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Phase 2B > Chronic Disease Management > Flashcards

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
Q

What would FEV1/FVC be in an obstructive pattern

A

Decreased <70%

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26
Q

What would FEV1/FVC be in a restrictive pattern

A

Normal or increased

Normal = 0.7-0.8

Increased = >0.8

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27
Q

What conditions cause an obstructive pattern

A

Asthma
COPD

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28
Q

Why are conditions an obstructive pattern

A

COPD or Asthma

As it creates airway resistance to expiratory flow - patient struggles to get air out quickly = decreased FEV1

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29
Q

How can you tell if a patient has asthma or COPD in spirometry

A

Both obstructive

Asthma - show reversibility following administration of bronchodilator e.g. salbutamol

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30
Q

Give examples of restrictive disorders

A

Pulmonary fibrosis/interstitial lung disease

Obesity

Neuromuscular

Chest/spine deformities

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31
Q

Describe the pattern of restrictive disorders

A

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

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32
Q

Define FEV1

A

Volume of air expelled in the 1st second of forced expiration (calculated as a % of predicted value)

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33
Q

How is COPD graded

A

Mild >80% (or equal to)
Moderate 50-80%
Very severe <30%

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34
Q

What % reversibility does asthma show to FEV1 when a bronchodilator is used

A

> 12%

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35
Q

What diurnal variation would suggest asthma on a peak flow

A

> 20%

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36
Q

Define FVC

A

Total volume expelled without a time limit from maximal inspiration to forced maximal expiration (calculate as a % of predicted value)

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37
Q

What happens to FVC in restricted disorders

A

Reduced

reduced lung expansion, so volumes the lung can hold is smaller

38
Q

What happens to FVC in obstructive disorders

A

Normal

Airway resistance to expiratory flow, but normal volume of air in the lungs

39
Q

Define FEV1/FVC ratio

A

Proportional volume breathed out in the first second compared to whole breath (normally 0.7/0.8)

40
Q

What does peak flow value depend on

A

Patients age, sex and height

41
Q

What is a normal reading of peak flow

A

400-600 L/min

42
Q

What are key questions to ask when taking a peak flow/spirometry questions

A

SOB
Cough
Haemoptysis
Wheeze
Chest pain
Systemic symptoms

43
Q

What conditions does haemoptysis suggest

A

Coughing up blood originating from the respiratory tract below the level of the larynx

Lung cancer
Pulmonary embolism

44
Q

Describe a wheeze

A

Asthma, COPD, anaphylaxis

A continuous coarse, whistling sound produced in respiratory airways during breathing

45
Q

What would respiratory history of chest pain suggest

A

Pleuritic

Worsened by deep inspiration

46
Q

Name respiratory risk factors

A

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
Q

What is a respiratory side effect of beta-blockers

A

Bronchoconstriction

48
Q

What is a respiratory side effect of NSAIDs

A

Bronchoconstriction

49
Q

What is a respiratory side effect of ACE inhibitors

A

Dry cough

50
Q

What is a respiratory side effect of oestrogen containing medicines

A

PE increased risk

51
Q

What is a respiratory side effect of amiodarone

A

Pleural effusions
Interstitial lung disease

52
Q

What is a respiratory side effect of methotrexate

A

Pleural effusions
Interstitial lung disease

53
Q

What is a respiratory side effect of nitrofurantoin

A

Pulmonary reactions
Pulmonary fibrosis

54
Q

Describe CRP

A

Measures the level of interleukin-6 produced by liver hepatocytes

Acute phase reactant

55
Q

Describe ESR

A

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
Q

What is the timing of CRP

A

Acute phase reactant

Rises within 48 hours of infection or inflammation and responds rapidly to treatment

57
Q

What is the timing of ESR

A

Slow to respond, can take up to 7 days

58
Q

What can effect the levels of CRP which could cause an incorrect number

A

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
Q

What can affect the levels of ESR which would cause an incorrect figure

A

Increases in females and with age

Influenced by lipids and glucose levels

60
Q

What is CRP useful in monitoring

A

Acute infections or inflammation

61
Q

What is ESR useful in monitoring

A

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
Q

What are they key questions to ask in ESR/CRP

A

New rashes, skin lesions
Check for malignancy
How does it affect your work
How do you feel in yourself today?
ICE

63
Q

What LFTs are marker of liver injury

A

AST ALT

64
Q

How do you remember which liver markers are liver tissue

A

T = tissue

AST, ALT

65
Q

Name the causes of raised AST/ALT

A

Hepatitis
Liver cirrhosis
Drug/toxin induced liver injury e.g. paracetamol overdose
Malignancy

66
Q

What ration of AST:ALT would suggest alcohol liver disease

A

> 2:1

67
Q

Describe AST/ALT

A

Enzymes in liver cells at high concentrations

Occur in pathologies that cause liver cells (hepatocytes) inflammation or damage

68
Q

How do you remember what liver marker is for the biliary tree

A

ALP

69
Q

Describe ALP

A

Biliary epithelial cells (cells lining the biliary tract) and bones

70
Q

When is ALP raised

A

Cholestasis - flow of bile from the liver is reduced or blocked

Bone disease

71
Q

Describe GGT

A

Found in hepatocytes and biliary epithelial cells

Non-specific but highly sensitive marker of liver damage

72
Q

What would

Increased ALP
Normal GGT

suggest

A

Bone disease

73
Q

What would

Increased ALP
Increased GGT

suggest

A

Cholestasis

74
Q

What would

Normal ALP
Increased GGT

suggest

A

Alcohol excess

75
Q

Describe bilirubin

A

Waste product haemoglobin breakdown

Predominately metabolised and excreted by the liver

76
Q

When does jaundice occur

A

Bilirubin > 50 micromol/L

77
Q

Describe pre-hepatic jaundice

A

Raised bilirubin levels in the blood

Excess bilirubin production

Increased red cell breakdown

Rest of LFTs = normal

Gilberts syndrome or anaemia

78
Q

Describe hepatocellular jaundice

A

Breakdown in bilirubin metabolism

Hepatocytes damaged = inability to metabolise unconjugated bilirubin (increases)

Increased bilirubin, ALT/AST levels

79
Q

What are the common causes of hepatocellular jaundice

A

Hepatitis
Cirrhosis
Malignancy
Drug/toxin indult

80
Q

Describe obstructive/cholestatic jaundice

A

Blockage in bile excretion pathway

Mainly conjugated bilirubin

Increased - ALP, GGT, bilirubin

Dark stools, pale urine

Intrahepatic and extrahepatic causes

81
Q

Name the intrahepatic causes of obstructive jaundice

A

= Obstruction of hepatic bile canaliculi

Hepatitis
Cirrhosis
Malignancy
Drugs - antibiotics, oral contraceptive pill, anabolic steroids

82
Q

Name the causes of extrahepatic jaundice

A

= obstruction of hepatic ducts or distal biliary tree

Gallstones
Primary sclerosing cholangitis
Intraluminal malignancy (cholangiocarcinoma)
Extraluminal malignancy - causing compression - head of pancreas tumours

83
Q

Describe albumin

A

Globular protein, synthesised by the liver

Helps bind water, cations, fatty acids and bilirubin

84
Q

What is the role of albumin

A

Maintains oncotic pressure of blood

85
Q

What is albumin a marker of

A

Non-specific marker of synthetic liver function

86
Q

What are the 2 reasons for a fall in albumin

A

Decreased albumin production e.g. malnutrition, severe liver disease

Increased albumin loss e.g. losing enteropathies, nephrotic syndrome

87
Q

What is the half life of albumin

A

20-days

88
Q

What are key history questions to ask in LFTs

A

Jaundice
Itching
Confusion
Ascites - bloating
GI bleeding
Hepatitis risk
Stools (pale), urine (dark)
Drugs
Malignancy flags

89
Q

What are questions to ask about hepatitis risk

A

Travel
IVDU
Tattoos
Family history
Alcohol

90
Q

What are key histories to ask with LFTs about drug use

A

Paracetamol overdose
Oral contraceptives
Antibiotics
Anabolic steroids

91
Q
A

Phase 2B (15 decks)

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