| Definite | Probably Not | Alarm symptoms (may require admission) |
| Slurring | Dizziness | Known AF; or high stroke risk |
| Clumsiness | Confusion | Recurrent TIAs; more than 2 in last 2 weeks |
| Tingling/numbness | General weakness | Patient on anticoagulant. May need brain scan |
| Visual disturbance | ABCD2 score of 4 or more |
Thanks to Practice Nurse 41 8
Type I diabetes occurs when there is a loss of insulin secretion ability due to automimmune destruction of the beta cells in pancreatic tissue. Patients generally present with the symptoms of hyperglycaemia including ketoacidosis.
Type I diabetes is the most common form in young people (affecting aout 0.5% of the population); bringing with it the potential for problems such as retinopathy, neuropathy, nephropathy and vascular disease.
Small amounts of insulin are produced by the pancreas throughout the day to ensure cells have access to glucose, and suppress the release of stored glucose from the liver. During fasting periods, glucagon is released to ensure glucose supplies for brain function.
Carbohydrates are digested in order to provide glucose, which results in the release of insulin titrated to the supply of glucose to use and store glucose in suitable quantities.
Insulin needs to be replaced in type I diabetes patients to ensure 24 hour cover. Boluses may also need to be prescribd to match carbohydrate intake at mealtimes. Often this can be suitably treated with a twice daily insulin if the patient’s daily routine is predictable, for patients whose lifestyle is more varied, titrated insulin may be required perhaps involving a pump or more frequent injections.
Carbohydrate awareness is important for those with type I diabetes because it is carbohydrates that affect blood glucose levels, and therefore patients need to be aware of the carbohydrate values of the foods they consume. This is particularly important for those titrating their insulin.
One of the ways insulin titration is done is through ‘dose adjustment for normal eating’ (DAFNE) which was designed for those with type I diabetes and can contribute to an improved quality of life and satisfaction for patients. Research shows that patients on DAFNE treatment are less likely to be admitted to hospital with ketoacidosis or hypoglycaemia, and also the treatment can make huge cost savings for providers. It consists of a 38 hour training course delivered in a group session based around competency skills. The scheme is successful in promoting understanding of diabetes, awareness of implications regarding diet, and the skills and knowledge required to count carbohydrates and titrate insulin accordingly with the use of DAFNE algorithms.
Limiting intake fo sodium to less than 3g prolongs the survival of patients living with heart failure according to Korean study. J Clin Nursing 2011;20;3029-3038
Patients with a history of myocardial infarction will need appropriate follow-up in primary care to manage risk factors as far as possible, provide patient education and ensure patients are on correct medication.
Patient education to reduce risks of further MIs is important. In particular, patients should be advised to increase their fruit and vegetable intake to at least 5 portions daily, reducing salt and fat intake, adopting a Mediterranean-style diet including consumption of oily fish. Additional supplements of beta carotene, vitamin C or E are not connected with improving outcomes and reducing cardiac risks. NICE guidelines recommend post-MI patients to consume at least 7g of omega-3 fatty acids per week (2-4 portions of oil fish). For patients unable to achieve this, 1g daily omega-3 ester (Omacor) can be prescribed for up to four years for patients who have had an MI in the previous 3 months. Patients should also be advised to reduce their alcohol consumption to low-moderate levels (less than 21 units per week for men and 14 for women).
Obesity needs to be monitored and managed, as this will not only reduce lipid levels as well as blood pressure but also other conditions such as diabetes.
Smoking cessation help should be offered if appropriate. Nicotine replacement therapy is not advised immediately after an MI, but in the long-term continuing to smoke is a serious risk factor.
All post-MI patients should be offered cardiac rehabilitation with an emphasis on exercise. NICE guidelines recommend moderate exercise for 20-30 minutes (enough to feel lightly breathless) five times per week. Brisk walking is ideal. Sexual activity poses no more risk of a further MI, than in a person who had not had an MI. Although when treating erectile dysfunction it is important to remember that PDE5 (phosphodiesterase 5) inhibitors should be avoided in patients using nicorandil, but can be considered in stable patients six months post-MI.
The optimum lipid target is a total cholesterol of <4mmol/l, LDL cholesterol of <2mmol.
A brief anxiety and depression assessment may be required – referring on to mental health services if necessary.
Air travel can be considered three weeks post-MI, and although the DVLA need not necessarily be notified, it is inadvisable to drive in the four weeks immediately post-MI.
Optimum prescribing for post-MI patients includes:
Daily aspirin (proven to reduce death rate by 25%). This is a lifelong treatment and is a first-line drug. Clopidogrel may be prescribed instead of aspirin if a patient has a well-documented hyper-sensitivity. Clopidogrel may be prescribed alongside aspirin for 12 months in patients with non-ST segment elevation acute coronary syndrome.
ACE inhibitors (particularly in patients with left ventricular dysfunction or heart failure), although current NICE guidelines recommend all patients post-MI should be prescribed ACE inhibitors, after checking renal function. If the patient develops a severe cough or oedema, this would need to be reassessed.
Beta-blockers are responsible for a reduction in mortality of up to 25%. New patients may need to be informed that beta blockers can cause lethargy, but this should resolve after a few weeks.
Statins help reduce lipid levels, and it has been found that after five years’ use they prevent further cardiovascular events in 10% of patients. Statins can be started after liver function and CK has been measured to determine the patient’s baseline, although raised liver enzymes should not necessarily rule out the patient from statin therapy. A statin may be augmented by ezetimibe to reduce LDL and total cholesterol.
A low HDL cholesterol (<1mmol/l) is of particular risk to patient with type II diabetes. Fibrates are effective at raising HDL cholesterol.
Particular attention needs to be paid to the patient’s blood pressure – for post-MI patients the target is <130/80mmHg. To achieve this the beta blocker dose may need to be increased or the patient may also require a diuretic or calcium channel blocker.
Using varenicline before planning to quit smoking can improve 12 week success rates, by alleviating withdrawal discomfort and reducing pleasure gained from smoking.
Hajek P. et al (2011) Use of varenicline for four weeks before quitting smoking. Archives of Internal medicine. 171, 8, 770-777.
Gastroenteritis occurs when a person comes into contact with a causative agent which develops an inflammation of the gastro-intestinal tract. This can be caused not just by contaminated food, but also in some cases by anti-inflammatory drugs or antibiotics. It also may be as a result of a food allergy, which may present as nausea and vomiting, adominal pain and diarrhoea.
There are various bacteria that can cause gastroenteritis; shigella, salmonella, clostridium difficiel, staphylococcus, yersinia, salmonella, campylobacter jejuni. E coli is one that cause severe gastroenteritis, with patients often presenting with severe watery (non-bloody) diarrhoea and fever.
Gastroentiritis caused by viruses is frequently referred to as ‘stomach flu’ despite not being related to the influenza virus. Half of gastroetniritis is caused by norovirus, although this generally is prevalent in the period from October to April.
Rotavirus is more common in infants under one year old and is seasonal, as is the astrovirus which affects predominantly children and the elderly, whereas the adenovirus is not seasonal and generally affects children up to two years old.
Gastroenteritis can be caused by parasitic infections, generally Giardia. The parasite grows in the gut and symptoms of gastritis appear after about a week, but can last for a further six if not treated. Generally this would be treated with metronidazole. Cryptosporidium is another parasite that can cause gastroenteritis.
Care needs to be taken that the patient doesn’t become dehydrated; watching particularly for signs of dry mouth or tongue, drowsiness, dizziness or light-headedness, fainting, reduced urine output, lethargy or sunken eyes.
A study has found if people adhered to the recommended 5 portions of fruit and vegetables each day and reduced their daily intake of salt to 3.5g as well as their saturated fat intake to 3% of their daily energy intake, this could prevent around 33,000 deaths each year. It was calculated that 20,800 coronoary artery disease deaths, 5,876 stroke deaths, amd 6,481 cancer deaths could be prevented each year by following such guidance. Around 12,500 deaths would be in the 75 years and under category.
Scarborough P et al (2010) Modelling the impact of a healthy diet on cardiovascular disease and cancer mortality Journal of Epidemiology and Community Health. Doi:10.1136/jech.2010.114520
A study by University of California, San Francisco and published in the Cancer Research journal has found that men with localised prostate cancer who walk briskly for three or more hours per week can halve the rate at which the cancer grows and metastasises. Men who exercised more had fewer instances of bone mets, disease recurrence and death (although those with healthier lifestyles tended also not to smoke and were often younger).
Children are more at risk of injury and illness abroad than adults; often suffering from various insect or animal bites, infestations, respiratory disorders febrile illnesses or various types of diarrhoea (although if the infant is being breastfed it is afforded some protection in this respect).
Before vaccinations for specific overseas areas are contemplated it is essential that the child’s UK vaccination schedule is up to date. Some travel vaccines are not licensed for younger children and therefore this may mean they are not covered for such diseases. It is important to be up to date with health risks in the area to be visited, so a travel consultation is essential.
Diarrhoea is more common in children than in adults (particularly toddlers who may not be walking, or tend to put fingers in mouth). Rehydration sachets therefore, are vital for the first aid kit. Children need to be observed for signs of dehydration, whether they have increased thirst, or dry mouth, or their urine output is decreased, or more serious symptoms including feeling weak, dizzy, light-headed, drowsy, or reduced tears when crying. In severe dehydration the eyes, cheeks, abdomen and fontanelle will appear sunken. There needs to be assured access to suitable drinking water to counteract this. If the child starts vomiting or develops a fever, or has faecal blood, medical advice must be sought to rule out malaria.
Rabies is more common in children than in adults, so the ‘don’t touch’ rule needs to be reinforced with children – even for animals that look dopey.
Notice must be taken of the malaria status of the destination area. Suitable measures need to be taken – DEET, impregnanted mosquito nets, anti-malarials etc.
