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Phase 2b > Chronic disease management > Flashcards

Chronic disease management Flashcards

1
Q

INR + WARFARIN CHART

How would you start the consultation?

A
  • I understand you are… and I can see from your results that your INR is…
  • Check patients understanding of INR/warfarin.
  • Explain what INR is and risks of high/low.
  • Explain why they are on warfarin.
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2
Q

INR + WARFARIN CHART

What is warfarin?

A

Warfarin is an anticoagulant meaning that its job is to stop the blood from clotting too easily.

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3
Q

INR + WARFARIN CHART

What is INR?

A

Stands for international normalised ratio and it provides information about someone’s bloods tendency to clot.

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4
Q 
INR + WARFARIN CHART
What would you expect the INR to be in...
i) a normal, healthy person?
ii) someone on warfarin?
iii) someone at increased bleeding risk?
iv) someone at increased clotting risk?
A

i) 1
ii) 2–3
iii) >3
iv) <2

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5
Q

INR + WARFARIN CHART

What are the risks of having a high or low INR?

A
  • The higher the INR, the longer it takes the blood to clot and so the increased bleeding risk.
  • The lower the INR, the thicker the blood and so there’s an increased clotting risk.
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6
Q

INR + WARFARIN CHART

Why do people take warfarin?

A
  • Commonly used to treat blood clots (DVT/PE/prevent stroke in AF).
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7
Q

INR + WARFARIN CHART

What would you ask about in the Hx of PC?

A
  • How they are feeling?
  • Any recent illnesses?
  • Any diarrhoea/vomiting?
  • Any high INR symptoms?
  • Any low INR symptoms?
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8
Q

INR + WARFARIN CHART

What are high INR symptoms?

A
  • Bloody/dark stool or blood in vomit, urine.
  • Headache, severe stomach ache.
  • Increased bruising.
  • Prolonged bleeding after minor cuts/menstrual/gum bleeding.
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9
Q

INR + WARFARIN CHART

What are low INR symptoms?

A
  • Stroke (sudden weakness/numbness in limb, visual changes, inability to speak).
  • DVT/PE (pain/swelling/redness/heat in limbs, new SOB/chest pain).
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10
Q

INR + WARFARIN CHART

What would you ask about in PMH?

A
  • Liver failure (lack of clotting factors).

- Bleeding disorders (haemophilia, factor 7 deficiency).

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11
Q

INR + WARFARIN CHART

What would you ask about in DH?

A
  • Do you know how many times you are meant to be taking the warfarin?
  • How/when do you take it?
  • Have you missed any doses? (Double doses?)
  • Are you finding it okay or are you struggling with dose?
  • Any other medications.
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12
Q

INR + WARFARIN CHART

What is important about the administration of warfarin?

A
  • Same time every day.
  • No double dosing if missed a dose.
  • Taking too much can increase bleeding risk (and INR).
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13
Q

INR + WARFARIN CHART

What other medications are important to enquire about?

A
  • Aspirin, NSAIDs.
  • Herbal medication (St John’s wart).
  • OCP/HRT.
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14
Q

INR + WARFARIN CHART

What would you ask about in SH?

A
  • Enquire about diet, any changes either increase/decrease in vitamin K.
  • Binge drinking alcohol (increase INR).
  • Smoking (increase INR).
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15
Q

INR + WARFARIN CHART

Explain more specifically why diet is important when taking warfarin.

A
  • Green fruit/veg like broccoli, kale, celery, cucumber, green beans/apples/grapes, pears, avacado contain vitamin K.
  • Not necessary to avoid these feeds but important to keep same as vast changes can change the INR.
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16
Q

INR + WARFARIN CHART

What advice would you give a patient at decreasing their bleeding risk?

A
  • Avoid activities that can cause bleeding/bruising.
  • Brush/shave gently.
  • Tell dentist and any other healthcare professional that you take anticoagulation.
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17
Q

INR + WARFARIN CHART

How can you treat an elevated INR?

A
  • Vitamin K.
  • Blood components may be given during a transfusion to help stop bleeding.
  • Adjust warfarin dose.
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18
Q

INR + WARFARIN CHART

How can you treat a decreased INR?

A
  • LMWH, warfarin.

- Compression stockings if immobile.

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19
Q

INR + WARFARIN CHART

What is the mechanism of action of warfarin and how regularly do patients need their INR checked?

A
  • Vitamin K antagonist (blocks vitamin K epoxide reductase enzyme) leading to decrease in factors 2, 7, 9 + 10.
  • Initially, daily blood tests and then maintenance and once a month.
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20
Q

HbA1c DIABETIC CHECK

What are the HbA1c diagnostic values?

A 
Normal = 42mmol/L or <6.0%
Pre-diabetes = 42
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21
Q

HbA1c DIABETIC CHECK

How would you start the consultation?

A
  • I understand you are… and I can see from your results that your HbA1c is…
  • Check when patient diagnosed, T1/T2 and their understanding of their diabetes/HbA1c.
  • How well do you think your diabetes is being managed?
  • Benefits of lowering HbA1c.
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22
Q

HbA1c DIABETIC CHECK

What is HbA1c?

A
  • HbA1c shows us the average blood glucose level which is the sugar in your blood over the past 2–3 months as the sugar can stick to some of the cells in the blood.
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23
Q

HbA1c DIABETIC CHECK

What are the benefits of lowering HbA1c?

A
  • Reduces risk of retinopathy (eye problems), neuropathy (losing sensation in hands/feet) and nephropathy (kidney issues).
  • Less likely to suffer from cataracts, heart failure and amputation.
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24
Q

HbA1c DIABETIC CHECK

What you ask about in Hx of PC?

A
  • How are they feeling?
  • Any recent infections/illnesses?
  • Any hospital admissions for DKA/hypos?
  • Any symptoms of diabetes?
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25
Q

HbA1c DIABETIC CHECK

What is the importance of recent infections/illnesses?

A
  • D+V/illness can affect the amount of insulin required due to release of glucose.
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26
Q

HbA1c DIABETIC CHECK

What are the symptoms of diabetes?

A
  • Polyuria.
  • Polydipsia.
  • Weight loss.
  • Vision changes.
  • Tingling in feet.
  • Impotence.
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27
Q

HbA1c DIABETIC CHECK

What would you ask about in PMH?

A
  • Any CVS/cerebrovascular/renal/visual complications?

- Any co-morbidities?

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28
Q

HbA1c DIABETIC CHECK
What conditions can HbA1c be…
i) falsely raised in?
ii) falsely decreased in?

A

i) Renal failure, chronic excessive alcohol, B12 deficiency.

ii) Blood loss, sickle cell disease, thalassaemia.

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29
Q

HbA1c DIABETIC CHECK

What would you ask about in DH?

A
  • What diabetes medication do you take?
  • How/when you take your medication, any side effects?
  • Are you finding this okay or are you struggling with dose?
  • If insulin, injecting correctly (site rotation).
  • Monitoring glucose levels?
  • Any other medications/changes.
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30
Q

HbA1c DIABETIC CHECK

What would you ask about in SH?

A
  • ADLs
  • Diet.
  • Exercise.
  • Smoking.
  • Alcohol.
31
Q

HbA1c DIABETIC CHECK

What would you specifically ask about in ADLs?

A
  • How is your mood/sleep?
  • Are your home circumstances okay?
  • Do you feel like your disease is affecting your ADLs?
32
Q

HbA1c DIABETIC CHECK

What would you specifically ask about in diet?

A
  • Adhering to dietary restrictions?

- Been on a recent diet/tried to lose weight?

33
Q

HbA1c DIABETIC CHECK

What advice can you give for lowering HbA1c?

A
  • Dietary modifications.
  • Physical activity.
  • Take extra care when ill.
  • Monitor blood sugar levels.
  • Support available.
34
Q

HbA1c DIABETIC CHECK

What advice can you specifically give about dietary modifications?

A
  • Awareness of snacking + sugary foods/carbs affecting the blood sugar level.
35
Q

HbA1c DIABETIC CHECK

What advice can you specifically give about physical activity?

A
  • Getting regular exercise can help stop blood sugar levels rising.
  • Check with doctor first because some diabetes medicines can lead to hypoglycaemia if you exercise too much.
36
Q

HbA1c DIABETIC CHECK

What advice can you specifically give about taking extra care when ill?

A
  • “Sick day rules”.
  • Check blood sugar more regularly (4h).
  • Keep taking diabetes medications even if you don’t feel like eating.
  • Check ketones.
  • Contact diabetes team if you need to.
37
Q

HbA1c DIABETIC CHECK

What advice can you specifically give about monitoring BMs + the support available?

A
  • BMs so you can spot increase early + takes steps to prevent it.
  • GP, diabetes nurses, online resources, training courses.
38
Q

PEAK FLOW/SPIROMETRY

What advice can you give about peak flow and spirometry?

A
  • Take peak flow before using preventer inhaler + always use same peak flow meter.
  • Spirometry measures functional lung volumes.
39
Q

PEAK FLOW/SPIROMETRY

What are some causes of obstructive lung disease?

A
  • Reversible (asthma) or irreversible (COPD).
  • Bronchiectasis.
  • Inhaled foreign body.
  • Tumour.
40
Q

PEAK FLOW/SPIROMETRY

Explain the spirometry values for obstructive lung disease.

A
  • Takes a long time to exhale (wheeze) so not much breathed out at 1 second but overall volume isn’t bad.
  • FEV1
41
Q

PEAK FLOW/SPIROMETRY

What are some causes of restrictive lung disease?

A

Usually diseases of the interstitium affecting chest wall movement + elasticity;

  • Scoliosis, kyphosis, ankylosing spondylitis.
  • Neuromuscular diseases like Guillain-Barré syndrome, myasthenia gravis.
  • Pulmonary fibrosis, sarcoidosis, asbestosis.
42
Q

PEAK FLOW/SPIROMETRY

Explain the spirometry values for restrictive lung disease.

A

Due to restriction, lung volumes are small + most of the breath is out in the first second.
- FEV1/FVC >80% due to FVC being proportionally lower.

43
Q

PEAK FLOW/SPIROMETRY

How would you start the consultation?

A
  • I understand you are… and I can see from your results that your peak flow/spirometry is…
  • Check patients understanding of peak flow/spirometry + their condition.
44
Q

PEAK FLOW/SPIROMETRY

Explain what peak flow and spirometry is.

A
  • 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 speed (flow) of air that can be inhaled/exhaled.
45
Q

PEAK FLOW/SPIROMETRY

What would you ask about in Hx of PC?

A
  • How are they feeling?
  • Any recent illnesses/infections?
  • Any SOB?
  • Any particular time you notice condition worsens?
  • Red flags.
46
Q

PEAK FLOW/SPIROMETRY

What are the red flags in Hx of PC?

A
  • Wheeze getting worse.
  • Affecting ADLs.
  • Waking up at night with symptoms (SOB, cough).
  • Using reliever inhaler more than usual.
47
Q

PEAK FLOW/SPIROMETRY

What would you ask about in DH?

A
  • How well do you think your condition is being controlled?
  • What medications do you take?
  • Which inhalers do you use + how often?
  • Do you take any other medications (if steroids then its severe).
  • Any beta-blockers, ACEi?
  • Check inhaler technique + check inhaler use has been assessed by the nurse.
48
Q

PEAK FLOW/SPIROMETRY

What would you ask about in SH?

A
  • Any (new pets).
  • Recent travel? (Polluted).
  • Housing situation (damp).
  • Hayfever.
  • Smoking/alcohol.
  • Impact of condition on life.
49
Q

PEAK FLOW/SPIROMETRY

What advice could you give to someone with a poor peak flow/spirometry result?

A
  • Stop smoking.
  • Avoid precipitants.
  • Vaccination (flu).
  • Exercise.
  • Eating.
  • Support.
50
Q

INFLAMMATORY MARKERS

What is CRP?

A
  • Non-specific marker produced by liver + increases in presence of inflammation.
  • Acute marker.
51
Q

INFLAMMATORY MARKERS

In what conditions is CRP routinely measured to assess the disease activity?

A
  • Rheum (RA, JIA, seronegative arthritis).
  • Crohn’s disease.
  • Vasculitis, polyarteritis nodosa.
  • Pancreatitis.
52
Q

INFLAMMATORY MARKERS

What conditions does CRP aid with diagnosis and monitor infection?

A
  • Infective endocarditis.
  • Abscess post-op infection.
  • Response to Abx.
53
Q

INFLAMMATORY MARKERS

What can cause an increase in CRP?

A
  • Burns, trauma.
  • Infections (pneumonia, TB).
  • Chronic inflammatory diseases (SLE, vasculitis, RA).
  • MI, IBD, cancers.
54
Q

INFLAMMATORY MARKERS

What is ESR?

A
  • Increased fibrinogen means RBCs stick together and so fall faster.
  • Raised ESR = rate of fall quicker.
  • ESR rises + falls slowly.
55
Q

INFLAMMATORY MARKERS

What can cause a raised ESR?

A
  • Malignancy (lymphoma, colonic/breast carcinomas).
  • Haem (multiple myeloma, anaemia of chronic disease + iron deficiency together).
  • Connective tissue disorders (SLE, RA, polymyalgia rhumatica + GCA).
  • Infections (TB, acute hepatitis, bacterial).
56
Q

INFLAMMATORY MARKERS

How would you start a consultation?

A
  • I understand you are… and I can see from your results that your CRP/ESR is…
  • Check patients understanding of CRP/ESR + their condition.
57
Q

INFLAMMATORY MARKERS

How would you explain to a patient what CRP/ESR is?

A
  • Marker of inflammation which tells us that there could be a flare up in your condition or new infection detected.
58
Q

INFLAMMATORY MARKERS

What would you ask about in Hx of PC?

A
  • How are they feeling?

- Any recent illnesses/infections?

59
Q

INFLAMMATORY MARKERS

What would you ask about in DH?

A
  • 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?
60
Q

INFLAMMATORY MARKERS

What would you ask about in SH?

A
  • Recent travel anywhere?
  • Smoking? Alcohol?
  • Impact of condition on life.
61
Q

INFLAMMATORY MARKERS

What advice would you give to someone in controlling their condition?

A
  • Stop smoking.

- Advice on disease management if they’re non-compliant?

62
Q

LFTs

What can high or low albumin be a sign of? What are globulins?

A
  • High = severe infections/dehydration, chronic inflammatory diseases, hepatitis.
  • Low = malnutrition (Crohn’s/UC/coeliac), renal/liver disease.
  • Total proteins.
63
Q 
LFTs
What is...
i) ALP
ii) AST or ALT
iii) GGT
A

i) ALP is synthesised due to bile duct obstruction.
ii) Liver disease markers of drugs, toxins, viral (increases).
iii) Liver disease markers of drugs/alcohol (increases).

64
Q

LFTs

What do different levels of bilirubin tell you?

A
  • High conjugated = liver/bile duct disease.

- High unconjugated = Gilbert’s or haemolytic anaemia.

65
Q

LFTs

What can liver enzymes increase in?

A
  • Chronic high alcohol excess.
  • Obesity (esp. in men).
  • Smoking (esp. in women).
  • Drug reaction.
66
Q 
LFTs
What does increased...
i) GGT + ALP
ii) AST + ALT
iii) GGT + ALP > AST + ALT
show?
A

i) Biliary problems.
ii) Hepatic problems.
iii) Obstructive jaundice.

67
Q

LFTs

How would you start the consultation?

A
  • I understand you are… and I can see from your results that your LFTs are…
  • Check patients understanding of LFTs + their condition.
68
Q

LFTs

How would you explain LFTs to a patient?

A
  • Certain markers in your blood can detect if there’s any problems in the function of your liver.
69
Q

LFTs

What would you ask about in Hx of PC?

A
  • How are they feeling?
  • Any recent illnesses/infections?
  • Oedema/jaundice/bloating/stools/urine/fever/itching.
70
Q

LFTs

What would you ask about in PMH?

A
  • Gallstones in past.
  • Crohn’s/UC?
  • Surgery in past if malabsorption they may have had some of their bowel removed.
71
Q

LFTs

What would you ask about in DH?

A
  • 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.
72
Q

LFTs

What would you ask about in SH?

A
  • Recent foreign travel anywhere?
  • Smoking? Alcohol? Recreational drugs/toxins?
  • Diet.
  • Impact of condition on life.
  • Unprotected sex.
73
Q

LFTs

What advice

A
  • Stop smoking/alcohol/drugs.
  • Diet advice.
  • Advice on disease management if they’re non-compliant.

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