Chronic Disease Management in General Practice – Sample Assessment

Scenario 12 year old Kevin Kehoe has had asthma since he was 5 years old. He is currently on salbutamol via metered dose inhaler two puffs up to four times daily as needed and beclomethazone 100 micrograms also via metered dose inhaler using a spacer device (Volumatic™) two puffs twice daily. He has been brought by his mother for review of his asthma treatment.

What issues would you wish to cover in taking the patient’s history in this consultation ?  Symptoms –Nocturnal cough/wheeze? –Exercise induced cough/wheeze? –Cough/ wheeze/ breathlessness at other times? –Any ‘attacks’ since last review –How much salbutamol he is having to use

What other issues would you would want to cover in this consultation?  Adverse effects of treatment –Oral thrush  Treatment adherence –Is he taking his medicines as prescribed? –Is he using the Volumatic? –Is he using inhaler at school  Potential allergens/ provokers –Pets –House dust mite –Other –Smoking – passive or active

Other issues  Concerns – his and/or mother’s –Will he ‘grow out of it’? – still possible but less likely if he remains asthmatic into adolesence –Will treatment affect his growth?

What physical examinations and investigations would you carry out in this case?  Chest auscultation esp for wheeze (rhonchi)  Chest expansion  Peak expiratory flow rate Not chest Xray, nor pulse oximetry, or any bloods expect possibly RAST test for IgE (only useful if other indicators of atopy e.g. eczema and there are other indicators of possible single or few allergens)

For each examination/ investigation state how it contributes to your management of Kevin  Chest auscultation esp for wheeze (rhonchi) – if present suggests inadequate control now and therefore change of therapy required immediately  Chest expansion – if reduced (hyperinflated, barrel chest) suggest inadequate long term control and, therefore, needs increase in long term treatment and closer monitoring  Peak expiratory flow rate – compared to historical and expected. If reduced indicates inadequate control.

You find that his asthma control is inadequate. What modifications to his current treatment might be considered in order to try and improve his control?  Add long acting beta-agonist e.g. salmeterol  Increase beclamethazone up to 800mcgrms daily  Add leukotriene receptor antagonist e.g. montelukast (Singular)  Further efforts to ensure adherence – dry powder devices considered if unhappy with Volumatic  Add theophylline e.g. aminophylline (but difficult to get dose right esp in children – very narrow therapeutic index)  Oral steroids e.g. prednisolone  Further efforts to eliminate allergens/ pollutants

Your practice nurse suggests you should establish an asthma clinic in your practice i.e. set aside a specific 3 hour slot each week during which you would review patients with asthma according to a protocol. Outline briefly the advantages and disadvantages to establishing such a clinic

Advantages and Disadvantages of an asthma clinic to the patient  Advantages –More systematic monitoring of disease and treatment –More systematic education re condition –Better asthma control  Disadvantages –Threat to confidentiality –May be less convenient – has to go when clinic on rather than when suits patient –Threat to access for other non-asthma patients when clinic is on – easier to deal with if multi-doctor practice

Advantages and Disadvantages of an asthma clinic to practice –Easier to administer (including chasing up defaulters) and schedule (visits all for same condition take more predictable amounts of time) –Can assemble resources better (especially special equipment/ staff) –Can organised nurse and doctor care in a more efficient way – preliminary assessment by nurse followed by short doctor review (unless problems in which case doctor spends more time – this is facilitated by clinic arrangement) –Freedom from distractions – easier to follow protocols all the way through. –Costs (time etc.) of setting up –Can get repetitive if all patients at clinic have same condition –May take longer because pressure to complete protocol (more work) –Risk of being idle if patients DNA (fail to show)

Advantages and Disadvantages of an asthma clinic to the system –Better asthma control – fewer resources (e.g. hospital) used on ‘rescue’ from acute attacks –More cost effective (as long as costs of running clinic are not excessive) –Greater patient satisfaction –Up front costs – set up, extra staff etc. –May require shift of resources from secondary to primary care – politically difficult –Patient dissatisfaction with inconvenience/ lack of access when patient wants