Chronic disease: angina, AF, heart failure, stroke and type 2 diabetes

To assess how you support a patient with several long-term conditions: the red flags for each, the medicines and what to check before giving them, self-management teaching, and what a chronic disease management programme offers in Ireland.

Mr Michael Hayes, 72, on the medical ward after a fall at home. He has stable angina with a GTN spray, atrial fibrillation on apixaban and bisoprolol, heart failure on furosemide and ramipril, type 2 diabetes on metformin, and a previous TIA. He tells you he "cannot keep track of all the tablets", his ankles have been swelling, and he has been skipping the water tablet so he can go to the shops.

You are required to identify the risks in what he tells you, say what you check before giving each medicine, teach him the warning signs that need urgent help, and explain what support he can get after discharge.

1. Explore what he is finding hard and why he skips the furosemide; no blame
2. Heart failure: swelling and weight gain are fluid; daily weight at the same time, report a gain of 2 kg in three days, breathlessness lying flat or at night, salt and fluid advice as prescribed
3. Furosemide: timing so he can go out (morning, or two doses with the second by early afternoon), check blood pressure, potassium and renal function, watch for dizziness and dehydration
4. Atrial fibrillation: apixaban every day without missing, bleeding signs to report, no over-the-counter NSAIDs, tell every clinician and dentist; take the pulse and describe it
5. Bisoprolol: check pulse and blood pressure before giving, withhold and report if the pulse is below 50 or he is hypotensive or symptomatic, per the prescription and local policy
6. Angina: GTN spray under the tongue, sit down, repeat after 5 minutes, call 112 or 999 if pain persists 5 minutes after the second dose or is different from usual
7. Stroke: FAST, face, arms, speech, time; call 112 or 999 immediately; previous TIA raises his risk
8. Type 2 diabetes: metformin with food, hold it if vomiting, dehydrated or having contrast; HbA1c target usually 53 mmol/mol or lower; feet, eyes, kidneys checked yearly
9. Say what the GP chronic disease management programme gives him: two structured reviews a year for heart disease, heart failure, AF, stroke and diabetes with a medical card or GP visit card
10. Make it manageable: a blister pack or dosette, a written list, one pharmacy, the daughter or public health nurse involved if he agrees, referral to the heart failure nurse and the pharmacist

Throughout: communicate in an accurate, clear and effective manner; demonstrate a level of competence essential for safe practice.