risk scores and chronic disease mx Flashcards
what are the 3 main important points in the chronic disease mx station?
data analysis: current control
impact of disease on work, mood, sleep, social interactions
adherence to tx regimen and factors effecting
give the general questioning structure for the chronic disease station
we have these results which measure your X
youre results show X
do you know what this is and why we measured it
ask patient to establish why result is high/low
explain you will try and improve result
ask about sx
ask about current adherence (factors effecting: memory, SE, cost, didnt want to) and councel them
impact on home life
their concerns
what is a normal INR?
1
if on warfarin 2-3
what is warfarin?
vit K antagonist-> decreases factors 2,7,9, 10
can a dose of warfarin be doubled to catch up?
no
what qs are important in an INR/warfarin chronic disease station?
we have results measuring your INr
your INR is X which shows X
do you know what warfarin is-is an anticoagulant, stops blood clotting too easily
risks of high/low: higher INR=longer it takes to clot=increased risk bleeds. lower INR=thicker blood=increased clotting risk
why on warfarin-tx DVT, PE, prevent stroke in AF
sx: how feeling, infections, D+V (and blood), high INR (bruising, headace, stomach pain, blood in urine, prolonged bleeding after cuts/menstruation/gum bleeding), low INR (stroke, DVT)
PMH: liver failure, bleeding disorders, AF
drug hx: do you know how many times meant to be taking warfarin, how and when, do you miss doses, do you double doses, any issues. other meds=st johns wort, aspirin, nsaids, OCP/HRT, abx
diet: vit k-green veg, alcohol
what advice is given for INR control
avoid activities causing bruising/bleeding, brish/shave gently, tell HCP you take anticoag
if elevated: VIt K, if no explanation warfarin dose reduced
if low: LMWH, warfarin, compression stockings
DOACs generally preferred unless liver dysfunction or renal impairment, or over 120kg
what is a normal HbA1c?
42mmol/L or <6%
pre-diabetes: 42-47
diabetes>48
what important qs are asked for HbA1c hx
when were you tiagnosed, T1 or 2
HbA1c-acurate blood sugar over 2-3m, how well do you think your diabetes is being managed
benefits of reducing: decreased risk eye problems, losign sensation in hands and feet or kidney problmes
how are you feeling, recent infections, any DKA/hypos, sx diabetes
PMH: CVD, cerebrovascular, retinal, renal
medication: what, when, SE, struggling, monitoring leve;s, injection technique
socisl: mood, sleep, home, effects of disease, deit, exercise, smoking and alcohol
what can falsely raise or lower HbA1c?
increase: kidney failure, excess alcohol, vit B12 deficienct
deecrease: acute/chronic blood loss, sickle cell disease, thalassaemia
advice for HbA1c
dietary modifications: sugar, carbs and blood level
regular exercise-check with Dr to avoid hypos
take care when ill-check blood glucose more regularly, contact team
support: GP, diabeteic nurse, online, training courses
what does diurnal variation in peak flow suggest?
poorly controlled asthma
how can spirometry be interpreted?
obstruvtive: FEV1/FVC<70%, FEV1<80%
restritive: FEV1/FVC normal
what is important to ask in a peak flow/spirometry station?
peak flow measures how fast you can breathe out to see how well your lungs are working
spirometry measures lung function: amount and speed of air that can be inhaled/exhaled
how feeling, recent infection, sob, time notice worsening e.g. winter. red flags=wheeze getting worse, affecting ADL, waking up at night, using reliever more
how well do yuou think being controlled, medications, inhalers and how often, other meds, BB, inhaler technique assessed
any new pets, recent trave, damp housing, hayfever, smoking and alohol, impact on life
what advice is given at a peak flow/spirometry station?
stop smokong, avoid precipitating factors, vaccination, eating, exercise, support
what are the causes of obstructive lung disease?
asthma, COPD, bronchiectasis, inhaled forgein body, tumour
what are the casues of restrictive lung disease?
scoliosis, kyphosis, ankylosing spondylitis
guillain barre, myasthenia gravis, pulmonary fibrosus, sarcoidosis, asbestos
what inflammatory markers may be assessed
CRP and ESR
what qs are asked for inflammatory markers?
marker of inflammation, tell if flare up or new infection
how feeling, recent illnesses, sx
how well condition controlled, medcations, how often adherehce
recent travel, smoking, alcohol, impact on life
what advice is given for inflammatory markers?
stop smoking
disease mx and compliance
try and reduce result
any concerns
what is CRP and causees raise?
released by liver
acute and non specific
AI or inflammatory: JIA, RA, seronegative arthtitis, crohns, vasculitis, polyarteritis nodosa, pancreatitis
burns, trauma, infection, chronic inflammatory disease, MI, IBD, cancer
what is ESR and used for monitoring?
increased fibrinogen and CRP causes raised ESR
rises and falls slowly
temporal arteritis, systemic arteritis, polymyalgia rheumatica
what are liver function tests used for?
help diagnose and monitor liver disease and damage, levels of proteins and enzymes in blood
what increases liver enzymes?
chronic high alcohol, obesits, smoking, drug rxn
what are ALT and AST?
liver hepatic enzymes
markers of drugs, toxins and viral infections
indicate liver damage
what is ALP?
enzyme in liver and bone
marker for damage to biliary tree and bone disease
bile duct obstruction stimulates ALP synthesis
gall stones, primar biliary sclerosis, primary sclerosing cholangitis
hyperparathyroidism, osteomalacia, pagets
what is GGT?
alcoholic liver disease
what does increased ALP and GGT indicate?
cholestasis
what does increased ALP and ALT indicate?
cholestatic pattern
what does increased ALT and ALP indicate?
hepatocellular pattern
if increased AST and ALT same amount?
hepatic problems
increased ALT>AST?
chronic liver disrase
increased Ast>ALT?
cirrhosis and acute alcoholic hepatitis
what does GGT and ALP increased >AST and ALT?
obstructive jaundice
what is albumin?
produced in liver, indication synthetic function
low=liver damage-IBD, cronhs, hepatitis, cirrhosis
high-infection, dehydration, chronic inflammatory disease, hepatitis
what are globulins in liver?
total proteins
what is important to ask in LFTs?
how feeling, recent illnessses
prev gallstones, UC, crohns, surgery
how well managing, medication,s how often issues
travel, smoking, alcohol, recreational drugs, toxins, deit, impact on life
ICE
advice for LFTs?
stop smoking/alcohol/drugs
diet
disease mx and compliance
what are tumour markers?
produced by cancer cells or the body in response
tells if tx working, recurrenece, diagnosis, staging, prognosis
found in blood, urine, stools, tumours
what qs are asked for tumour markers?
how feeling, recent illnesses
sx: fatigue, wt loss, change in bowel or bladder, lump, sking canges, cough, swallowing, indigestion, muscles and joint aches, fevers, bleeding and bruising
how well being controlled, medication or tx, how often, issues
impact on life, concerns, support
how is diabetes risk score interpreted?
low: 0-6, 1%
increased: 7-15, 1 in 35
moderate: 16-25, 10%
high: 25-47, 25%
what qs are asked in diabetes risk assessment?
age
gender: M
ethnicity
relative with diabetes
waist measurement
ht and wt for BMI
HTN
sx: polyuria, polydipsia, fatigue, thrush, wt loss
what advice is given for diabetes risk?
lifestyle-8wk
regular meals, portion size, decrease fat/sugar
food and exercise diarry
exercise 150 min/wk
wt loss
what is the QRISK2 score?
risk of developing CVD next 10y aged 35-74
<10%=low,
10-20%=moderate
>20%=high
what qs are asked for QRISK2?
age
sex
ethnicity
BMI
CKD stage 4/5
AF
RA
DM
HTN tx
first degree relative <60 with angina or MI
smoking
cholesterol/HDL ratio
BP
how is QRISK2 mx?
<10%: lifestyle, smoking, exercise, deit, wt loss
>10%:lifestyle, tx comorbidities, lipid modification
what is the CHa2Ds2VaSc score?
risk stroke with AF
how is CHa2DS2VaSc calculated
CCF
HTN
age (>75, 65-75)
DM
stroke or TUA
vascular disease
female
how is CHADSVASC mx?
0=no anticoag
1=consider , maybe aspirin
2+required
DOAC, warfarin
if on anticoag: modifiable RF=HASBLED=HTN, renal/liver, labile INR, NSAIDs/antiplatelets, alcohol
lifestyle
warfarin: INR check, teratogenic, increased bleeding risk, diet
DOAC: non-reveersible, CI renal impairment and hx GI bleed
what is the FRAX score?
10 yr probability osteoporotic fracture in spine, hip, shoulder, wrist 40-90
what qs are asked for FRAX>
age
sex
wt
ht
femoral neck BMD
RA
secondary osteoporosis: kidney failure, cushings, coeliac, MS, hyperparathyroid, hyperthyroid, DM, prev fracture
drug: glucocorticoids, lithium, barbiturates
parental hip fracture
smoker
alcohol >3 units/d
how is FRAX mx?
low=<10%, reassess 5r: lifestyle-wt bearing exercise, no smoking or alocohol, calcium and vit D diet, shoes with good grip
intermediate: 10-20%: DEXA scan and tx bisphosponate if<2.5
high risk: DEXA and modify RF
what is the Well’s score?
for DVT
what is asked for Wells’
paralysis or immobilisation of leg
localised tenderness along deep venous system
entire leg swollen
calf swelling >10cm compared to other leg
pitting oedema in sx leg
collateral superficial veins
bedridden >3d or major surgery in 12w
active cancer within 6m
prev DVT
aldernative diagnosis more likelt -2
long haul flighrs, smoking, HRT/OCP
how is wells score mx?
0=unlikelt
1-2=moderate-17%
=>3 likely
D-dimer if unlikely, unreliable
USS dopler
PE=CTPA
tx: LMWH, warfarin or DOAC, compression stockings, find cause, diet, exercsie, smoking
