Chronic Medical Conditions Liz Borlase Brampton Medical Practice.
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Transcript of Chronic Medical Conditions Liz Borlase Brampton Medical Practice.
Chronic medical conditions
QOF and other chronic conditions Designing protocols – two groups
Cardiovascular cases – pairs Challenges of multiple morbidity
QOF Clinical Indicators Atrial fibrillation CHD HF Hypertension PAD Stroke/TIA DM Hypothyroid Asthma COPD
Dementia Depression Mental Health Cancer CKD Epilepsy Learning Disability Osteoporosis Rheumatoid arthritis Palliative care
Other chronic medical conditions
Addisons Coeliac disease HIV / AIDS Hyperthyroid Inflammatory bowel
disease Irritable bowel
syndrome
Migraine Multiple sclerosis Osteoarthritis Parkinsons disease Polymyalgia Psoriasis …………etc.
Designing protocols
M72 with letter from cardiology confirming new HF on echocardiogram, no other PMH
DH: furosemide 40mg daily, aspirin 75mg daily, and simvastatin 40mg nocte
Letter advises titrating ramipril and bisoprolol How is this to be organised within the PHCT? What? When? By whom? How will you check it is completed?
Heart failure - management
Manage other conditions eg BP Diuretics if needed Lifestyle etc ACE inhibitor or ARB Beta blocker Spironolactone Add ARB ?hydralazine & nitrates, pacing, digoxin
Heart failure - management
Refer for:
Diagnosis Severe heart failure not responding to
treatment Valve disease Pre-pregnancy or pregnant
Designing protocols
Pick another chronic disease from our list (not QOF)
Design a brief protocol for their follow up What? When? Where? How? By whom?
Case 1
F74 3/52 SOBOE Feels her heart thumping PMH - BP, THR, DM, TIA furosemide, amlodipine, alendronate and
Adcal D3 Irreg pulse ECG AF HR110
Investigations for AF
CVD risk - U&E, eGFR, LFT, Ca, TFT, Chol, HbA1C, FBC
Echo – younger patients, planning for cardioversion, HF, murmur
NOT routinely
Rate control
Over 65 With IHD Contraindications to antiarrhythmic drugs Unsuitable for cardioversion
C.I. to anticoagulation Large atrium, M.S. AF > 12 months Multiple failed attempts Reversible causes e.g. thyrotoxicosis
Rate control
Beta- blocker or rate-limiting calcium antagonist
Add digoxin if needed Target resting HR < 90 Target exercise HR < 200 minus age
Rhythm control
Symptomatic Younger Presenting first time, lone AF Secondary to corrected precipitant CHF
CHADS2 Scoring Scheme
Condition Points
C Congestive Heart Failure 1
H Hypertension 1
A Age >75 years 1
D Diabetes 1
S2 h/o Stroke or TIA 2
CHADS2 Scoring Scheme
CHADS2 score
Stroke risk % p.a.
Risk Therapy
0 1.9 Low Aspirin
1 2.8 Moderate Choice
2 4.0 High Warfarin
3 5.9
4 8.5
5 12.5
6 18.2
CHA2DS2-VASc Scoring
Condition Points
C Congestive Heart Failure 1
H Hypertension 1
A2 Age >75 years 2
D Diabetes 1
S2 h/o Stroke or TIA 2
V h/o Vascular Disease 1
A Age 65-74 years 1
S Female 1
Patient Decision Aids
National Prescribing Centre (provided by NICE)
http://www.npc.nhs.uk/patient_decision_aids/pda.php
Starting warfarin for AF
INR target 2.5 No loading dose Yellow book Phone number Patient information including diet Records Safety systems INRstar
Case 2
F42 nurse 3/12 intermittent palpitations Slight dizziness Similar 10y ago on nights PMH – anxiety, depression FH – thyroid disease, DM No current medication
Palpitations - causes
Stress, anxiety Menopause Hyperthyroid Anaemia Caffeine, alcohol Medication Chronic fatigue Hypoglycaemia
Palpitations - questions
Precipitating/relieving factors Regular/irregular Pulse Lifestyle Current stress/mood Weight change Periods
Case 3
M56 chest pain the day before After food Sweating 20 minutes Chest exam normal, BP 155/95 ECG normal
Chest pain - ?ACS
History of pain > 15 mins N&V, sweating, SOB
Cardiac unlikely if Continuous Unrelated to activity Brought on by breathing Associated dizziness, palpitations, tingling, swallowing sx
Cardiovascular risk factors Previous IHD Previous investigations
Chest pain – ACS
CURRENT PAIN, OR PAIN WITHIN 12h & ECG CHANGES
999 Ambulance GTN, opioids Aspirin ECG Pulse oximetry, oxygen only if sats <94% or if
COPD <88%
Chest pain – ACS
PAIN WITHIN 12h & NORMAL ECG, OR PAIN 12 – 72h
Urgent same-day hospital assessment
PAIN > 72h History, exam, ECG, troponin Then decide….
Stable chest pain
Confirmed IHD - treat or if uncertain Ix
Typical angina - ECG, bloods, aspirin, treat
Atypical angina – ECG, bloods, refer for Ix
Non-anginal chest pain – consider GI and MSK
Stable angina
GTN spray Aspirin, statin, BP, ACE I if DM Beta-blocker or calcium channel blocker Alternatives: long acting nitrates, ivabradrine,
nicorandil