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Chronic Medical Conditions

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Presentation on theme: "Chronic Medical Conditions"— Presentation transcript:

1 Chronic Medical Conditions
Liz Borlase Brampton Medical Practice

2 Chronic medical conditions
QOF and other chronic conditions Designing protocols – two groups Cardiovascular cases – pairs Challenges of multiple morbidity

3 Chronic medical conditions
Make a quick list….. or two!

4 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

5 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.

6 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?

7 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

8 Heart failure - management
Refer for: Diagnosis Severe heart failure not responding to treatment Valve disease Pre-pregnancy or pregnant

9 Heart failure - management
Seattle heart failure model

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12 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?

13 Tea break

14 Cardiovascular Chest pain Palpitations Breathlessness Ankle swelling
Dizziness/faints

15 Cardiovascular Cases…..

16 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

17 Investigations for AF CVD risk - U&E, eGFR, LFT, Ca, TFT, Chol, HbA1C, FBC Echo – younger patients, planning for cardioversion, HF, murmur NOT routinely

18 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

19 Rate control Beta- blocker or rate-limiting calcium antagonist
Add digoxin if needed Target resting HR < 90 Target exercise HR < 200 minus age

20 Rhythm control Symptomatic Younger Presenting first time, lone AF
Secondary to corrected precipitant CHF

21 Stroke prevention CHADS2

22 CHADS2 Scoring Scheme Condition Points C Congestive Heart Failure 1 H
Hypertension A Age >75 years D Diabetes S2 h/o Stroke or TIA 2

23 CHADS2 Scoring Scheme CHADS2 score Stroke risk % p.a. Risk Therapy 1.9
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

24 CHA2DS2-VASc Scoring Condition Points C Congestive Heart Failure 1 H
Hypertension A2 Age >75 years 2 D Diabetes S2 h/o Stroke or TIA V h/o Vascular Disease A Age years S Female

25 Patient Decision Aids National Prescribing Centre (provided by NICE)

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27 Starting warfarin for AF
INR target 2.5 No loading dose Yellow book Phone number Patient information including diet Records Safety systems INRstar

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29 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

30 Palpitations - causes Stress, anxiety Menopause Hyperthyroid Anaemia
Caffeine, alcohol Medication Chronic fatigue Hypoglycaemia

31 Palpitations - questions
Precipitating/relieving factors Regular/irregular Pulse Lifestyle Current stress/mood Weight change Periods

32 Palpitations - investigations
Bloods ECG 24h tape Event recorder

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34 Case 3 M56 chest pain the day before After food Sweating 20 minutes
Chest exam normal, BP 155/95 ECG normal

35 Chest pain - ?ACS History of pain Cardiac unlikely if
> 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

36 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%

37 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….

38 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

39 Stable angina GTN spray Aspirin, statin, BP, ACE I if DM
Beta-blocker or calcium channel blocker Alternatives: long acting nitrates, ivabradrine, nicorandil

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41 Multiple morbidity What are the challenges?
Any ideas for addressing these challenges?

42 Evaluation forms please….
Thank-you! Evaluation forms please….


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