluid in the body and decrease of kidney function which may cause the blood pressure to get even higher

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14
Q

Compliance in hypertension?

A
  1. Diuretic (HCTZ 12.5-25 mg daily)
  2. Calcium channel blocker (amlodipine 5-10 mg daily or nifedipine slow release 10-20 mg bd)
  3. ACE inhibitor (enalapril 10-40 mg od, lisinopril 10-40 mg od, or captopril 12.5-50 mg tid)
  4. Beta-blocker (atenolol 50 mg od or propranolol 40 mg bd)
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15
Q

Hypertension compliance in pregnancy?

A

methyldopa, nifedipine, hydralazine

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16
Q

Complications of hypertenion?

A
  1. Retinopathy:
    - Annual screening with dilated fundoscopy
  2. Cardiovascular:
    - Left ventricular hypertrophy, heart failure, cardiovascular disease, CVA with taking proper history and physical examination
  3. Renal failure:
    - Annual screening with urine dip for protein and serum creatinine
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17
Q

What is diabetes?

A

Diagnosis (repeated or single measurement with characteristic symptoms)
1. Fasting glucose >7 mmol/L [126 mg/dL] OR
2. Random glucose >11 mmol/L [200 mg/dL]

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18
Q

Diabetes control?

A
  1. Fasting glucose <7.2 mmol/L [130 mg/dL]
  2. Elderly may have less strict goal: symptom control and avoid hypoglycemia
  3. Hypertension: BP check every visit, treat if >130/80
  4. Dyslipidemia: low fat diet, statin
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19
Q

Diabetes compliance?

A
  1. Stop smoking
  2. Reduce/stop alcohol
  3. Restrict salt intake and low fat diet
  4. Reduce refined sugar intake
  5. Increase fibre intake
  6. Weight loss in obese people
  7. Encourage daily exercise
  8. Take meds daily
  9. Attend clinic regularly
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20
Q

When are general measures of diet/exercise implemented?

A

1-3 month trial if FBS<16.5 mmol/L= 300mg/dL

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21
Q

Medication compliance in diabetes?

A

If diet/exercise trial 1-3 month didn’t normalize FBS
1. Metformin 500 mg bd, titrated to max of 1 g tid
2. Glibenclamide 5 mg od, titrated to max of 10 mg bd
3. Insulin
i. Stop Glibenclamide
ii. Lente Insulin bd, units = half bodyweight (2/3 of totally daily dose in AM, 1/3 in PM)
Note - Pregnancy: Metformin and Insuline

22
Q

Classification of complications of diabetes?

A
  1. microvascular
  2. macrovascular
23
Q

Microvascular complications of diabetes?

A
  1. Retinopathy
    - Annual screening with dilated fundoscopy
  2. Renal failure
    - Annual screening with urine dip for protein and blood creatinine
  3. Peripheral neuropathy
    - Foot care and screening
24
Q

Macrovascular complications of diabetes?

A
  1. Cardiovascular complications
    - angina, myocardial infarction (with history and physical examination)
  2. Cerebrovascular complications
    - CVA
  3. Diabetic foot (also micro-vascular), need to check feet
25
Q

Asthma control?

A
  1. History
    - Breathlessness
    - Cough
    - Wheeze
    - Nocturnal cough
    - Chest tightness
    - Triggers
    - Emergency visits
    - Use of inhaler
  2. Peak flow
26
Q

Non-pharmacological asthma compliance?

A
  1. Inhaler technique
  2. No smoking
  3. Exposure to allergens (smoke, pollen, dust, dander)
  4. Loosing weight (when overweight) reduces amount and severity of asthma attacks
  5. Seek medical help early during attack
  6. Avoid drugs that can trigger attacks (NSAIDS, aspirin, b-blockers)
27
Q

Pharamcological asthma compliance?

A
  1. Relievers: salbutamol and ipratropium
  2. Preventers: beclomethasone inhaler, prednisone burst
  3. Controllers: long acting B agonists (salmeterol), theophylline, and leukotriene antagonists (montelukast)
    Note - Pregnancy : Important to control Asthma well, all the above medication can be used
28
Q

Stepwise approach to asthma compliance?

A
  1. inhaled salbutamol prn
  2. inhaled salbutamol 2 puffs qid
  3. salbutamol PLUS beclomethasone 2 puffs bd
  4. salbutamol, beclomethasone PLUS inhaled ipratropium or oral aminophylline
  5. ADD prednisolone daily for 5 days and increase frequency of inhaled salbutamol
29
Q

Asthma complcations?

A
  1. If frequent ORAL TABLETS steroid
    - Depriviation of growth in children
    - Osteoporosis
    - Diabetes Mellitis
  2. If frequent ORAL INHALER steroid
    - Oral candidiasis (explain patient to clean their mouth with water after inhaling)
30
Q

Steroid induced osteoporosis?

A

Steroids have effect on metabolism of Calcium and Vit D and bone

31
Q

Steroid induced DM?

A

Steroids can cause the liver to become resistant to insuline

32
Q

Epilepsy control?

A

Definition: recurrent seizures of unknown cause
- Ruled out treatable causes: infections, neuro-cysticercosis (Taenia Solium), tumour
- Medications needed if more than two seizures per year

33
Q

Epilepsy compliance?

A
  1. No bathing/swimming alone
  2. Care with fire, driving and climbing
  3. Young mothers with small children should be accompanied by another adult
  4. Take meds every day. No sudden stops or starts
  5. Fatigue and alcohol may increase the risk of seizures
34
Q

Pharmacological epilepsy compliance in children?

A
  1. Sodium valproate 20-40 mg/kg/day divided bd or tds or
  2. Phenobarbitone 5-8mg/kg daily or
  3. Carbamazepine 5-40 mg/kg/day divided bd (start with 5 and increase weekly with 5) or
  4. Phenytoin 4-8 mg/kg/day
    Note: Use the lowest dose that controls the seizures. Use the maximum dose of one medicine before adding another.
35
Q

Pharmacological epilepsy compliance in adults?

A
  1. Phenobarbitone sodium 60-180 mg at night or
  2. Carbamazepine 100 -200mg 1-2 times daily. Increase by 100 - 200 mg weekly until dose is 800 mg - 1200mg per day or
  3. Sodium valproate 600 - 2000mg daily divided in 2 doses or
  4. Phenytoin 150 - 300mg daily divided in 1-2 doses. Can be increased to 500mg daily.
    Note: Use the lowest dose that controls the seizures. Use maximum dose of one medicine before adding another.
    - There are many interactions between anti epileptics and other medication so ALWAYS check when prescribing medicines when a patient is on anti epileptics
36
Q

Epilepsy compliance in women of reproductive age?

A
  1. Young female patients should be advised to plan their pregnancy
    - When they wish to get pregnant folic acid 0.5mg once daily should be started and continued through the pregnancy.
  2. Anti epileptics interact with hormonal contraceptives as such that they lower the blood level concentration of the hormonal contraceptives so a copper IUD would be advisable
  3. It is important that Epilepsy is well controlled during pregnancy and all the above medication can be used.
37
Q

Epilepsy complications?

A

Seizure first aid for guardians
1. Nothing in mouth
2. No restraints
3. Recovery position

38
Q

HIV/AIDS control?

A
  1. No development of new HIV associated diseases
  2. Symptom control/resolution
  3. Start ART for all patients with confirmed HIV infection as soon as possible
  4. CD4 at start
  5. Routine viral load monitoring after ART initiation on the following schedule
    - 6 months
    - 2 years
    - 4 years
    - Every 2 years thereafter
39
Q

When to do targeted viral load testing?

A

Targeted viral load testing is when a patient gets ill or has any reason to believe that there may be failure
1. develops PPE = Pruritic Papular
2. Eruption or has a low CD4 when measured for whatever reason

40
Q

HIV/AIDS compliance?

A
  1. Review date
  2. Weight (and height for children under 18 years): should normalize after 6-12 months ART
  3. Screen for side effects and complications
  4. Safe sexual practices
  5. Proper nutrition
  6. Contraception if desired
41
Q

Pharmacological compliance of HIV/AIDS?

A
  1. Regimen 13A (tenofovir/lamivudine/dolutegravir) as standard 1st line for males from 30kg+ and women aged 45 years+
  2. Regimen 5A as standard 1st line for girls and women who may get pregnant while on ART from 30kg+
    - Once they have reached 30kg, routinely change all boys from 2A to 13A and all girls from 2A to 5A.
42
Q

HIV/AIDS complications?

A
  1. Infections
    - TB, CMV, Candidiasis, Tinea, Cryptococcal meningitis, Toxoplasmosis, Cryptosporidium, PCP
  2. Cancer
    - Kaposi sarcoma, lymphoma’s, Cervical carcinoma
  3. Other: wasting syndrome, neurological (AIDS dementia), HIV associated nephropathy, HIV associated cardiomyopathy
43
Q

Screening of TB in HIV/AIDS as a complication?

A

Screen all patients, at every visit, for TB
1. Cough of any duration
2. Fever
3. Night sweats
4. Weight loss/failure to thrive/malnutrition

44
Q

Which ART toxicities should you check for in HIV/AIDS?

A

Lactic acidosis
Pancreatitis
Severe hepatitis
Stevens-Johnson syndrome
Note: requires immediate cessation of ART

45
Q

Plan in chronic care?

A

5A’s of behaviour change
1. Assess
2. Advise
3. Agree
4. Assist
5. Arrange

46
Q

Assessment in chronic care?

A

1.What are the patient’s goals for the consultation?
2. Assess the clinical status and goals. Compare to previous visit. Assess risk factors
3. Assess patient’s adherence. Acknowledge patient’s efforts and successes with self management, even if limited.
4. Assess patient beliefs, behaviour and knowledge.
5. Assess conviction and confidence regarding target behaviours.

47
Q

Advice in chronic illness?

A
  1. Provide specific information about health risks and benefits of change
  2. Correct inaccurate language and complete gaps in patient’s understanding with neutral language.
  3. Reinforce key information for self management: symptoms and when to seek care, treatment and why it is important, how to monitor one’s own care
  4. Relate patient symptoms or lab tests to their behaviours
  5. Inform patients that behaviour issues are as important as taking medications
48
Q

Agree?

A
  1. Collaboratively set goals based on patient’s interest and confidence in their ability to change the behaviour
  2. Negotiate selection from different options or changes to the plan.
  3. Agree upon goals that reflect patient priorities.
  4. Look for input from family/spouse/caregiver
  5. Share perspectives about which is most important short term goal
49
Q

Assist?

A
  1. Identify personal barriers, strategies, problem-solving techniques and social/environmental support
  2. Consider a written or picture summary of plan.
  3. Prescribe treatments or medications.
  4. Address problems/”slips” with following the treatment plan
  5. Offer groups/support
  6. Elicit patient views and plans regarding resources
50
Q

Arrange?

A
  1. Specify plan for follow up and return appointment
  2. Check in on goals
51
Q

Summary of chronic care?

A
  1. Assessment (4C’s)
    - Complaints
    - Control
    - Compliance
    - Complications
  2. Plan (5 A’s)
    - Assess
    - Advise
    - Agree
    - Assist
    - Arrange

MBBS 4: Family Medicine (27 decks)

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