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Chronic Disease Management Flashcards

1
Q

What is INR based on

A

Measured on PT (prothrombin time) - measures how long for a blood clot to form based on prothrombin

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2
Q

What is the INR aim for ‘normal’ people

A

1

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3
Q

What is the INR aim for people on warfarin

A

2-3

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4
Q

What are the key symptoms to ask for high INR

A

Headache
Easy bruising
Blood in urine
Coughing blood
Blood in stools
Bleeding longer than usual

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5
Q

What are the key symptoms to ask for low INR

A

Calf swelling
Unilateral weakness
Slurred speech
Chest pain

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6
Q

What is key PMHx with INR

A

CKD
Liver failure
Bleeding doses

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7
Q

What should you ask with the overall history in INR

A

What do you understand about warfarin/INR

Do they have a diary

Changes in diet, weight, alcohol

Questions

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8
Q

Why is alcohol relevant in INR history

A

Chronic alcohol use decreases INR

Sudden stop INR will increase

Binge drinking - increases INR

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9
Q

What does a high INR mean

A

Increased bleeding

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10
Q

What does low INR mean

A

Increased clotting

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11
Q

What is important about changes in diet for vitamin K

A

Green leafy vegetables

Liver

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12
Q

What is important about medication history in INR

A

Prescribed, OTC (St Johns Wart)

Recent infection needing antibiotics

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13
Q

Describe the advice given about bleeding risk on warfarin

A

Less serious cuts/nose bleeds - apply pressure for longer periods

More serious - attend hospital

Always carry anticoagulation alert card

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14
Q

Describe how you take warfarin

A

INR monitoring booklet

Same time everyday

Different colours for different doses

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15
Q

What is important of women of childbearing age when taking warfarin

A

Take relevant contraceptives

Teratogenic

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16
Q

What lifestyle advice do you give for people on warfarin

A

Leafy greens - consistent diet, cranberry and grapefruit

Avoid binge drinking alcohol

Advice on brushing teeth, shaving and dental procedures

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17
Q

What should you do based on INR

A

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

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18
Q

What does HBA1c stand for

A

Directly proportional to measure of glycosylated Hb, 3 month period

Amount of sugar in your blood over the last 3 months

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19
Q

What is important history/information to take for HBA1c

A

Microvascular risk factors - could loose a limb (sensation)

Eyesight - changes in eyesight

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20
Q

What are the key questions to ask for diabetic management

A
  1. Why are you here?
  2. T1 or T2
  3. Do you understand what HBA1c is and what it means
  4. Do you know your previous HbA1c
  5. Current symptoms
    a. polyuria
    b. polydipsia
    c. weight changes
    d. skin changes
    e. sensation to limbs
    f. any changes to eyesight
  6. How do you feel now?
  7. Have you had any hospital admissions e.g. DKA, hypo
  8. Normal history etc. remember family history. Include medial compliance
  9. Find out the reasons for the changes
    a. recent changes in lifestyle
    b. alcohol
    c. diet
    d. exercise
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21
Q

What would an FEV1 be in an obstructive pattern

A

Decreased Less than 80%

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22
Q

What would FEV1 be in a restrictive pattern

A

Decreased - less than 80%

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23
Q

What would FVC be in an obstructive pattern

A

Normal - >80%

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24
Q

What would FVC be in a restrictive pattern

A

Decreased - less than 80%

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25
What would FEV1/FVC be in an obstructive pattern
Decreased <70%
26
What would FEV1/FVC be in a restrictive pattern
Normal or increased Normal = 0.7-0.8 Increased = >0.8
27
What conditions cause an obstructive pattern
Asthma COPD
28
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
29
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
30
Give examples of restrictive disorders
Pulmonary fibrosis/interstitial lung disease Obesity Neuromuscular Chest/spine deformities
31
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
32
Define FEV1
Volume of air expelled in the 1st second of forced expiration (calculated as a % of predicted value)
33
How is COPD graded
Mild >80% (or equal to) Moderate 50-80% Very severe <30%
34
What % reversibility does asthma show to FEV1 when a bronchodilator is used
>12%
35
What diurnal variation would suggest asthma on a peak flow
>20%
36
Define FVC
Total volume expelled without a time limit from maximal inspiration to forced maximal expiration (calculate as a % of predicted value)
37
What happens to FVC in restricted disorders
Reduced reduced lung expansion, so volumes the lung can hold is smaller
38
What happens to FVC in obstructive disorders
Normal Airway resistance to expiratory flow, but normal volume of air in the lungs
39
Define FEV1/FVC ratio
Proportional volume breathed out in the first second compared to whole breath (normally 0.7/0.8)
40
What does peak flow value depend on
Patients age, sex and height
41
What is a normal reading of peak flow
400-600 L/min
42
What are key questions to ask when taking a peak flow/spirometry questions
SOB Cough Haemoptysis Wheeze Chest pain Systemic symptoms
43
What conditions does haemoptysis suggest
Coughing up blood originating from the respiratory tract below the level of the larynx Lung cancer Pulmonary embolism
44
Describe a wheeze
Asthma, COPD, anaphylaxis A continuous coarse, whistling sound produced in respiratory airways during breathing
45
What would respiratory history of chest pain suggest
Pleuritic Worsened by deep inspiration
46
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?
47
What is a respiratory side effect of beta-blockers
Bronchoconstriction
48
What is a respiratory side effect of NSAIDs
Bronchoconstriction
49
What is a respiratory side effect of ACE inhibitors
Dry cough
50
What is a respiratory side effect of oestrogen containing medicines
PE increased risk
51
What is a respiratory side effect of amiodarone
Pleural effusions Interstitial lung disease
52
What is a respiratory side effect of methotrexate
Pleural effusions Interstitial lung disease
53
What is a respiratory side effect of nitrofurantoin
Pulmonary reactions Pulmonary fibrosis
54
Describe CRP
Measures the level of interleukin-6 produced by liver hepatocytes Acute phase reactant
55
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
56
What is the timing of CRP
Acute phase reactant Rises within 48 hours of infection or inflammation and responds rapidly to treatment
57
What is the timing of ESR
Slow to respond, can take up to 7 days
58
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
59
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
60
What is CRP useful in monitoring
Acute infections or inflammation
61
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
62
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
63
What LFTs are marker of liver injury
AST ALT
64
How do you remember which liver markers are liver tissue
T = tissue AST, ALT
65
Name the causes of raised AST/ALT
Hepatitis Liver cirrhosis Drug/toxin induced liver injury e.g. paracetamol overdose Malignancy
66
What ration of AST:ALT would suggest alcohol liver disease
> 2:1
67
Describe AST/ALT
Enzymes in liver cells at high concentrations Occur in pathologies that cause liver cells (hepatocytes) inflammation or damage
68
How do you remember what liver marker is for the biliary tree
ALP
69
Describe ALP
Biliary epithelial cells (cells lining the biliary tract) and bones
70
When is ALP raised
Cholestasis - flow of bile from the liver is reduced or blocked Bone disease
71
Describe GGT
Found in hepatocytes and biliary epithelial cells Non-specific but highly sensitive marker of liver damage
72
What would Increased ALP Normal GGT suggest
Bone disease
73
What would Increased ALP Increased GGT suggest
Cholestasis
74
What would Normal ALP Increased GGT suggest
Alcohol excess
75
Describe bilirubin
Waste product haemoglobin breakdown Predominately metabolised and excreted by the liver
76
When does jaundice occur
Bilirubin > 50 micromol/L
77
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
78
Describe hepatocellular jaundice
Breakdown in bilirubin metabolism Hepatocytes damaged = inability to metabolise unconjugated bilirubin (increases) Increased bilirubin, ALT/AST levels
79
What are the common causes of hepatocellular jaundice
Hepatitis Cirrhosis Malignancy Drug/toxin indult
80
Describe obstructive/cholestatic jaundice
Blockage in bile excretion pathway Mainly conjugated bilirubin Increased - ALP, GGT, bilirubin Dark stools, pale urine Intrahepatic and extrahepatic causes
81
Name the intrahepatic causes of obstructive jaundice
= Obstruction of hepatic bile canaliculi Hepatitis Cirrhosis Malignancy Drugs - antibiotics, oral contraceptive pill, anabolic steroids
82
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
83
Describe albumin
Globular protein, synthesised by the liver Helps bind water, cations, fatty acids and bilirubin
84
What is the role of albumin
Maintains oncotic pressure of blood
85
What is albumin a marker of
Non-specific marker of synthetic liver function
86
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
87
What is the half life of albumin
20-days
88
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
89
What are questions to ask about hepatitis risk
Travel IVDU Tattoos Family history Alcohol
90
What are key histories to ask with LFTs about drug use
Paracetamol overdose Oral contraceptives Antibiotics Anabolic steroids
91

Phase 2B (15 decks)

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