Risk assessment Flashcards
What is the risk assessment tool for osteoporosis? What does it measure?
- FRAX score
- Gives 10 year probability of a fracture in the spine, hip, shoulder or wrist for people aged 40–90 years old.
What are the components of the FRAX score?
- Age (40-90)
- Sex
- Weight (kg)
- Height (cm)
- Previous fracture
- Parent fractured hip
- Current smoker
- Glucocorticoids
- Rheumatoid arthritis
- Secondary osteoporosis
- Alcohol >3 units/day
- Femoral neck BMD
How can we incorporate the components of the FRAX score into a general history?
Personal information:
- Age.
- Sex.
- Weight (kg).
- Height (cm).
Past medical history:
- Rheumatoid arthritis.
- Previous fracture.
- 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).
Drug history:
- Glucocorticoids.
- Lithium.
Family history:
- Parental fractured hip.
Social history:
- Smoking.
- Alcohol intake (≥3 alcoholic drinks a day).
What is a T-score? What is a Z-score?
- A T-score shows how much your bone density is higher/lower than the bone density of a healthy 30-year old adult.
- A Z-score compares the condition of your bones with someone of your age/sex/weight/ethnicity.
What are the three different categories of a T-score?
- T–score ≥ –1 = normal bone density, no intervention.
- –2.5 < T–score ≤ –1 = osteopenia, consider medication, lifestyle advice
- T–score ≤ –2.5 = osteoporosis, medication, lifestyle advice.
What is the treatment offered for the three different categories of 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, treat 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.
How do we assess DVT risk?
Well’s score (probability of developing a DVT)
What are the different components of a Well’s score?
- Active cancer
- Bedridden >3 days or major surgery within 12 weeks
- Calf swelling >3cm compared to the other leg
- Collateral superficial veins present
- Entire leg swollen
- Localised tenderness along the deep venous system
- Pitting oedema in symptomatic leg
- Paralysis, paresis, or recent plaster immobilisation of the lower extremity
- Previously documented DVT
How can we incorporate the different components of a Well’s score into a general history?
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:
- Long-haul flights
- Smoking
- HRT/OCP if appropriate.
- Pregnancy if appropriate.
What do the three categories of Well’s score mean?
Score ≤0 = DVT unlikely, 5% prevalence
Score 1–2 = DVT moderate risk, 17% prevalence
Score ≥3 = DVT likely, 17–53% prevalence
> or equal to 2 – DVT likely (D-dimer and USS)
or equal to 1 – DVT unlikely (D-dimer)
What is the gold standard test for diagnosing a PE?
CTPA
How should we treat a DVT?
- LMWH, e.g. dalteparin
- Oral warfarin and maintain INR 2–3 or a DOAC.
- Compression stockings.
- Treat/seek underlying cause.
- Diet, exercise, smoking cessation.
What are the components of the diabetes risk score?
Non-modifiable risk factors (personal information):
- Age: 50 ≤ age < 60 = 5 points, 60 ≤ age < 70 = 9 points, ≥70 = 13 points.
- Gender: male = 1 point.
- Ethnicity: any other ethnic group other than white European = 6 points.
- Relative with diabetes (ask in family history): yes = 5 points.
Modifiable risk factors (past medical history):
- Waist measurement: 90 ≤ cm < 100 = 4 points, 100 ≤ cm < 110 = 6 points, ≥110cm = 9 points.
- Height and weight measurement for BMI: 25 ≤ kg/m2 < 30 = 3 points, 30 ≤ kg/m2 < 35 = 5 points, ≥35kg/m2 = 8 points.
HTN: yes = 5 points.
What are the 4 categories of the diabetes risk score and what do they mean?
- Low risk = 0 – 6 points, 1 in 100 risk.
- Increased risk = 7 – 15 points, 1 in 35 risk.
- Moderate risk = 16 – 24 points, 1 in 10 risk.
- High risk = 25 – 47 points, 1 in 4 risk.
What is the lifestyle advice we can give to someone for the diabetes risk score?
- Regular meals/portion size
- Decrease fat/sugar/salt
- Moderate alcohol.
- Exercise 150mins/week
- Weight loss.
What are the signs of diabetes?
5Ts:
- Toilet (polyuria).
- Thirsty (polydipsia).
- Tiredness (more than usual).
- Thrush (genital itching secondary to infection).
- Thinner (unintentional weight loss).
What does the CHA2DS2VaSc score assess?
Stroke risk in AF
What are the different components of the CHA2DS2VaSc score?
- 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.
What are the different categories of the CHA2DS2VaSc score and what do they mean? What happens if they are already on an anticoagulant?
- 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).
- If already on anticoagulant:
Manage modifiable risk factors for bleeding (HAS BLED – uncontrolled HTN, renal/liver disease, labile INR, using NSAIDs/antiplatelets, alcohol consumption).
What is the general lifestyle advice, warfarin advice, and DOAC advice that we can offer to those with an increased CHA2DS2VaSc score?
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.
What does the Q-RISK3 score measure? When is it only valid?
- Calculates the patient’s risk of developing an
MI or stroke over the next 10 years. - Only valid if the patient does not already have
a diagnosis of coronary heart disease (inc.
angina/MI), stroke or TIA
What are the different components of a Q-RISK3 score?
Personal information:
- Age.
- Sex.
- Ethnicity.
- BMI (height cm, weight kg).
Past medical history (C.A.R.D.S M.E.M.):
- CKD (stage 3/4/5).
- Atrial fibrillation.
- Rheumatoid arthritis.
- Diabetic status.
- Systemic lupus erythematosus (SLE).
- Migraines.
- Erectile dysfunction.
- Severe mental illness
Drug history:
- Antihypertensives (blood pressure medication).
- Atypical antipsychotics.
- Steroids.
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).
What are the 3 different categories of the Q-RISK3 score and what do they mean?
<10% = low risk.
10–20% = moderate risk.
>20% = high risk.
What is the management plan for the different types of Q-RISK3 score?
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:
- Stop smoking.
- Exercise.
- Diet change/weight loss.
- 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.
What does the ABCD2 score measure?
Risk of stroke after a TIA.
What are the different components of the ABCD2 score? What could we also enquire about in the history?
- 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?
What are the different categories of ABCD2 score and what do they mean?
- Score ≤3 = seen within 7 days
- Score 4 ≤ score < 6 = specialist within 24 hours
- Score >6 = specialist referral immediately
What is the lifestyle advice, treatment, secondary prevention for TIAs? What should patients not do for at least a month following a TIA?
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.
What is the advice for taking bisphosphonates (FRAX)?
Bisphosphonates:
- Should be taken on an empty stomach with water - food and other beverages will decrease the amount of alendronate absorbed by the body.
- Stay stood or sat up for 30 mins after - to prevent the medication flowing back from your stomach and causing heartburn as they can irritate the oesophagus and stomach.
What does the HASBLED score assess?
Assesses the 1-year risk for major bleeding associated with oral anticoagulation (AF - warfarin)
What are the different components of the HASBLED score?
- Hypertension
- Abnormal renal or liver function
- Stroke
- Bleeding
- Labile INRs
- Elderly (>65 years)
- Drugs or alcohol
What are the different categories of the HASBLED score and what do they mean?
0 = low risk
1-2 = moderate risk
≥3 = high risk / 7
