Chronic Disease Histories

Question 1

What should be asked in the history for an INR Chronic Disease station?

Answer 1

• Explain result to patient.
  o International normalized ratio (INR) is a measure of how long it takes the blood to form a clot. An INR range of 2.0 – 3.0 is generally normal for people taking warfarin.
• Review: Px of over-anticoagulation:
  o Easy bleeding, bruising
  o Rash
  o Malaena, haematuria
  o hemoptysis, hematemesis
  o Menorrhagia
• Impact on life: How does it affect their mood, social life, hobbies, and everyday life.
• PMH: new diagnoses, recent fever
• Drug Hx: warfarin history (adherence + S/E), new prescribed, OTC, drugs, allergies
• Social Hx: smoking, alcohol, diet (green vegetables (high Vit K which counteracts the effects), cranberries, grapefruit juice (inhibits warfarin metabolism))
  o Exercise
  o Housing
  o Pets
  o Hobbies
  o Occupation
• Pregnancy screen
• FHx
• ICE – what do they think could be causing the changes in their INR range
• Wash hands, thank patient
  Note:
  o Lifestyle: eating healthier (fruit and vegetables e.g. kale, spinach – lots of vitamin K) and drinking grapefruit juice

Question 2

What should be the structure of a peak flow diary history for chronic disease?

Answer 2

• Explain result to patient.
  o Peak flow is a measure of how quickly you can blow air out of your lungs. Its measured by blowing as hard and fast into the peak flow meter.
  o It’s used to pick up changes in your airways before you have symptoms, for example, if your airways become inflamed and tight, the peak flow will be lower than normal, so this can be used as a sign that your asthma is getting worse.
• Asthma review:
  o How do you think your asthma is controlled?
  o SOB, cough, wheeze, chest tightness
• Impact: how does it affect their mood, social life, hobbies, and everyday life.
• PMH: asthma, recent infection, other conditions, new diagnoses
• Drug Hx: asthma medication (frequency/when/effectiveness), pump technique, spacer, other drugs, new drugs, OTC, adherence, side effects, allergies
• Social Hx: smoking, alcohol, diet, exercise, housing, pets, hobbies, occupation
• FHx
• ICE – what do they think could be causing the changes (infection, smoke, pets, living conditions, pollution, stress, obesity)
• Wash hands, thank patient
  Note:
  o Smoking, stress
  o Living conditions
  o New pet

Question 3

What is the correct structure for a spirometry data based chronic disease history?

Answer 3

• Explain result to patient.
  o Spirometry is a test used to help diagnose and monitor certain lung conditions by measuring how much air you can breathe out in one forced breath.
  o It can be used to help diagnose asthma and COPD. If you’ve been diagnosed with one of these conditions, its helpful to assess the severity of the condition or see how you’re responding to the treatment.
  o The measurements will show whether the problem with your lungs is obstructive or restrictive.
   In an obstructive condition, the amount of air you breathe out is reduced due to narrowing of the airways, but the amount of air your lungs can hold is normal (COPD, asthma).
   In a restrictive condition, the amount of air you breathe in is reduced because your lungs aren’t able to fully expand (pulmonary fibrosis).
  o Forced expiratory volume / forced vital capacity = if < 0.7 then obstructive. Restrictive has a normal FEV/FVC.
• Asthma review:
  o How do you think your asthma is controlled?
  o SOB, cough, wheeze, chest tightness
• COPD review: SOB, cough, sputum, blood, wheeze, wt loss, tiredness
• Impact: how does it affect their mood, social life, hobbies, and everyday life.
• PMH: asthma/COPD, recent infection, other conditions, new diagnoses
• Drug Hx: medication (frequency/when/effectiveness), pump technique, spacer, other drugs, new drugs, OTC, adherence, side effects, allergies
• Social Hx: smoking, alcohol, diet, exercise, housing, pets, hobbies, occupation
• FHx
• ICE – what do they think could be causing the changes (infection, smoke, pets, living conditions, pollution, stress, obesity)
• Wash hands, thank patient
  Note:
  o Smoking, stress
  o Living conditions, air pollution
  o Work – chemicals, dust, fumes
  o New pet

Question 4

What is the correct structure for a HBA1c review station for chronic disease?

Answer 4

• Explain result to patient.
  o Hb is found in RBCs and they carry oxygen. HbA1c is a special type of Hb which is attached to a sugar molecule, this occurs when the blood glucose levels are too high due to poor control.
  o The normal HbA1c level is around 42mmol/mol, and the target for someone with diabetes is around 48mmol/mol.
• Diabetes review:
  o How do you think your diabetes is controlled?
  o Toilet more? Drinking more? Fatigue, wt loss, eye problems, neurological + CVS symptoms
  o Check feet
• Impact: how does it affect their mood, social life, hobbies, and everyday life.
• PMH: diabetes timeline, other conditions, new diagnoses
• Drug Hx: diabetes, blood glucose and injection technique, drugs, new drugs, OTC, adherence, side effects, allergies
• Social Hx: smoking, alcohol, diet, exercise, any changes, housing, pets, hobbies, occupation
• FHx
• ICE – what do they think could be causing the changes in HbA1c
• Wash hands, thank patient
• To complete: BMI, blood pressure, visual acuity, fundoscopy, peripheral neuro, diabetic foot exam
  Note:
  o Diet – lots of takeaways
  o Alcohol + smoking
  o New job – really stressful + sat down all down

Question 5

What is the correct structure for an inflammatory review with CRP and ESR for Chronic Disease?

Answer 5

• Explain result to patient.
  o CRP is an inflammatory marker which rises when there is inflammation, and it correlates to active IBD. Therefore, it can be used as a good indicator of disease severity, and to see how well the treatment is working.
• Ask how they think their condition is controlled.
• How does their condition affect their mood, social life, hobbies, and everyday life.
• IBD review: abdo pain, diarrhoea, bloody stools, vomiting.
• PMH: IBD, autoimmune conditions, other conditions, new diagnoses
• Drug Hx: IBD drugs, new drugs, OTC, adherence, side effects, allergies
• Social Hx: smoking, alcohol, diet, exercise, any changes, housing, pets, hobbies, occupation
• FHx
• ICE – what do they think could be causing the changes in their LFTs
• Wash hands, thank patient
  Note:
  o Drugs (NSAIDs), adherence to treatment
  o Infection
  o Stress, smoking, alcohol, caffeine, foods (fatty, greasy, spicy)

Question 6

What is the correct structure for a LFT results based chronic disease station?

Answer 6

• Explain result to patient.
• ALT, AST, ALP, GGT – hepatocellular damage and cholestasis
  o ALT (10-fold↑) = hepatocellular damage: ALT + GGT > AST = alcoholic, AST > ALT = fatty.
  o ALP (3-fold↑) = cholestasis.
  o If there is a rise in ALP, look at the GGT – a rise is suggestive of biliary epithelial damage + bile flow obstruction.
  o A raised ALP + normal GGT = non-hepatobiliary pathology e.g. bone metastases, vit D deficiency, bone fracture, etc.
• Bilirubin, albumin, PT – liver’s synthetic function
• Ask how they think their condition is controlled.
• How does their condition affect their mood, social life, hobbies, and everyday life.
• Liver review: N + V, wt loss, loss of appetite, jaundice, swelling of ankles, ascites.
• PMH: other conditions, new diagnoses
• Drug Hx: drugs, new drugs, OTC, adherence, side effects, allergies
• Social Hx: smoking, alcohol, diet, exercise, any changes, housing, pets, hobbies, occupation
• FHx
• ICE – what do they think could be causing the changes in their LFTs
• Wash hands, thank patient
  Note:
  o Started on methotrexate (immunosuppressant) which damages the liver  cirrhosis
  o New job, diet, alcohol, smoking