Chronic Diseases - Clinical Medicine

Question 1

What are chronic conditions?

Answer 1

• Chronic conditions are diseases lasting more than 3 months and some have no cure
• The disease would normally result in significant adjustment for the individual and increased contact with medical services

Question 2

Provide 6 examples chronic diseases

Answer 2

• Alzherimer’s
• Arthritis
• Asthma
• Cancer
• MS
• Epilepsy

Question 3

Describe the people involved in chronic disease management

Answer 3

• Practice nurses have a key role in primary care
• District nurses’ role is important for elderly and houseband
• GP in primary care may be main person responsible for others
• Pharamacists
• Specialist teams: consultant, specialist nurses
• Other health professionals: CPNs, counsellors, psychologists, psychiatrists
• Social servives, home care
• Voluntary agencies: self-help groups, disease groups, benefits advisors
• Occupational health dept at workplace

Question 4

Describe the regular reviews regarding a patient’s condition that should be made including the disease, treatment and secondary prevention

Answer 4

This disease

• Check patient understanding
• Monitor disease progress

The treatment

• Check patient understanding
• Montor adherence, effectiveness, side effects, adverse effects

Secondary prevention

• Check patients understanding of risk of other conditions developing
• Assess/monitor/treat risk factors

Question 5

What regular reviews should be made on a patient themselves who is suffering from a chronic disease

Answer 5

• Effects on feelings - sick role, self-esteem, stigma
• Effects on life e.g., relationshipps, work, finance, other acitivies, hosuing, mobility
• Effects on family/carers

Question 6

Describe a doctor’s respone to chronic illness

Answer 6

• Curative medicine approach
• Sense of failure or feeling overwhelmed as many cannot be cured
• Perspective of palliative medicine

Question 7

Chronic diseaes can co-exist. Give two reasons for this and provide an example for each reason

Answer 7

1. May occur beacuse one disease directly causes another e.g., diabetes leads to renal damage
2. May occur because both conditions share a common cause e.g., poor diet/secondary lifestyle increases risk of range of conditions e.g., diabetets and hypertension

Question 8

a) Give 2 unmodifiable risk factors of chronic disease
b) Give 5 modifiable risk factors of chronic disease

Answer 8

a) Age and genetic (inherited) risk

b)

• Diet and excercise - act in party by causing obesity
• Pollution
• Smoking
• Alcohol consumption
• Social factors e.g., deprivation

Question 9

what is chronic back pain?

Answer 9

Back pain that persists for more than three months

Question 10

Low back pain is a major cause for long term sickness amongst workforces. Provide 6 examples of team members that may be involved in care of chronic back pain

Answer 10

1. GP or nurse practitioner
2. Physiotherapist
3. Osteopathy or chiropractic practitioner
4. Radiology service
5. Orthopaedic surgeon
6. Rheumatologist

Question 11

Chronic disease follows several different courses with consequent differences in the reponse of the individual to that disease. Desrcibe the 3 possible trajectories and provide examples for each

Answer 11

1. Short period of evident decline e.g.,
2. Long term limitation with intermittent serious episodes - e.g., heart and lung cancer
3. Prolonged dwindling - e.g., frailty and dementia

Question 12

What is pain?

Answer 12

An unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage

Question 13

What is chronic primary pain?

Answer 13

Pain existing as a disea by itself and associated with emotional distress

Question 14

What is nociceptive pain?

Answer 14

Pain arising from activation of nocieptors following tissue injury - A delta and C-fibre terminals

Question 15

What is neuropathic pain?

Answer 15

Pain arising from disease or damage to the nervous system

Question 16

Pain signifies a threat to body integrity. Pain is interoceptive rather than exteroceptive. What do these two terms mean?

Answer 16

Interoceptive = sensing internal body states

Exteroceptive = sensing external environment

Question 17

Describe the role of the limbic system in chronic pathological pain

Answer 17

Enhanced activation of the limbic system amplifies the negative threat of your interoceptive state which is a key factor that drives chronic pathological pain

Question 18

Nociception is what drives cognition of something unpleasant happening which is happening in the context of the way your suffering is manifested and the way you behave and how you interact with the social environment. A consideration of all these is known as?

Answer 18

Biopsychosocial pain management

Question 19

What factors are involved in the biopsychosocial pain management?

Answer 19

• Nociception
• Cognititon (pain)
• Affective (suffering)
• Illness (pain behaviour)
• Social environment

Question 20

How well do drugs work in pathological pain?

Answer 20

• As studies have gotten bigger and better, the number needed to treat (NNT) have increased across all classes off drug, in chronic pain or neuropathic pain
• NNT is still only between 4 and 10 so only a minority of patients are going to be very responsive to medication and a lot of patients will not respond at all

Question 21

If drugs aren’t the answer, how else can we modify distress and emotion? Provide 4 examples

Answer 21

Pain mangement programme

• Psychology
• Physiotherapy
• Occupational therapy
• Educatiion

Question 22

List the common physical illness causes of feeling tired all the time

Answer 22

• Sleep disorders e.g., insomnia, restless leg syndrome, obstructive sleep apnoea
• Infections- especially glandular fever and long Covid
• Hormonal –e.g., thyroid, diabetes, hypopituitarism, Addison’s
• Anaemia and iron deficiency (consider coeliac disease)
• Chronic cardiac, respiratory, renal, liver, haematological, neurological and rheumatological disease
• Malignancy
• Medication related e.g., opiates, anti-epileptics, betablockers, anti-depressants
• Toxins – carbon monoxide, heavy metals

Question 23

List the common psychological, social, and phsyiologcal causes of feeling tired all the time

Answer 23

• Anxiety
• Depression
• Stress
• Somatisation disorder
• Drug and alcohol dependency
• Old age
• Pregnancy
• Menopause

Question 24

a) What is chronic fatigue syndrome?
b) What symptoms may it involve?

Answer 24

a) Severe disabling fatigue lasting more than 6 months with no other explanation found. It is not due to ongoing exertion, not relieved by rest and causes reduced levels of activity. The symptoms are present >50% of the time

b)

• Memory/cognitive impairment
• Myalgia
• Headache
• Unrefreshing sleep
• Post-extertional malaise (lasting > 24 hours) and/or orthostatic intolerance

Question 25

Describe the 7-step approach to the diagnosis of the fatigue

Answer 25

1. Characterise the fatigue 2. Assess presence of complaints suggesting organic illness associated with fatigue 3. Evaluate psychiatric screening 4. Ask questions on sleep quantity and/or quality 5. Peform a physical examination 6. Undertake investigations

Question 26

Describe the classification of fibromyalgia

Answer 26

* Pain for _at least three months_ - The upper and lower body, right and left sides, axial skeleton * 11/18 tender points

Question 27

What are the characteristic features of fibromyalgia?

Answer 27

* Fatigue * Sleep disturbance - light sleep 8-10 hrs, unrefreshed, morning stiffness, mental and physical fatiguabilty * Stiffness * Paraethesia * Headaches * Irritable bowel * Cold hands * Depression * Anxiety * Daytime restless legs

Question 28

What are criticisms of fibromyalgia diagnosis

Answer 28

* Criteria are a compromise * There is no gold standard pathology * Not grounded in any clear pathological process * Fibromyalgia may just be one end of the spectrum

Question 29

Describe the epidemiology of fibromyalgia

Answer 29

* Prevalence: fibromyalgia 1-10% and chronic widespread pain 10-20% * F:M = 3:1 = three times more common in women than men * Rises with age to a maximum in 60s * Disability level comparable to RhA

Question 30

What are the clinical descriptions that patient use to describe fibromyalgia

Answer 30

* 'It hurts all over' * May ahvea focus, but shifts * Burning, radiating, gnawing * Moderate or severe * Worse than that of RhA * Cold damp weather * Exhibit hyperalgesia (an increased sensitivity to feeling pain and an extreme response to pain) and allodynia (neuropathic pain due to a stimulus that does not normally provoke pain e.g., light feather touch, cold temperatures)

Question 31

What will you find on examination of patient with fibromyalgia

Answer 31

* Tender points are the only reliable physical finding * No muscle wasting * No synovial inflammation * No other abnormalities

Question 32

What will you find on investigation of a patient suffering from fibromyalgia

Answer 32

Normal * No inflammatory markers * No metabolic or endocrine abnormality * Muscle enzymes and electromyography (EMG normal)

Question 33

What diseases overlap with fibromyalgia?

Answer 33

* Chronic fatigue syndrome * Myofascial pain syndrome - pressure on sensitive points in your muscles, causingpain in muscles and unrelated partsof body e.g., whiplash, writer's cramp, telegraphists cramp, repetitive strain * Irritable bowel syndrome * Migraine * Irriatable bladder * Post-traumatic syndrome

Question 34

What disease can fibromyalgia present in?

Answer 34

* Inflammatory rheumatic disease - 30% * Inflammatory myositis and myopathies * Hypothyroidism * Multiple sclerosis

Question 35

Describe 8 causes of fibromyalgia

Answer 35

1. Infection - widespread pain follows infectious mononucleosis n 20%, 20% have persistent symptoms after Lyme 2. Trauma - associations with leg fracture, neck fracture, hypermobility 3. Genetics - familial clustering, HLA associations 4. Muscle abnormality - intrinsic muscle abnormalities have been detected (but likely to be secondary to inactivity or to pain) 5. Psychological abnormality - greater psychological symptoms, greater prevalence of depression in family, healthcare seeking behaviours 6. Sleep abnormality - slow wave disruptions triggers FM, EEG patterns reported 7. Neuroendocrine - reduced growth hormone, prolactin, 5HT, CRH response to stress 8. CNS autonomic sensitisation - altered pain threshold on physiological testing at tender points and other sites, increased heart rate variability, CSF substance P levels (neurotransmitters) increases causing increased sensitivity of nerves to pain or heighten awareness to pain, brain regional blood flow abnormalities in areas related to pain processing and abnormal termporal summation of pain

Question 36

Describe the managment of fibromyalgia

Answer 36

Drug treatment * Anti-inflammatory (however no better than a placebo) * Antidepressants - low dose tricyclic antidepressants, amitriptyline effective in reducing pain, serotonin reuptake inhibitors (short term effect) * Opiates - tramadol, ketamine Non-drug treatment * Education * Excercise * Physical therapy * Behavioural * Cognitive therapy * Mediation * Biofeedback * Stress management * Hypnotherapy * Acupuncture * Homeopathy (A "treatment" based on the use of highly diluted substances, which practitioners claim can cause the body to heal itself)

Question 37

Describe the prognosis of fibromyalgia

Answer 37

* Conflicting * Tertiary centres show little change over a decade * Better outcome in community studies, where (at best) 25% remit at 2 years * Predicting better outcome: young age, lower pain score

Question 38

According to Parsons’ ‘Sick role’, someone who is ill gains rights and responsibilities. What are the rights and responsibilties of the 'sick role'

Answer 38

Rights 1. The sick are not obliged to perform their normal social roles 2. The sick are not considered responsible for their own state/being 'in the sick role' Responsibilites 1. The sick are obliged to want to get well as soon as possible 2. The sick are obliged to consult and cooperate with medical experts

Question 39

What are the main functions of the 'sick role'?

Answer 39

* To control illness * Reduce the disruptive effects on the social systems by returning the ill to good health as quickly as possible

Question 40

Why may patients find the sick role appealing?

Answer 40

* Devolves them of personal responsibilty for the cause of their illness * Legitamises avoidance of the unappealing aspects of everyday life - work, chores, being pleasant to people, being active, eating healthily * Suggests that illness should be cured, rather than having to live with the symptoms * Suggests that it's the doctor's role to cure them

Question 41

What are treatment/actions for chronic pain and co-morbidies e.g., depression

Answer 41

* Explanation + guidance about the factors worsening pain * Cognitive Behavioural Therapy (sleep, depression, anxiety) * Counselling (relationship problems) * Fitness certificates for work/Occupational health involvement * Antidepressants * Graded activity/pacing * Physiotherapy * Sleep hygiene * Medication review to reduce side effects

Question 42

What are the problems with prescribing NSAIDs

Answer 42

* GI ulceration * Renal toxicity * Cardiac failure * Hepatic roxicity

Question 43

What are the problems with prescribing opioids?

Answer 43

* Falls and fracture * Hypogonadism (a condition in which the body doesn't produce enough of the hormone that plays a key role in masculine growth and development during puberty (testosterone) or enough sperm or both) * Dependance * No evidence for benefit in chronic non-cancer pain * Evidence suggests higher disability * Higher pain levels * Poorer QOL

Question 44

What are the problems with gabapentinoids?

Answer 44

* Drowsiness * Anxiety * Dissociation * Dependancy

Question 45

What are the problems with tricylic antidepressants?

Answer 45

* Cardiac toxicity * Dementia

Question 46

What are the advantages of wearables and home monitoring medical equipment?

Answer 46

* Diagnostic * Remote monitoring * Provides motivation * Aids in monitoring asymptomatic disease * Real life measurements * Preserves resources

Question 47

What are the disadvantages of wearables and home monitoring medical equipment?

Answer 47

* Neuroticism (long-term tendency to negative and anxious thoughts) * False reassurance * Can become to reliant on it

Question 48

a) What is chronic regional pain syndrome? b) Name 4 causes? c) Descrbe the clinical presentation d) Describe the treatment

Answer 48

a) Complex disorder that occurs in the absence of nerve injury, characterised by pain, abnormal blood flow, trophic changes to the skin, sensory disturbance and autonomic features. b) Orthopaedic operations, fractures, herpes zoster or the cause may be unknown (idiopathic). c) * Presents weeks to months after an initial insult and in the neighbouring area. * Patients may complain of allodynia, hyperalgesia or even neuromuscular features such as weakness. * Pain * Abnormal blood flow * Trophic changes to skin * Sensory disturbance * Autonomic features d) Normally self-limiting but can be treated with amitriptyline, gabapentin or sympathetic nerve blocks.