Chronic Disease Management Flashcards
What is INR based on
Measured on PT (prothrombin time) - measures how long for a blood clot to form based on prothrombin
What is the INR aim for ‘normal’ people
1
What is the INR aim for people on warfarin
2-3
What are the key symptoms to ask for high INR
Headache
Easy bruising
Blood in urine
Coughing blood
Blood in stools
Bleeding longer than usual
What are the key symptoms to ask for low INR
Calf swelling
Unilateral weakness
Slurred speech
Chest pain
What is key PMHx with INR
CKD
Liver failure
Bleeding doses
What should you ask with the overall history in INR
What do you understand about warfarin/INR
Do they have a diary
Changes in diet, weight, alcohol
Questions
Why is alcohol relevant in INR history
Chronic alcohol use decreases INR
Sudden stop INR will increase
Binge drinking - increases INR
What does a high INR mean
Increased bleeding
What does low INR mean
Increased clotting
What is important about changes in diet for vitamin K
Green leafy vegetables
Liver
What is important about medication history in INR
Prescribed, OTC (St Johns Wart)
Recent infection needing antibiotics
Describe the advice given about bleeding risk on warfarin
Less serious cuts/nose bleeds - apply pressure for longer periods
More serious - attend hospital
Always carry anticoagulation alert card
Describe how you take warfarin
INR monitoring booklet
Same time everyday
Different colours for different doses
What is important of women of childbearing age when taking warfarin
Take relevant contraceptives
Teratogenic
What lifestyle advice do you give for people on warfarin
Leafy greens - consistent diet, cranberry and grapefruit
Avoid binge drinking alcohol
Advice on brushing teeth, shaving and dental procedures
What should you do based on INR
Major bleeding – vit K IV + prothrombin complex
INR > 8 + minor bleeding – vit K IV, repeat dose after 24 hours if still > 5
Above + no bleeding – give vit K PO same as above
5-8 + minor bleeding – vit K IV
5-8 no bleeding – hold 1-2 doses and reduce subsequent maintenance dose
What does HBA1c stand for
Directly proportional to measure of glycosylated Hb, 3 month period
Amount of sugar in your blood over the last 3 months
What is important history/information to take for HBA1c
Microvascular risk factors - could loose a limb (sensation)
Eyesight - changes in eyesight
What are the key questions to ask for diabetic management
- Why are you here?
- T1 or T2
- Do you understand what HBA1c is and what it means
- Do you know your previous HbA1c
- Current symptoms
a. polyuria
b. polydipsia
c. weight changes
d. skin changes
e. sensation to limbs
f. any changes to eyesight - How do you feel now?
- Have you had any hospital admissions e.g. DKA, hypo
- Normal history etc. remember family history. Include medial compliance
- Find out the reasons for the changes
a. recent changes in lifestyle
b. alcohol
c. diet
d. exercise
What would an FEV1 be in an obstructive pattern
Decreased Less than 80%
What would FEV1 be in a restrictive pattern
Decreased - less than 80%
What would FVC be in an obstructive pattern
Normal - >80%
What would FVC be in a restrictive pattern
Decreased - less than 80%
What would FEV1/FVC be in an obstructive pattern
Decreased <70%
What would FEV1/FVC be in a restrictive pattern
Normal or increased
Normal = 0.7-0.8
Increased = >0.8
What conditions cause an obstructive pattern
Asthma
COPD
Why are conditions an obstructive pattern
COPD or Asthma
As it creates airway resistance to expiratory flow - patient struggles to get air out quickly = decreased FEV1
How can you tell if a patient has asthma or COPD in spirometry
Both obstructive
Asthma - show reversibility following administration of bronchodilator e.g. salbutamol
Give examples of restrictive disorders
Pulmonary fibrosis/interstitial lung disease
Obesity
Neuromuscular
Chest/spine deformities
Describe the pattern of restrictive disorders
E.g. pulmonary fibrosis
Lower FVC - restrict lung expansion, reducing the amount of air the lungs can hold (vital capacity)
Reduced FEV1 = decrease in compliance and elasticity, harder for the lungs to force air out quickly
FEV1 and FVC have decreased = FEV1/FVC remain normal
Define FEV1
Volume of air expelled in the 1st second of forced expiration (calculated as a % of predicted value)
How is COPD graded
Mild >80% (or equal to)
Moderate 50-80%
Very severe <30%
What % reversibility does asthma show to FEV1 when a bronchodilator is used
> 12%
What diurnal variation would suggest asthma on a peak flow
> 20%
Define FVC
Total volume expelled without a time limit from maximal inspiration to forced maximal expiration (calculate as a % of predicted value)
What happens to FVC in restricted disorders
Reduced
reduced lung expansion, so volumes the lung can hold is smaller
What happens to FVC in obstructive disorders
Normal
Airway resistance to expiratory flow, but normal volume of air in the lungs
Define FEV1/FVC ratio
Proportional volume breathed out in the first second compared to whole breath (normally 0.7/0.8)
What does peak flow value depend on
Patients age, sex and height
What is a normal reading of peak flow
400-600 L/min
What are key questions to ask when taking a peak flow/spirometry questions
SOB
Cough
Haemoptysis
Wheeze
Chest pain
Systemic symptoms
What conditions does haemoptysis suggest
Coughing up blood originating from the respiratory tract below the level of the larynx
Lung cancer
Pulmonary embolism
Describe a wheeze
Asthma, COPD, anaphylaxis
A continuous coarse, whistling sound produced in respiratory airways during breathing
What would respiratory history of chest pain suggest
Pleuritic
Worsened by deep inspiration
Name respiratory risk factors
Pre-existing respiratory disease (asthma, COPD)
Family history (CF, alpha-1 antitrypsin deficiency)
Smoking
Vaping/e-cigarette use
Occupation exposure (e.g. coal mining, farming)
Hobbies e.g. bird keeping
Vaccinations?
What is a respiratory side effect of beta-blockers
Bronchoconstriction
What is a respiratory side effect of NSAIDs
Bronchoconstriction
What is a respiratory side effect of ACE inhibitors
Dry cough
What is a respiratory side effect of oestrogen containing medicines
PE increased risk
What is a respiratory side effect of amiodarone
Pleural effusions
Interstitial lung disease
What is a respiratory side effect of methotrexate
Pleural effusions
Interstitial lung disease
What is a respiratory side effect of nitrofurantoin
Pulmonary reactions
Pulmonary fibrosis
Describe CRP
Measures the level of interleukin-6 produced by liver hepatocytes
Acute phase reactant
Describe ESR
Measure of the rate at which red bloods cells separate from the plasma and fall to the bottom of the test tube
Measured in mm/hr
What is the timing of CRP
Acute phase reactant
Rises within 48 hours of infection or inflammation and responds rapidly to treatment
What is the timing of ESR
Slow to respond, can take up to 7 days
What can effect the levels of CRP which could cause an incorrect number
Can be generated by adipocytes in obese individuals
Liver failure can be low
Can be normal in myeloma and patients with connective tissue disorders
What can affect the levels of ESR which would cause an incorrect figure
Increases in females and with age
Influenced by lipids and glucose levels
What is CRP useful in monitoring
Acute infections or inflammation
What is ESR useful in monitoring
Response to treatment and routine monitoring
Good measure of immunoglobins and use in conditions e.g. connective tissue disorders, myeloma, and some rheumatological malignancies
What are they key questions to ask in ESR/CRP
New rashes, skin lesions
Check for malignancy
How does it affect your work
How do you feel in yourself today?
ICE
What LFTs are marker of liver injury
AST ALT
How do you remember which liver markers are liver tissue
T = tissue
AST, ALT
Name the causes of raised AST/ALT
Hepatitis
Liver cirrhosis
Drug/toxin induced liver injury e.g. paracetamol overdose
Malignancy
What ration of AST:ALT would suggest alcohol liver disease
> 2:1
Describe AST/ALT
Enzymes in liver cells at high concentrations
Occur in pathologies that cause liver cells (hepatocytes) inflammation or damage
How do you remember what liver marker is for the biliary tree
ALP
Describe ALP
Biliary epithelial cells (cells lining the biliary tract) and bones
When is ALP raised
Cholestasis - flow of bile from the liver is reduced or blocked
Bone disease
Describe GGT
Found in hepatocytes and biliary epithelial cells
Non-specific but highly sensitive marker of liver damage
What would
Increased ALP
Normal GGT
suggest
Bone disease
What would
Increased ALP
Increased GGT
suggest
Cholestasis
What would
Normal ALP
Increased GGT
suggest
Alcohol excess
Describe bilirubin
Waste product haemoglobin breakdown
Predominately metabolised and excreted by the liver
When does jaundice occur
Bilirubin > 50 micromol/L
Describe pre-hepatic jaundice
Raised bilirubin levels in the blood
Excess bilirubin production
Increased red cell breakdown
Rest of LFTs = normal
Gilberts syndrome or anaemia
Describe hepatocellular jaundice
Breakdown in bilirubin metabolism
Hepatocytes damaged = inability to metabolise unconjugated bilirubin (increases)
Increased bilirubin, ALT/AST levels
What are the common causes of hepatocellular jaundice
Hepatitis
Cirrhosis
Malignancy
Drug/toxin indult
Describe obstructive/cholestatic jaundice
Blockage in bile excretion pathway
Mainly conjugated bilirubin
Increased - ALP, GGT, bilirubin
Dark stools, pale urine
Intrahepatic and extrahepatic causes
Name the intrahepatic causes of obstructive jaundice
= Obstruction of hepatic bile canaliculi
Hepatitis
Cirrhosis
Malignancy
Drugs - antibiotics, oral contraceptive pill, anabolic steroids
Name the causes of extrahepatic jaundice
= obstruction of hepatic ducts or distal biliary tree
Gallstones
Primary sclerosing cholangitis
Intraluminal malignancy (cholangiocarcinoma)
Extraluminal malignancy - causing compression - head of pancreas tumours
Describe albumin
Globular protein, synthesised by the liver
Helps bind water, cations, fatty acids and bilirubin
What is the role of albumin
Maintains oncotic pressure of blood
What is albumin a marker of
Non-specific marker of synthetic liver function
What are the 2 reasons for a fall in albumin
Decreased albumin production e.g. malnutrition, severe liver disease
Increased albumin loss e.g. losing enteropathies, nephrotic syndrome
What is the half life of albumin
20-days
What are key history questions to ask in LFTs
Jaundice
Itching
Confusion
Ascites - bloating
GI bleeding
Hepatitis risk
Stools (pale), urine (dark)
Drugs
Malignancy flags
What are questions to ask about hepatitis risk
Travel
IVDU
Tattoos
Family history
Alcohol
What are key histories to ask with LFTs about drug use
Paracetamol overdose
Oral contraceptives
Antibiotics
Anabolic steroids
