1
Q
INR
- what is it?
- normal values?
A
This blood test looks to see how quick your blood clots.
- Normal = 1
- Normal for those on warfarin= 2-3
2
Q
Vitamin K dependant clotting factors
A
1972
- X, IX, VII, II
3
Q
Vitamin K containing foods
A
Broccoli, spinach, kale, celery, cucumber, green beans, green grapes, pears, avocado= avoid these if you are on anti-coagulants
4
Q
Warfarin: what is it, MOA
A
Anti-coagulant used to treat blood clots, blocks the enzyme vitamin K epoxide reductase which inhibits vitamin K dependant clotting factors. Very important to have INR checked regularly. If you miss a dose DO NOT double dose.
5
Q
What does a high INR mean?
What are the symptoms?
A
Blood takes longer to clot so is dangerously thin. Symptoms: - Unusual, severe headache - Severe stomach ache - Increased bruising - Prolonged bleeding after minor cuts - Bleeding from gums - Vomiting blood - Blood in urine - Bloody/dark stools
6
Q
What increases risk of elevated INR?
A
1) Too much anti-coagulation medication
check adherence to medication, are they double dosing?
2) Other medications: aspirin, NSAIDs, herbal medications, omeprazole, rifampicin, prednisolone
3) Liver failure
4) Bleeding disorders: haemophilia, factor VII
5) Decrease Vit K intake
6) Alcohol
7) Smoking
7
Q
How is an elevated INR treated?
A
- Vitamin K
- Blood components during a transfusion to help stop
your bleeding - Warfarin dose may be decreased and INR rechecked in 4-7 days
8
Q
How can I prevent elevated INR?
A
- Measure INR regularly
- Medication compliance
- Control your Vitamin K intake
- Do not smoke
9
Q
How do I decrease my risk of bleeding?
A
- Avoid activities that may cause bleeding or bruising
- Brush and shave gently
- Tell your dentist and other healthcare professionals if you take anticoagulant medicine (e.g. medical alert jewellery)
10
Q
Things to ask in HxPC
A
- any recent illness, fever, N/V/D, significant pain or stress?
- Side effects of warfarin? (all of the bleeding ones)
11
Q
Things to ask in DHX
A
- Confirm current Warfarin dose, any missed doses?- - — Taking it at the same time everyday?
- Double dosing?
- Any new medicines, discontinued medicines since last INR check?
- NSAIDS, aspirin, antibiotics, amiodarone, steroids
12
Q
Things to ask in SHx
A
- Any major changes (fasting, weight watchers), liver or 7 consumption?
- Diet rich in vitamin K or lacking vitamin K I .e. sudden change in intake of vitamin k rich foods? cranberry juice?
13
Q
Low INR - what does it mean? what are the symptoms?
A
Blood may be dangerously thick. Symptoms:
- Sudden weakness in any limb
- Numbness or tingling anywhere
- Visual changes
- Sudden onset of slurred speech or inability to speak
- New pain, swelling, redness or heat in body parts
- New SOB or chest pain
14
Q
Causes of low INR
A
- Supplements containing vitamin K
- High intake of foods that contain Vitamin K
- Oestrogen containing medications e.g. birth control pills and hormone replacement therapy
15
Q
Treatment for low INR
A
- Warfarin
- LMWH
16
Q
HBA1c
- What is it?
- Normal values? (pre-diabetic, diabetic)
A
Glycated haemoglobin - Gives the average blood glucose level over the previous two or three months Normal= 42 mmol/mol or <6.0% Pre-diabetes= 42-47 mmol/mol or 6-6.4% Diabetes= 48 mmol/mol or >6.5%
17
Q
Benefits of lowering HbA1c
A
Reduces the risk of
- Retinopathy
- Neuropathy
- Diabetic nephropathy
- Cataracts
- Heart failure
- Amputation
18
Q
Management plan for lowering HbA1c
A
- Be careful what you eat : dietary modifications
- Physical activity (check with doctor to see if chance of hypogylcaemia)
- Medications e.g. insulin, metformin, sulphonylureas
- Take extra care when you are ill, sick day rules
- Monitor blood sugar levels
19
Q
Conditions where it might be falsely raised
A
kidney failure
chronic excessive alcohol intake
vitamin B12 deficiency
20
Q
Conditions where it might be falsely decreased
A
acute or chronic blood loss
sickle cell disease
thalassemia
21
Q
Medications that may increase HbA1c levels
A
corticosteroids
22
Q
Things to ask in the presenting complaint?
A
I understand that you are…. and I can see from your results that your HbA1c is…..
- When were you diagnosed with DM?
- What type is it?
- How are you feeling about it?
- benefits of it being too high/ too low
- Any recent illness/infection
- Any hospital admissions for DKA
- Polyuria, polydipsia, weight loss, changes in vision, diabetic neuropathy, impotence (erectile dysfunction)
23
Q
Things to ask in the PMH
A
Any cardiovascular/ cerebrovascular/ renal/ visual complications
24
Q
Things to ask in the DHx
A
- How do you think your diabetes is being controlled?
- Do you think it is going well?
- What are you taking?
- Any recent changes to the meds?
- How and when are you taking it?
- Injecting correctly? rotate the sides?
- Any side effects?
- Are you monitoring your glucose regularly?
25
Things to ask in SHx
- How is your mood/sleep?
- Is it affecting your ADL?
- What is your diet like? have you been on any diet lately or tried to lose any weight?
- Exercise
- Smoking
- Drinking
26
Things to say in the advice
- Explain why the HbA1c levels are what they are
- Management advice
- Mention support that is available: diabetes nurse, online resources, training courses
27
PEAK FLOW: what is the blue inhaler for?
Reliever inhaler- immediate rescue from acute symptoms
28
What is the brown inhaler for?
Preventer inhaler- not everyone gets one, only if you have poorly controlled asthma and are struggling with day-day activities (if you need to use blue inhaler >3 times or symptoms everyday)
29
Good peak flow habits
- Take your peak flow BEFORE using your preventer inhaler
| - Always use the same peak flow meter
30
Red flags for peak flow usage:
- Wheeze is getting worse
- Affecting ADL
- Waking up at night with symptoms
- Using reliever inhaler more than usual
31
Restrictive lung diseases
- Sarcoidosis
- Kyphosis
- Ankylosing spondylitis
- NM diseases (Guillain-barre syndrome, myasthenia gravis)
- Asbestosis
- Silicosis
- Pulmonary fibrosis
- Any of the interstitial lung diseases
32
Things to say in the HxPC
I understand that you are..... and I can see from your results that your peak flow/ spirometry is...
- Check patient understanding of peak flow/spirometry and their condition
– How well do you think your asthma/COPD is being managed?
– any recent infections or illnesses?
– Any breathlessness?
– Any breathlessness that has possibly woken you up at night?
– Cough
– Wheeze
33
Things to ask in the DHx
Are you currently taking any medication?
Which inhalers do you use
How often are you using your inhaler
Any other medication to help? For example, if they are taking oral steroids,
you know that the asthma is pretty severe.
Beta-blockers?
Check inhaler technique and check inhaler use has been assessed by the
nurse
34
Thighs to ask about SHx and exacerbations
```
Smoking
Alcohol
Impact of condition on life
Is there any particular time you notice that your asthma is worse e.g. is it
worse during the winter months?
Any pets/any new pets?
Recent travel anywhere? (you would want to be weary of places which are
particularly polluted)
Housing – (there may be damp)?
Hayfever
```
35
Lifestyle advice (look at resp FC)
- Smoking
- Avoiding precipitants
- Vaccination
- Exercise
- Eating
- Support
36
What is peak flow?
The peak flow test measures how fast you can breathe out, so you can see how well your lungs are working.
37
What is spirometry?
It measures lung function, specifically the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled
38
CRP
Non-specific marker
Substance produced by the liver and increases in the presence of
inflammation
39
Name types of conditions where CRP is monitored. Name 3 examples for each
1. Assessment of disease activity of autoimmune/ auto-inflammatory conditions
RA, spondyloarthopathies, Crohn's, Vasculitis
2. Assistance with diagnosis and monitoring of infection
Bacterial endocarditis, response post-op antibiotic therapy
3. Differentiation between inflammatory conditions
SLE vs RA
Crohn's vs UC
40
Causes of elevated CRP
```
Causes of an elevated CRP
Burns
Trauma
Infections e.g. pneumonia or tuberculosis
Heart attack
Chronic inflammatory diseases e.g. lupus, vasculitis, rheumatoid arthritis
IBD
Certain cancers
```
41
ESR
A type of blood test that measures how quickly erythrocytes settle at the bottom of a test tube that contains a blood sample. Normally they settle quite slowly, a faster than normal rate may indicate some sort of inflammation.
42
Malignant causes of ↑ ESR
- malignant lymphoma
| - carcinomas of colon and breast
43
Haematological causes of ↑ ESR
- multiple myeloma
| - anaemia of acute or chronic disease combined with iron deficiency anaemia ( not iron deficiency anaemia alone)
44
Connective tissue disorder ↑ ESR
- SLE
- Rheumatoid arthritis
- Polymyalgia rheumatic
- Temporal arteritis
45
Infections that ↑ ESR
- TB
- Acute hepatitis
- bacterial
46
Name 7 components of LFTs
1. Albumins
2. Globulins
3. ALP
4. GGT
5. AST or ALT
6. Bilirubin
7. Liver enzymes
47
Causes of high albumin
- Severe infections
- Severe dehydration
- Chronic inflammatory diseases,
- Hepatitis
48
Causes of low albumin
- Malnutrition e.g. crohn's, coeliac disease
– kidney disease
- Liver disease e.g. hepatitis, cirrhosis
49
Causes of ↑ ALP
Bile duct obstruction stimulates ALP synthesis so raised in:
- Obstructive liver disease
- Increased osteoblastic activity
50
When is bilirubin high?
| conjugated vs unconjugated
high conjugated = liver or bile duct disease
| high unconjugated = Gilbert’s or haemolytic anaemia
51
Tumour markers
Substances that are found at higher than normal values in the blood, urine and tissue of a person with cancer.
52
Uses of tumour markers
1. Screen for cancers early on in people at high risk
2. Chance of recurrence of a cancer
3. Chance of recovery
4. Response to treatment
5. Guide treatment decisions
53
Problems with tumour markers
A condition or disease other than cancer can increase tumour marker levels.
Some tumour marker levels may be high in people without cancer
Tumour marker levels may vary over time, making it hard to get consistent results
54
Carcinoembryonic antigen (CEA)
- Normal range?
- What is it?
- What are the uses?
- The main use of CEA is as a tumour marker, especially with intestinal cancer (particularly colorectal cancer), but can be used for lung , breast, liver cancer.
- A rising CEA level indicates progression or recurrence of the cancer.
- Normal = <2.5ng/ml in adult non-smoker
- Normal = <5.0ng/ml in a smoker
55
Prostate specific antigen (PSA)
- Levels are high in?
- Normal levels?
```
Protein made by the prostate gland.
No specific normal or abnormal level of PSA in the blood and levels may vary
over time in the same man.
Levels are high in:
– Men with prostate cancer
– Prostatitis
– Benign prostatic hyperplasia
```
56
ADvantages of PSA
It can help pick up prostate cancer before you have any symptoms
It may help to pick up a fast-growing cancer at an early stage
57
Disadvantages of PSA
You may have a raised PSA level even if you do not have prostate cancer
The PSA test may miss out prostate cancer
If the PSA level is raised, you may need more tests e.g. biopsy which can
cause side effects such as pain, infection, blood in the urine
58
How to explain what PSA is to a patient?
The PSA test is a blood test that measures the amount of prostate specific antigen (PSA) in your blood. PSA is a protein produced by normal cells in the prostate and
also by prostate cancer cells. It’s normal to have a small amount of PSA in your blood, and the amount rises as you get older and your prostate gets bigger. A raised
PSA level may suggest you have a problem with your prostate, but not necessarily cancer.
59
Things to ask in HxPC of PSA
I understand you are… and I can see from your results that your PSA levels are.......
How much do you know about PSA and what it means?
Just going to ask you some questions which will help me figure out why your results are the way they are
How are you feeling today, Any symptoms at all?
Frequency, urgency, nocturia, haematuria, dysuria, hesitancy, straining, intermittent flow, poor stream, incomplete emptying, post micturition dribbling, incontinence.
60
Things to ask in PMH
- History of an enlarged prostate?
- Any recent urinary tract infections or urinary tract surgery?
- Catheterization?
- Any trauma to the prostate?
- Inflammation of the prostate?
- Recent rectal examination?
61
DHx
Any medications a the moment?
| e.g. finasteride?
62
FHx
Any family history of problems with the prostate.
63
SHx
- ADL
- Smoking
- Alcohol
- Diet
- Exercise
- Sexual history – ejaculation increases it
Phase 2b
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