Risk Assessment

Question 1

Cardiovascular risk calc

Answer 1

QRISK

Question 2

What is QRISK

Answer 2

Gives risk of a person developing CVD over the next 10 years in those aged 35–74;

Question 3

Personal Info QRISK

Answer 3

Age.
o Sex.
o Ethnicity.
o BMI (height cm, weight kg).

Question 4

PMH QRISK

Answer 4

CKD (stage 4/5).
o Atrial fibrillation.
o Rheumatoid arthritis. o Diabetic status.

Question 5

Drug Hx QRISK

Answer 5

Antihypertensives

Question 6

FHX QRISK

Answer 6

Angina, MI in 1st degree relative <60 years

Question 7

Direct measurements QRISK

Answer 7

Cholesterol/HDL ratio
o Systolic blood pressure (mmHg).

Question 8

Risk score of QRISK %

Answer 8

<10% = low risk. 10–20% = moderate risk. >20% = high risk.

Question 9

Management Risk LOW

Answer 9

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 –
o Stop smoking.
o Exercise.
o Diet change/weight loss.
o Disease control/medication adherence.

Question 10

Management QRISK >10%

Answer 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.

Question 11

Stroke risk in AF

Answer 11

CHA2DS2VaSc

Question 12

CHA2DS2VaSc categories

Answer 12

Congestive heart failure (PMH) = 1 point.
- HTN (PMH) = 1 point.
- Age (personal information) –
o 65≤age<75=1point.
o ≥75 = 2 points.
- Diabetes (PMH) = 1 point.
- Stroke/TIA (PMH) = 2 points.
- Vascular disease (PMH) = 1 point.
- Sex category female (personal information) = 1 point.

Question 13

CHAD score 0

Answer 13

No anticoagulant required

Question 14

Score 1 CHADV

Answer 14

Consider anticoagulation with vitamin K antagonist like warfarin within therapeutic range (INR 2–3) or a DOAC (rivaroxaban, apixaban), maybe aspirin.

Question 15

Score 2+ CHADV

Answer 15

Score 2 or more = anticoagulation required with vitamin K antagonist like warfarin within therapeutic range (INR 2–3) or a DOAC (rivaroxaban, apixaban).

Question 16

Difference in men and women CHADV

Answer 16

Women will always have score of one so inc boundaries by 1

Question 17

CHADV is already on anticoag

Answer 17

Manage modifiable risk factors for bleeding (HAS BLED – uncontrolled HTN,
renal/liver disease, labile INR, using NSAIDs/antiplatelets, alcohol consumption).

Question 18

General lifestyle advice CHADVAs

Answer 18

Avoid alcohol.
- Smoking cessation.
- Healthy diet.
- Exercise.

Question 19

Warfarin Advice

Answer 19

• Needs INR check.
• Teratogenic.
• Can interfere with other medications.
• Increased bleeding risk.
• Diet control.
• Can be reversed with vitamin K.

Question 20

DOAC advice

Answer 20

Non-reversible.
- Increased bleeding risk.
- Expensive.
- C/I in renal impairment/Hx of GI bleed.

Question 21

FRAX

Answer 21

Gives 10 year probability of a fracture in the spine, hip, shoulder or wrist for people aged 40–90 years old.

Question 22

Personal History FRAX

Answer 22

Age.
o Sex.
o Weight (kg). o Height (cm).

Question 23

PMH FRAX

Answer 23

Rheumatoid arthritis.
o Previous fracture.
o Secondary osteoporosis;
▪ Kidney failure, hyperthyroidism, coeliac disease, kidney failure, T1DM, chronic liver disease, premature menopause.
o Femoral neck BMD from previous DEXA-T scan (g/cm2).

Question 24

Causes of secondary osteoporosis

Answer 24

Kidney failure, hyperthyroidism, coeliac disease, kidney failure, T1DM, chronic liver disease, premature menopause.

Question 25

Drug HX FRAX

Answer 25

Glucocorticoids.
o Lithium.

Question 26

FHX FRAX

Answer 26

Parental fractured hip.

Question 27

SHX FRAX

Answer 27

Smoking.
o Alcohol intake (≥3 alcoholic drinks a day).

Question 28

What is a T score

Answer 28

A T-score shows how much your bone density is higher/lower than the bone density of a healthy 30-year old adult.

Question 29

What is a Z score

Answer 29

A Z-score compares the condition of your bones with someone of your age/sex/weight/ethnicity.

Question 30

T score >= 1

Answer 30

normal bone density, no intervention.

Question 31

-2.5 < Score <= -1

Answer 31

osteopenia, consider medication, lifestyle advice

Question 32

T score <= -2.5

Answer 32

osteoporosis, medication, lifestyle advice.

Question 33

Treatment for low FRAX score

Answer 33

(≤10%, reassess 5y) –

Lifestyle advice;
▪ More weight-bearing exercise, quitting smoking and limiting alcohol.
▪ Calcium + vitamin D rich diet, balance exercises.
o Home adaptations;
Getting rid of throw rugs, installing grab bars.
Wearing shoes with good grip

Question 34

Intermediate FRAX

Answer 34

(10 < % < 20) –
DEXA scan to measure BMD + if ≤–2.5, Tx with bisphosphonate like alendronate 10mg OD or denosumab (RANK-L), teriparatide.

Question 35

High Risk FRAX

Answer 35

T-score >–2.5 modify risk factors and reassess in 2 years. o T score <–2.5 Tx
if ≤–2.5, Tx with bisphosphonate like alendronate 10mg OD or denosumab (RANK-L), teriparatide.

Question 36

ABCD2

Answer 36

Risk of stroke after AF

Question 37

ABCD2 categories

Answer 37

Age ≥60 = 1 point.
- BP ≥140/90mmHg = 1 point.
- Clinical features;
o Unilateral weakness = 2 points.
o Speech disturbance without weakness = 1 point. - Duration –
o ≥60 minutes = 2 points.
o 10≤minutes<60=1point. - Diabetes = 1 point.
Could also enquire about atrial fibrillation.
Have they had any other TIAs in the past? How long apart were they?

Question 38

Score of ABCD2

Answer 38

Score ≤3 = seen within 7 days
Score 4 ≤ score < 6 = specialist within 24 hours Score >6 = specialist referral immediately

Question 39

TIA treatment Lifestyle advice

Answer 39

Lifestyle advice;
o Diet (lower fats and cholesterol). o Exercise more.
o Smoking cessation.
DO NOT DRIVE FOR AT LEAST 1 MONTH FOLLOWING A TIA.

Question 40

TIA treatment medically

Answer 40

300mg aspirin immediately then continued long term 75mg OD. o Clopidogrel 75mg.
Secondary prevention (adherence to medication); o Control HTN.
o Statin for patients with high cholesterol.
Carotid endarterectomy if ICA stenosis >70%

Question 41

HPC Wells

Answer 41

Paralysis, paresis or recent immobilisation of leg = 1 point.
o Localised tenderness along the deep venous system = 1 point.
o Entire leg swollen = 1 point.
o Calf swelling >3cm compared to other leg (measured 10cm below the tibial
tuberosity) = 1 point.
o Pitting oedema, confined to symptomatic leg = 1 point. o Collateral superficial veins present = 1 point.

Question 42

PMH Wells

Answer 42

Bedridden recently >3 days or major surgery within 12 weeks = 1 point. o Active cancer (treatment or palliation within 6 months) = 1 point.
o Previous DVT = 1 point.
Alternative Dx to DVT as or more likely = –2 points.

Question 43

SHx wells

Answer 43

can ask about long-haul flights, smoking and HRT/OCP if appropriate.

Question 44

Wells score interpretation

Answer 44

Score ≤0 = DVT unlikely, 5% prevalence Score 1–2 = DVT moderate risk, 17% prevalence Score ≥3 = DVT likely, 17–53% prevalence

Question 45

Actions of wells score

Answer 45

D-dimer is good for a negative exclusion, high specificity, low sensitivity –
o If negative then it can be ruled out.
o If positive it isn’t diagnostic.
o Good if they have a low clinical probability score.
- USS doppler veins if high risk.
- CTPA is gold standard for diagnosing PE.

Question 46

DVT Treatment

Answer 46

LMWH.
- Oral warfarin and maintain INR 2–3 or a DOAC.
- Compression stockings.
- Treat/seek underlying cause.
- Diet, exercise, smoking cessation.

Question 47

Non modifiable RF diabetes

Answer 47

Age - 50+, 60+, 70+
Gender - male
Ethnicity - Any other ethnic group other than white European = 6 points.
Relative with diabetes

Question 48

Modifiable RF Diabetes

Answer 48

Waist measurement;
▪ 90≤cm<100=4points.
▪ 100≤cm<110=6points.
▪ ≥110cm = 9 points.
o Height and weight measurement for BMI;
▪ 25≤kg/m2<30=3points.
▪ 30≤kg/m2<35=5points.
▪ ≥35kg/m2 = 8 points.
o HTN;
▪ Yes = 5 points.

Question 49

Risk scores Diabetes

Answer 49

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.

Question 50

Risk reduction of diabetes

Answer 50

Regular meals/portion size, decrease fat/sugar/salt, moderate alcohol.
Exercise 150mins/week
oWeight loss

Question 51

Recognising signs of diabetes 5 T

Answer 51

• Toilet (polyuria).
  o Thirsty (polydipsia).
  o Tiredness (more than usual).
  o Thrush (genital itching secondary to infection). o Thinner (unintentional weight loss).