Risk Assessement Station Flashcards
GENERAL TIPS
BE DIRECT MENTION WHICH RISK SCORE YOURE USING
Diabetes Risk
Points based out of 47
Non-modifiable risk factors - BHASE
Height and weight for BMI
= 20-30 - 3 pts
= 30-35 - 5 pts
> 35 - 8 pts
HTN - 5 pts
- Age
= 50-50 - 5 pts
= 60-70 - 9 pts
> 70 - 13 pts - Sex
= male - 1 pt - family history of T2DM - 5pts
- Ethnicity
= anything other than white European - 6 pts
Modifiable risk factors -
- Waist measurement
= 90-100cm - 4pts
= 100-110cm - 6pts
> 110cm - 9pts
Low risk = 0-6 points = 1/100
Increased risk = 7-15 = 1/35
Moderate risk = 16-24 = 1/10
High risk = 25-47 = 1/4
Diabetic
Risk reduction of diabetes
Lifestyle advice –
- Regular meals/portion size, decrease fat/sugar/salt, moderate alcohol.
- Exercise 150mins/week
- Weight loss.
Recognising signs of diabetes, 5Ts –
- Toilet (polyuria).
- Thirsty (polydipsia).
- Tiredness (more than usual).
- Thrush (genital itching secondary to infection).
- Thinner (unintentional weight loss).
Cardiovascular risk - QRISK3 score %
If you got 100 people with the same risk factors as you and put then in one room X% would have a future cardiovascular event (heart attack/ stroke)
Personal information – BASE
- BMI
- Age.
- Sex.
- Ethnicity
Past medical history (C.A.R.D.S.M.M.A.H ) -
- CKD (stage 4/5).
- Atrial fibrillation.
- Rheumatoid arthritis.
- Diabetic status.
- SLE
- Migraine
- Severe Mental health issues
- Angina
- HTN
Drug history –
- Antihypertensives.
Family history –
- Angina/heart attack in first degree relative <60 years old.
Social history –
- Smoking status.
Direct measurements –
- Cholesterol/HDL ratio
- Systolic blood pressure (mmHg).
<10% = low risk.
10–20% = moderate risk.
>20% = high risk.
Risk reduction of high cholesterol
Management <10% –
- Advise that risk is low but further reductions in risk can often still be achieved.
- Offer advice on relevant lifestyle factors that can be improved –
1Stop smoking.
2Exercise.
3Diet change/weight loss.
4 Disease control/medication adherence.
Management >10% –
- Offer advice on any relevant lifestyle factors to reduce risk.
- Consider reviewing any relevant comorbidities that may not be optimally controlled.
- Discuss the benefits and risks of taking a lipid modification therapy.
Stroke risk in atrial fibrillation – CHA2DS2VaSc score /9
- Congestive heart failure (PMH) = 1 point.
- HTN (PMH) = 1 point.
- Age (personal information) –
= 65 ≤ age < 75 = 1 point.
= ≥75 = 2 points. - Diabetes (PMH) = 1 point.
- Stroke/TIA (PMH) = 2 points.
- Vascular disease (PMH) = 1 point.
- Sex category female (personal information) = 1 point
Score 0 = no anticoagulation required.
Score 1 = consider anticoagulation with vitamin K antagonist like warfarin within therapeutic range (INR 2–3) or a DOAC (rivaroxaban, apixaban), maybe aspirin.
Score 2 or more = anticoagulation required with vitamin K antagonist like warfarin within therapeutic range (INR 2–3) or a DOAC (rivaroxaban, apixaban).
Risk reduction for stroke
If already on anticoagulant – Manage modifiable risk factors for bleeding.
General lifestyle advice –
- Avoid alcohol.
- Smoking cessation.
- Healthy diet.
- Exercise.
Warfarin advice –
- Needs INR check.
- Teratogenic.
- Can interfere with other medications.
- Increased bleeding risk.
- Diet control.
- Can be reversed with vitamin K.
DOACs advice –
- Non-reversible.
- Increased bleeding risk.
- Expensive.
- C/I in renal impairment/Hx of GI bleed.
HASBLED score for risk of bleeding
H - HTN = 1 pt
A - Abnormal liver or renal function = 1 or 2 pt
S - Stroke = 1 pt
B - Bleeding = 1 pt
L - Labile INR = 1 pt
E - Elderly (age > 65) = 1 pt
D - Drugs or Alcohol = 1 or 2 pt
FRAX score - Osteoporosis risk
Gives 10 year probability of a fracture in the spine, hip, shoulder or wrist for people aged 40–90 years old.
Personal information – BASE
- BMI (Height kg and weight cm)
- Age
- Sex
- Ethnicity
GRAB PASSSS
Glucocorticoids + lithium (PDH)
Rheumatoid arthritis (PMH)
Age
Bone mineral density
Previous + parental fractures (FH)
Alcohol (>3 alcoholic drinks a day)
Size (height and weight)
Smoking
Sex
Secondary osteoporosis;
= Kidney failure, hyperthyroidism, coeliac disease, kidney failure, T1DM, chronic liver disease, premature menopause.
- Femoral neck BMD from previous DEXA-T scan (g/cm2).
T/Z score–
T-score shows how much your bone density is higher/lower than the bone density of a healthy 30-year old adult.
Z-score compares the condition of your bones with someone of your age/sex/weight/ethnicity.
T ≥ –1 = normal bone density, no intervention
– 1 < T ≤ – 2.5 = osteopenia, consider medication, lifestyle advice
T ≤ –2.5 = osteoporosis, medication, lifestyle advice
Treatment for FRAX scores
Low risk (≤10%, reassess 5y) –
- Lifestyle advice;
= More weight-bearing exercise, quitting smoking and limiting alcohol.
= Calcium + vitamin D rich diet, balance exercises.
- Home adaptations;
= Getting rid of throw rugs, installing grab bars.
= Wearing shoes with good grip.
- Intermediate risk (10 < % < 20) –
- DEXA scan to measure BMD + if ≤–2.5, Tx with bisphosphonate like alendronate 10mg OD or denosumab (RANK-L), teriparatide.
- High risk (≥20%) –
= T-score >–2.5 modify risk factors and reassess in 2 years.
= T score <–2.5 Tx as above.
Risk of stroke after TIA – ABCD2 /7
- Age ≥60 = 1 point.
- BP ≥140/90mmHg = 1 point.
- Clinical features;
= Unilateral weakness = 2 points.
= Speech disturbance without weakness = 1 point. - Duration –
= ≥60 minutes = 2 points.
= 10 ≤ minutes < 60 = 1 point. - Diabetes = 1 point.
Could also enquire about atrial fibrillation.
Have they had any other TIAs in the past? How long apart were they?
Score ≤3 = seen within 7 days
Score 4 ≤ score < 6 = specialist within 24 hours
Score >6 = specialist referral immediately
TIA treatment
Lifestyle advice;
- Diet (lower fats and cholesterol).
- Exercise more
- Smoking cessation.
Antithrombotic treatment;
- 300mg aspirin immediately then continued long term 75mg OD
- Clopidogrel 75mg.
Secondary prevention (adherence to medication);
- Control HTN
- Statin for patients with high cholesterol.
Carotid endarterectomy if ICA stenosis >70%
DO NOT DRIVE FOR AT LEAST 1 MONTH FOLLOWING A TIA.
DVT – Wells’ score
History of presenting complaint –
- Paralysis, paresis or recent immobilisation of leg = 1 point.
- Localised tenderness along the deep venous system = 1 point.
- Entire leg swollen = 1 point.
- Calf swelling >3cm compared to other leg (measured 10cm below the tibial tuberosity) = 1 point.
- Pitting oedema, confined to symptomatic leg = 1 point.
- Collateral superficial veins present = 1 point.
Past medical history –
- Bedridden recently >3 days or major surgery within 12 weeks = 1 point.
- Active cancer (treatment or palliation within 6 months) = 1 point.
- Previous DVT = 1 point.
Alternative Dx to DVT as or more likely = –2 points.
Social history can ask about long-haul flights, smoking and HRT/OCP if appropriate.
Score ≤0 = DVT unlikely, 5% prevalence
Score 1–2 = DVT moderate risk, 17% prevalence
Score ≥3 = DVT likely, 17–53% prevalence
Risk management for DVT
Actions
- D-dimer is good for a negative exclusion, high specificity, low sensitivity –
= If negative then it can be ruled out.
= If positive it isn’t diagnostic.
= Good if they have a low clinical probability score.
- USS doppler veins if high risk.
SCORE O: D DIMER TESTING
If negative = ruled out
+ve = further testing is needed (not diagnostic)
SCORE 1-2: HIGH SENSITIVITY D DIMER TESTING
SCORE 3 +: DVT LIKELY = NEEDS ULTRASOUND DOPPLER
> GOLD STANDARD: CTPA (for diagnosing PE)
DVT treatment
- LMWH.
- Oral warfarin and maintain INR 2–3 or a DOAC.
- Compression stockings.
- Treat/seek underlying cause.
- Diet, exercise, smoking cessation.
IKRAS ACRONYM FOR DVT WELLS SCORE
CUTE BAPS
C- Calf swelling > 3cm + Collateral superficial veins present
U- Unilateral pitting oedema
T- Tenderness
E- Entire swollen leg
B- Bedridden/surgeries
A- Active cancer
P- previous DVT
S- superficial veins
