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Chronic disease management Flashcards

1
Q

what is INR?

A

international normalised ratio

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2
Q

how is INR checked?

A

blood test

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3
Q

how often is INR checked?

A

variable
usually every 4 weeks if stable
can be everyday of very unstable

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4
Q

why do we check INR?

A

check the effect of warfarin, check dosage of warfarin, check bleeding risk

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5
Q

what is the ideally range of INR when on warfarin?

A

2-3 (can vary based on patient)

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6
Q

why is it important to keep INR in range?

A

narrow therapeutic range

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7
Q

what does it mean if INR is >3?

A

increased risk of bleeding

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8
Q

what does it mean if INR is <2?

A

increased risk of clotting

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9
Q

why might someone be on warfarin?

A

mechanical heart valve, AF, clotting disorder, post surgical, post DVT, post MI or stroke

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10
Q

why might INR be low?

A

increased vit K intake
bad adherence to warfarin, reduced intake
soya protein intake
vitamins
hyperlipidaemia
hypothyroidism
nephrotic syndrome
drugs - rifampicin (TB treatment)

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11
Q

why might INR be high?

A

hyperthyroidism
low vitamin K intake
poor nutrition
diarrhoea (malabsorption of vit K)
CHF
cancer
liver disease
connective tissue disorders
fever
increase warfarin consumption
fenugreek / camomile
drug interactions - antibiotics, antifungals, antidepressants, aspirin (anticoagulants), NSAIDs, paracetamol

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12
Q

what past medical history should you ask about in particular from someone on warfarin?

A

Liver failure (lack of clotting factors).
Bleeding disorders (haemophilia, factor 7 deficiency).

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13
Q

why do you need to ask a patient on warfarin about their diet?

A

Vit K in their diet e.g. green leaf veg, olive oil
foods that effect warfarin e.g. grapefruit

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14
Q

why do you need to know why someone is on warfarin?

A

this affects the dose and the duration of the treatment
e.g. DVT treatment is only 13 weeks

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15
Q

why do you need to know how long someone has been taking warfarin?

A

this can affect how stable their INR is and how often they should be getting it checked

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16
Q

why do you need to know what side affects the patient is having for warfarin?

A

it can affect their adherence as they might want to avoid the side effects

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17
Q

why do you need to know their alcohol in take?

A

binge drinking can affect INR, regular drinking doesn’t have an effect

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18
Q

what sort of things can effect adherance?

A

memory, confusing dosing, unaware of the risks, side effects of drug, cost of prescriptions

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19
Q

what are the common side effects of warfarin?

A

heavy bleeding - heavy menstrual periods
red urine
black stools
abdominal pain
joint pain
swelling
headaches
coughing up blood
vomiting blood or coffee ground vomit

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20
Q

what can we do if INR is low?

A

give advice on adherence,
reducing vitamin k intake,
treat other conditions that may affect INR,
increase dose of warfarin (only if not other factors seem to be contributing)
LMWH
compression stockings if immobile

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21
Q

what are low INR symptoms?

A

Sudden weakness/numbness/tingling in any limb, visual changes, inability to speak (stroke symptoms).
New pain, swelling, redness, heat in body parts or new SOB or chest pain (DVT/PE symptoms).

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22
Q

what are high INR symptoms?

A

Headache, severe stomach ache.
Increased bruising.
Prolonged bleeding after minor cuts/menstrual bleeding/gum bleeding.
Blood in urine.

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23
Q

what can we do if INR is high?

A

advice on understanding dosing and not having too high of a dose,
treat other diseases contributing,
drug interaction information and advice,
take off drugs that interact,
vitamin k
blood transfusion
decrease dose of warfarin (only if no other factors are contributing)

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24
Q

what advice might you be asked to give if someones INR is too high?

A

Decreasing risk of bleeding;
Avoid activities that can cause bleeding/bruising.
Brush/shave gently.
Tell dentist and any other HCP that you take anticoagulants

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25
what is HbA1c?
glycated haemoglobin, haemoglobin bound to sugar
26
what does HbA1c level tell us?
gives us a picture of blood sugar levels over the past 8-12 weeks
27
what are the target ranges for HbA1c?
<42 = normal, 42-47 = pre-diabetes, >48 = diabetes (target range for someone with diabetes is as close to 48 as possible)
28
how are HbA1c levels brought down?
health diet, good adherence to drugs loosing weight, keeping active
29
what affect does lowering HbA1c levels have on someone with diabetes?
improvement by 1% = 25% reduction microvascular complication and reduces the likelihood of amputation due to PVD by 43%
30
what sort of questions do you need to ask someone with a high HbA1c level?
affect on life how is their diet are they exercising do they smoke (increases risk fo vascular disease) alcohol intake compliance to drugs any side effects of drugs any symptoms they are feeling
31
what sort of symptoms could someone with a high HbA1c level present with?
fatigue, polyuria, polydipsia, blurred vision, loosing weight, burning/tingling/numbness in limbs
32
what are the complications of badly controlled diabetes?
macrovascular - CAD, PAD, stroke microvascular - retinopathy, nephropathy (test urine for macroalbumaemia then treated with antihypertensives), neuropathy (foot ulcers and numbness in leg)
33
what is the treatment pathway for T2DM?
lifestyle advice, metformin, sulfonureas, insulin
34
what is peak flow measuring?
a measure of how quickly you can blow air out of your lungs
35
how is peak flow measured?
blow out hard into peak flow device
36
what is a normal peak flow?
varies with height, gender, age, weight etc
37
what would suggest badly controlled asthma on peak flow?
significant difference between results (diurnal variation)
38
what does a low peak flow suggest?
narrowing of the airways
39
what could a low peak flow suggest?
asthma, COPD, bronchiectasis, foreign body inhalation, tumour
40
what does spirometry do?
Diagnose and monitor certain lung diseases – measure how much breath out in one forced breath, and maximal amount of air you can blow out
41
what do the results of spirometry show?
FEV1: Depends on age, sex, height, mass, ethnicity. Obstructive: FEV1/FVC ratio = <70% Restrictive: FEV1/FVC ratio = NORMAL
42
what presenting complaint questions should you ask a peak flow / spirometry patient?
how are you feeling today? has your condition got worse / better? have you had any recent illnesses? have you been short of breath at all? has your wheeze been getting worse? is this affecting you're ADL? any symptoms during the night? how often are you using your blue inhaler?
43
what questions should you ask in the drug history of a peak flow / spirometry patient?
what medications do you use? when do you use your medications / how often what other medications are you taking (ask about b eta blockers specifically) what is your inhaler technique? adherence to medications
44
what social history questions should you ask a peak flow / spirometry patient?
any new pets? any recent foreign travel? housing situation (damp?) hayfever? occupation smoking alcohol affect on daily life activities
45
what advice might you be asked to give to a peak flow / spirometry patient?
stop smoking avoid tiggers get flu vaccine exercise / loose weight support group
46
what is the treatment pathway for asthma?
SABA SABA + ICS SABA + ICS + LTRA SABA + ICS + LABA +/- LTRA
47
how is COPD treated?
SABA, ICS, LAMA + LABA combined therapy or combination if indicated
48
what is CRP?
non-specific marker of inflammation. produced by liver increases n the presence of inflammation
49
which disease is CRP routinely monitored in?
Rheumatoid arthritis juvenille arthritis seronegative arthritis ankalosing spondylitis reactive arthritis psoriatic arthritis crohn's vascultitis polyarthritis nodosa pancreatitis
50
what disease is CRP used for diagnosis and monitoring of infection?
infective endocarditis abcess post operation infection response to antibiotics
51
what would cause a raised CRP?
infection, burns. chronic inflammation, MI, IBD, cancers
52
what is ESR?
measure of RBC sedimentation rate. Measures the amount of time it take for RBCs to sink to the bottom of a test tube in inflammation, fibrinogen increase causes RBCs to stick together and sink quicker rises and falls slowly
53
what questions should be asked in an inflammatory marker consultation?
how are you feeling today? any recent infections? how well controlled is your condition? what medication are you on? do you always take your medication correctly? any issues with medication? any other medications? joint pain? recent travel? smoking status? alcohol status? how condition is impacting life
54
what advice may you have to give in the inflammatory marker consultation?
smoking cessation control of condition / disease mangement
55
what medications are people with rheumatoid arthritis commonly on?
methotrexate (or other DMARD) NSAIDs
56
what medications are people with crohn's disease commonly on?
sulfasalazine (AMINOSALICYLATES (5-ASAs) steroids NSAIDS
57
what does a high albumin suggest?
malnutrition, kidney or liver disease
58
what does low albumin show?
severe infection, dehydration, chronic inflammation, hepatitis
59
what does high conjugated billirubin show?
liver or bile duct problem
60
what does high unconjugated billirubin show?
gilberts, haemolytic anaemia (pre-hepatic jaundice)
61
what would cause liver enzymes to be high?
chronic alcohol excess obesity (especially in males) smoking (females) reaction to drugs
62
what does a high ALP suggest?
bile duct obstruction osteoblast activity (paget's, osteomalacia, vitamin D deficiency)
63
what does a high GGT suggest?
alcohol or dug excess
64
what does a high AST or ALT indicate?
liver damage due to toxins, drugs, viruses
65
what does it suggest if GGT is raised aswell as ALP?
more likely to be a hepatic problem than a bone problem
66
what does it suggest if the AST:ALT ratio is high?
alcoholic hepatitis or acute hepatitis
67
what questions should be asked in a LFT consultation?
how are you feeling today? any recent infections? any PMH of gallstones, Crohn's, UC, surgery etc. how well controlled is their condition medications for condition any other medication adherence travel smoking alcohol drugs impact on life
68
what advice might you have to give on a LFT history?
smoking / alcohol / drug cessation diet advice management of condition

Phase 2b Medicine (6 decks)

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