What questions need to be asked regarding chronic disease management?
-You will need to ask the patient a relevant history and explore the reasons why a particular disease is not as well controlled as it should be.
- Ask how well the disease is currently controlled and if there have been any changes in circumstances that may have changed this
- Assess the impact on the patients life. mood, ability to work, quality of sleep, social interactions etc.
- Ask focussed questions to establish the patients’ adherence with their treatment regimen and any factors influencing this.
- Look at the data provided and ascertain the problem e.g. if an inflammatory marker is going up or is the disease under control e.g. increased HbA1c or if the peak flow diary is showing good control or not?
What questions need to be asked in the diabetes risk score?
- Male or female
- Age
- Ethnicity
- Relative with type 2 diabetes
- Waist size
- BMI
- High blood pressure
What are the questions asked in a Q-risk score?
Social and family history
- Age
- Gender
- Ethnicity
- Smoking status
- Diabetes
- Family history of heart attack or stroke under 60
- Cholesterol
- BMI
Past medical history
- CKD
- AF
- Migraines
- Rheumatoid arthritis
- SLE
- Severe mental illness
Medication history
- Antipsychotic
- Steroids
- Treatment for erectile dysfunction
- Blood pressure treatment
What is included in the CHA2DS2-VASC score
- C- Congestive heart failure
- H- Hypertension
- A- age 2 points for over 75 1 point for over 65
- D- Diabetes
- S2- Stroke or a TIA
- V- Vascular disease: this includes PAD, heart attack
- A- Age
- S- Sex one point is assigned for female
Greater than or equal 2 in men and greater or equal to 3 in women
What is included in ABCD2 score?
- Age 1 point if above 60
- Blood pressure 140/90 at time of evaluation
- Clinical features 2 points for speech and 1 point for weakness/numbness
- Duration 2 points of longer than 60 mins- 10-59 is 1 point
- Diabetes
What is included in the Wells risk score?
HPC
- Calf swelling more than 3cm
- Superficial veins present
- Entire leg swollen
- Pitting oedema
- Localised swelling and tenderness
- Rule out a PE and other causes
PMH
- Active cancer
- Bed ridden recently with major surgery
- Paralysis or recent lower limb immobilisation
- Previous DVT
Medication
- Anticoagulants
- The pill- ask about if there is a possibility of pregnancy
Social history
- Ask about foreign travel
- Ask about job
- Ask about exercise
What is asked in the FRAX score?
- Age
- Gender
- BMI: low BMI is associated with an increased fracture risk
- Previous fractures
- Parental hip fractures
- Smoking
- Alcohol consumption
- Long- term glycococotricooid steroid use
Cerebellar exam
- Walk
- Heel to toe walking
- Romberg’s test
- Slurred speech, British constitution, baby
- Nystagmus
- Tone is arms
- Finger to nose and flip hand
- Hold hands out and test for rebound
- Knee jerk reflex
- Heel shin test
What is INR?
- International normalised ratio: normal INR is 1 and people on warfarin should aim for 2-3.
What is warfarin and when should it be taken?
- It is a vitamin K antagonist.
- It needs to be taken at the same time every day, regular blood tests need to be done. DO NOT DOUBLE DOSE
What to ask in an introduction for INR chronic disease management?
- Ask if they know what warfarin is and what it does
- Explain the higher the INR the longer taken for blood to clot
- Explain why they’re on warfarin
What questions to ask for PC in INR history?
- How are they feeling
- Any recent illness or infections
- Diarrhoea, vomiting
- High INR-Headache, bruising, bleeding, blood in urine
- Low INR- stroke symptoms, DVT/PE symptoms
What are the drug history and PMHx questions to ask in INR?
Past medical history- liver failure or any clotting disorders
Drug history
- How many times a day are you meant to take it
- Double doses
- Struggling to keep up with doses
- Any other medication ask about herbal as well
What to ask in social history INR?
- Change in diet: eating lots of green vegetables: do need to stop just keep consistent
- Alcohol and smoking can increase INR
- How are they feeling
- Sleep disturbance
- Weight change
- Impact of ADLs
Treatments INR?
- Elevated: vitamin K and blood transfusion, can also lower the dose
- Low: give more warfarin and compression stockings
What are the different values for HbA1c?
- Normal is 42 and below
- Pre diabetes is 42-47
- Diabetes is 48
What are the intro questions?
- Ask about when they were diagnosed and if it was type 1 or 2
- Explain what HbA1c is
- Explain the benefits of reducing it
- How well are they controlling g it
What are the questions in PC to ask?
- How are they feeling
- Any recent infections
- Any hypos
- Any symptoms of diabetes: polydipsia, polyuria, weight loss/gain, visual changes, changes to sensation
- Sleep disturbance
What are the PMHs to ask in HbA1c?
- Any complications associated with diabetes
Falsely raised-: - kidney disease
- Alcohol
- Vitamin B deficiency
Falsely lowered
- Acute/chronic blood loss
- Sickle cell disease
- Thalassaemia
drug history questions to ask in HbA1c?
- What diabetes medications are you taking
- How often and are there any side effects
- Injecting correctly, and monitoring
- Any other medications?
Social history questions HbA1c?
- How is mood, is it affecting ADLs
- How is diet
- Exercise
- Smoking and alcohol
- Impact diabetes has on life
Advice for lowering HbA1c?
- Diet
- Exercise
- Take extra care when ill
- Monitor
- Support available
Presenting complaint asthma?
- Ask about how they’re doing
- Have they got a cough
- Shortness of breath
- Exacerbations recently
- How is there current situation affecting the ADLs, socialising, work, exercise, home situation
Drug history questions for asthma?
- Ask what medications they take? Which inhalers do they use
- How often do they use their inhalers? Is this more frequent than usual?
- Are they on any steroids, check they’re not on beta blockers
- Ask about inhaler technique and when their last appointment to check this was?
