CHRONIC DISEASE MANAGEMENT

Question 1

What are some key general questions to make sure you ask in any chronic disease management station

Answer 1

Confirm when they were diagnosed/had this problem established

Do you know what we are measuring is/why we have measured it? CHECK UNDERSTANDING

Ask about any new symptoms they are having, specific to the disease

Ask about their current adherence to their treatment regime (if relevant), and factors that can influence this, eg side effects of medication

How it is affecting their day to day life, physically and emotionally

Question 2

How would you explain INR to a patient in patient-friendly language?

What is the normal range and what should it be for people on Warfarin?

Answer 2

• International normalized ratio: is a measure of how long it takes for your blood to clot - the longer the INR, the longer time it’ll take for your blood to clot.

normal INR is 1 and people on warfarin should aim for 2-3.

Question 3

What is warfarin and when should it be taken?

Answer 3

• It is a vitamin K antagonist.
• It needs to be taken at the same time every day, regular blood tests need to be done. DO NOT DOUBLE DOSE

Question 4

Why may people commonly be on Warfarin?

Answer 4

Commonly used to treat blood clots (DVT/PE/prevent stroke in AF).

Question 5

What questions would you ask in a presenting complaint for an INR history?

Answer 5

Ask how they are feeling?
Any recent infections/illnesses?

Any diarrhoea/vomiting?
Bloody/dark stool or vomit.

Question 6

What are symptoms you should ask for that could point to a patient having a high INR

Answer 6

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

Question 7

What are symptoms you should ask for that could point to a patient having a low INR

Answer 7

Any low INR symptoms?
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).

Question 8

What things in a PMH can influence an INR

Answer 8

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

Question 9

What things in a social history can cause an INR to increase? What comment should you make about such things?

Answer 9

Enquire about their diet, any changes either increase/decrease in vitamin K intake;

Foods containing vitamin K are green fruit/veg like broccoli, kale, celery, cucumber, green beans, green apples/grapes, pears, avocado.

It’s not necessary to avoid these foods but it’s important to keep the amount of vitamin K consistent if you’re on warfarin.

Binge drinking alcohol and smoking can cause INR to increase.

Question 10

How can you treat a low INR

Answer 10

Treating low INR –
LMWH, warfarin.

Compression stockings if immobile.

Question 11

How can you treat a high INR

Answer 11

Vitamin K.
Blood components may be given during a transfusion to help stop bleeding.
If there is no clear explanation then the warfarin dose can be decreased and INR rechecked.

Question 12

what extra things do you need to ask in an INR history

Answer 12

Weight change (weight gain can decrease INR)
Sleep
How long they’ve been taking warfarin
Establish Vitamin K intake, and why that has changed if relvevant

Question 13

What specific things would you need to ask in a FRAX/osteoporosis related history

Answer 13

ask drug history
Specifically ask about Oral steroids

Ask PMH, Specificially about rheumatoid arthritis
Ask about conditions that are risks for
secondary osteoporosis (T1DM, Osteogenesis imperfecta, Hyperthyroidism, Premature menopause, (for female patients), malnutrition/malabsorption,
liver disease)

Any family HIstory of hip factures
Personal history of Fractures and nature - were they low impact?

Question 14

What is a normal Hba1c

What is prediabetic and what is diabetic

Answer 14

Normal is 42mmol/L or <6.0%
Pre-diabetes is 42 < mmol/L ≤ 47 or 6–6.4%
Diabetes is ≥48mmol/L or 6.5%

Question 15

How can you explain what Hba1c is to a patient

Answer 15

HbA1c shows us the average blood glucose level over the previous 2–3 months as the sugar sticks to cells in our blood.

Question 16

What general things do you need to establish in an Hba1c history

Answer 16

What type of DM
When were they diagnosed
Hows it affecting their life,
Any changes in exercise, diet, alchohol –> anything that can influence their hba1c
How well they feel their diabetes is being managed
Have they been recently ill at all

Question 17

What things around medication do you need to estabslish in an Hba1c history

Answer 17

Adhereance to medication
Any side effects of medication (polyuria, Hypos, thrush around genitals)

Are they injecting insulin at the same site

Question 18

What specific symptoms do you need to enquire about in a hba1 history

Answer 18

Polyuria and polydipsia
Vision/visual changes
Ask about neuropathy/tingling
Stress levels and mood
Sleep disturbance
Weight change, either gain or loss
Impotence

Question 19

How would you explain Peak flow and spirometry to a patient

Answer 19

Peak flow test measures how fast you can breathe out so you can see how well your lungs are working.
Spirometry measures lung function, specifically the amount (volume) and the speed (flow) of air that can be inhaled/exhaled.

Question 20

What things may be a presenting complaint in a patient with chronic asthma

What other general questions should you ask as part of a PC

Answer 20

Any recent illnesses/infections?
Any SOB?
Any hospital admissions due to asthma at all?
Is there any particular time you notice your condition worsens (winter etc).

Wheeze is getting worse.
Affecting ADL.
IF they are Waking up at night with symptoms (SOB, cough).
Using reliever inhaler more than usual.

Question 21

What key things should you ask about in a drugs/allergy history in chronic asthma management

Answer 21

What medications do you take? Which inhalers do you use and how often?

Have the number of times you’ve needed to use an inhaler changed.

Do you take any other medications (if on steroids then severe).
Any beta-blockers.
Ask about inhaler technique and check inhaler use has been assessed by the nurse.

Do they use a spacer

Ask about allergies/hayfever, and any allergies in the family and excema

Question 22

What key things should you ask about in a social history for chronic disease management of asthma

Answer 22

Any (new) pets?
Recent travel anywhere?
Particularly to places that are polluted.
Housing situation (damp)?
Hayfever.
Smoking? Alcohol?
are you exposed to any cigarette smoke

Any changes to job? what do you do?
Impact of condition on life.

Question 23

How would you explain what CRP is to a patient

Answer 23

Substance produced by the liver and increases in the presence of inflammation.
Acute marker.

Question 24

How would you explain what ESR is to a patient, and what is the key difference between ESR and CRP

Answer 24

Increased fibrinogen means RBCs stick together and so fall faster.
Raised ESR = rate of fall quicker.
ESR rises and falls slowly.

Question 25

What key things would you bring up in an inflammatory marker history?

Answer 25

Check patients understanding of inflammatory markers

How are they feeling?
Any recent illnesses/infections?

How well do you think your condition is being controlled?
What medications do you take? How often?
Any issues taking your mediation?
Do you take any other medications?

Recent travel anywhere?
Smoking?
Alcohol?
Impact of condition on life.

Question 26

What things can cause a large increase in CRP?

Answer 26

bacterial infection
abscess
Crohn’s disease
Connective Tissue diseases (but not SLE)
Malignancy
Trauma
Necrosis (eg MI)

Question 27

What things can cause a normal to slight elevation in CRP?

Answer 27

Viral infection
Steroid/octogens use
Ulcerative Colitis
SLE
Morbid Obesity
Atherosclerosis

Question 28

What are some causes of:

High Albumin
Low albumin

Answer 28

Low;
Can be a sign of malnutrition (Crohn’s/UC, coeliac).
Kidney disease, liver disease (hepatitis, cirrhosis).

High;
Severe infections/dehydration, chronic inflammatory diseases, hepatitis.

Question 29

What are some causes of a high ALP

Answer 29

Bile duct obstruction stimulates ALP synthesis;
Increase in obstructive liver disease.
Non-hepatic origin like increased osteoblastic activity in Paget’s, osteomalacia, vitamin D deficiency.

Question 30

In what common scenarios would you the following phenomena

Raised GGT

Raised AST or ALT –

Raised GGT + ALP –

Raised AST + ALT –

GGT + ALP risen > AST + ALT

Answer 30

GGT –
Liver disease markers of drugs/alcohol (increases)

AST or ALT –
Liver disease markers of drugs, toxins, viral (increases).

GGT + ALP –
Biliary problems.

AST + ALT –
Hepatic problems.

GGT + ALP risen > AST + ALT –
Obstructive jaundice.

Question 31

What questions would you ask in a LFT management history

Answer 31

How are they feeling?
Any recent illnesses/infections?

PMH –
Gallstones in the past.
Crohn’s/UC.
Surgery in past if malabsorption may have had some bowel removed.

DH –
How well do you think your condition is being controlled?
What medications do you take? How often?
Any issues taking your medication?
Do you take any other medications.

SH –
Recent travel anywhere?
Smoking?
Alcohol?
Recreational drugs/toxins?
Diet.
Impact of condition on life.