Long Term Conditions Flashcards
Define diabetes mellitus
Metabolic disorder group
Persistent hyperglycemia is caused by deficient insulin secretion =/- resistance to insulin
Define type 1 diabetes
Absolute insulin deficiency causes persistent hyperglycaemia
Define type 2 diabetes
Insulin resistance and a relative insulin deficiency result in persistent hyperglycaemia
Define gestational diabetes
Hyperglycaemia develops during pregnancy
- usually resolves after delivery
Causes of type 1 diabetes
Destruction of beta-cells in pancreatic islets of Langerhans
- autoimmunity
Complications of type 1 diabetes
Microvascular - nephropathy - retinopathy - chronic painful neuropathy - autonomic neuropathy Macrovascular - CVD Metabolic - DKA - dyslipidaemia Increased risk for other autoimmune conditions Reduced QoL Skin complications Infections Reduced life expectancy
Presentation of type 1 diabetes
Ketosis Rapid weight loss Under 50 years BMI below 25 Personal/FH of autoimmune disease Random plasma glucose over 11
Precipitating factors of DKA
Infection Physiological stress Inadequate insulin or non-adherence Drugs - corticosteroids - diuretics - salbutamol
Presentation of DKA
Increased thirst and urinary frequency Weight loss Inability to tolerate fluids Persistent vomiting +/-diarrhoea Abdominal pain Lethargy/confusion Fruity smell of acetone on breath Acidotic breathing - deep sighing respiration Dehydration
Treatment targets for type 1 diabetics
HbA1c at 48 mmol/mol (6.5%) or lower
Advise routine self-monitoring of blood glucose
- fasting 5-7 mmol/L
- random of 4-9 mmol/L
Causes of type 2 diabetes
Insulin resistance/insensitivity and insulin deficiency
Risk factors for type 2 diabetes
Obesity and inactivity
FH
Ethnicity - Asian, African and Black communities at greater risk
History of gestational diabetes
Poor dietary habits - low fibre, high GI diet
Drug treatments - statins, corticosteriods
PCOS
Metabolic syndrome
Low birth weight for gestational age
Complications of type 2 diabetes
Macrovascular - CVD Microvascular - nephropathy - retinopathy - chronic painful neuropathy - autonomic neuropathy Metabolic - dyslipidaemia Psychological Reduced QoL Infections Reduced life expectancy Dementia
Drug management of type 2 diabetes
Metformin - gradually increase dose over several weeks to reduce GI side effects - monitor renal function If metformin contrindicated or not-tolerated - gliptin - pioglitazone - sulfonylurea - SLGT-2i Statin - reduce CVS risk ACEi/ARB if hypertensive
Lifestyle management of type 2 diabetes
Emphasise importance of healthy balanced diet - high fibre - low GI index - low-fat dairy - oily fish Regular exercise - lowers blood glucose levels - reduced CVS risk - help with weight management Max 14 units alcohol a week - may exacerbate hypoglycaemic effects of drugs Smoking - CVS risk
Risk factors for diabetic foot
Neuropathy Limb ischaemia Ulceration Callus formation Infection/inflammation Deformity Gangrene Charcot arthropathy
Define COPD
Chronic Obstructive Pulmonary Disease
- emphysema = loss of parenchymal lung texture
- chronic bronchitis = cough and sputum production for at least 3 months for 2 consecutive years
Risk factors for COPD
Tobacco smoking Occupational exposure - dusts - coal, grains, silica - fumes or chemicals - welding fume, dyes Air pollution Genetics - alpha1-antitrypsin deficiency Lung development - maternal smoking - pre-term birth Asthma
Complications of COPD
Reduced QoL Increased morbidity and mortality Depression and anxiety Cor pulmonale Frequent chest infections Secondary polycythaemia - overproduction of RBCs Respiratory failure - increased airway resistance Pneumothorax - bulla Lung cancer Muscle wasting and cachexia
Clinical presentation of COPD
Breathlessness - persistent, progressive over time, worse on exertion
Chronic/recurrent cough
Regular sputum production
Frequent lower respiratory tract infections
Wheeze
Cyanosis
Raised JVP
Cachexia
Hyperinflation of chest
Use of accessory muscles/pursed lip breathing
Features of spirometry of COPD
Post bronchodilator FEV1/FVC less than 0.7
Clinical features of cor pulmonale
Peripheral oedema Raised JVP Systolic parasternal heave Loud pulmonary second heart sound Hepatomegaly
Investigations for COPD
Chest x-ray
Full blood count - anaemia, polycythaemia
Spirometry
MRC dyspnoea scale
1 - not troubled by breathlessness except during strenuous exercise
2 - short of breath when hurrying or walking up slight hill
3 - walks slower than contemporaries on level because of breathlessness, has to stop for breath
4 - stops for breath after 100m or few mins on level
5 - too breathless to leave house
Differential diagnosis of COPD
Asthma Bronchiectasis Heart failure Lung cancer ILD Anaemia TB Cystic fibrosis Upper airway obstruction
Define acute exacerbation of COPD
Sustained worsening of person’s symptoms from usual stable state
- acute in onset
Causes of acute exacerbations of COPD
Respiratory tract infections
- commonly rhinovirus
Smoking
Enviromental pollutants
Clinical presentation of acute exacerbations of COPD
Increased breathlessness
Increased cough
Increased sputum production and change in colour
Differential diagnosis of acute exacerbations of COPD
Pneumonia PE Pneumothorax Acute heart failure Pleural effusion Cardiac ischemia/arrhythmia Lung cancer Upper airway obstruction
Management of COPD
Stop smoking Pneumococcal and influenza vaccinations Pulmonary rehabilitation SABA or SAMA to increase exercise tolerance LABA or LAMA
Management of acute exacerbations of COPD
Increase dose or frequency of SABA Oral corticosteroids - 30mg oral prednisolone Antibiotics - amoxicillin - doxycycline - clarithromycin
Define asthma
Chronic respiratory condition associated with airway inflammation and hyper-responsiveness
Risk factors for asthma
PMH/FH of atopic disease Male sex for pre-pubertal asthma Female sex for persistence of asthma from childhood to adulthood Respiratory infections in infancy Exposure to tobacco smoke Premature birth and low birth weight Obesity Social deprivation Exposure to inhaled particles Workplace exposure
Complications of asthma
Death Respiratory complications - irreversible airway changes - pneumonia - pulmonary collapse - respiratory failure - pneumothorax Imparied QoL - fatigue - underperformance and time off school/work
Clinical presentation of asthma
Wheeze - expiratory polyphonic Cough Breathlessness Chest tightness Episodic, diurnal and triggered/exacerbated by exercise, viral infections or exposure to cold air or allergens
Spirometry of asthma
FEV1/FVC greater than 70%
Bronchodilator reversibility
Variable peak expiratory flow readings
Differential diagnosis of asthma
Bronchiectasis COPD Ciliary dyskinesia Cystic fibrosis Dysfunctional breathing Foreign body aspiration GORD Heart failure ILD Lung cancer Pertussis PE TB Upper airway cough syndrome Vocal cord dysfunction
Definition of complete control of asthma
No daytime symptoms No night-time waking No need for rescue medication No asthma attacks No limitations on exercise Normal lung function Minimal side effects from medication
Management of asthma
Personalised asthma plan Routine vaccinations Inhaler technique Inhaled SABA - reliever ICS - preventer LTRA
Define MI
Necrosis of section of myocardial tissue due to ischaemia
Risk factors for MI
Male sex Advancing age Socioeconomic status Geographical location - highest in scotland, lowes in england Obesity Smoking Hyopetesnion Hypercholesterolaemia DM FH
Complications of MI
Acute heart failure Chronic heart failure Post-infarction angina Stroke Depression Anxiety Sudden death
Secondary prevention of previous MI
Relevant lifestyle changes reduce risk - stop smoking - cardioprotective diet - physically active - weight loss - alcohol less than 14 units Cardiac rehabilitation programme Medications - ACEi - aspirin + clopidogrel/ticagrelor - beta-blocker - statin
Definition of hypetension
Systolic over 140
Diastolic over 90
Stages of hypertension
1 - 140/90 to 159/99
2 - 160/100 to 180/120
3 - over 180/120
Risk factors for hypertension
Age Sex Ethnicity Social deprivation Lifestyle Anxiety and emotional stress
Complications of hypertension
HF Coronary artery disease Stroke Chronic kidney disease Peripheral arterial disease Vascular dementia
Investigations for target organ damage due to hypertension
Haematuria Urine albumin:creatinine ratio HbA1c Electrolytes, creatinine and eGFR 12-lead ECG Serum total cholesterol and HDL cholesterol - CVS risk
Secondary causes of hypertension
Renal disorders - chronic pyelonephritis - diabetic nephropathy - glomerulonephritis - PCKD - obstructive uropathy - renal cell carcinoma Vascular - coarctation of aorta - renal artery stenosis Endocrine - primary hyperaldosteronism - phaeochromocytoma - cushing's syndrome - acromegaly - hypothyroidism - hyperthyroidism Drugs - alcohol - ciclosporin - COCP - corticosteroids - erythropoietin - NSIADs
Management of hypertension
Lifestyle advice - diet and exercise - reduce caffeine - reduce dietary sodium - smoking cessation - reduce alcohol consumption Drug management - ACEi/ARB - CCB - over 55 or black African/Afro-Caribbean - thiazide-like diuretic
Define heart failure
Ability of heart to maintain the circulation of blood is impaired as a result of structural or functional impairment of ventricular filling or ejection
Classification of heart failure
Ejection fraction - heart failure with reduced ejection fraction (HR-REF) - heart failure with preserved ejection fraction (HR-PEF) Time course - acute - chronic Symptomatic severity - 1-4
Causes of heart failure
Myocardial disease - coronary artery disease - hypertension - cardiomyopathies Valvular heart disease Pericardial disease Congestive heart disease Arrhythmias High output states - anaemia - thyrotoxicosis - phaeochromocytoma - septicaemia - liver failure - thiamine deficiency Volume overload - end-stage chronic kidney disease - nephrotic syndrome Obesity Drugs - alcohol - cocaine - NSAIDs
Complications of heart failure
Cardiac arrhythmias - AF - ventricular arrhythmias Depression Cachexia CKD Sexual dysfunction Sudden cardiac death
Clinical features of chronic heart failure
Breathlessness
Fluid retention
Fatigue, decreased exercise tolerance, increased recovery time after exercise
Light headedness or history of syncope
Tachycardia
Laterally displaced apex beat, heart murmurs or 3rd/4th heart sounds
Raised JVP
Enlarged liver
Tachypnoea, basal crepitations, pleural effusions
Management of heart failure
Relive fluid overload - loop diuretic
ACEi
Beta-blocker
Consider statin and antiplatelet
