Regular medical examinations with a chronic disease (formerly the annual follow-up)

The situation of your chronic disease is checked in the regular examinations.

Chronic diseases include, for example, diabetes, hypertension, coronary artery disease, COPD, asthma, rheumatic diseases, and cancer.

The emphasis in the treatment of chronic diseases lies on self-care – patients take care of themselves 8,760 hours a year, but they meet health care professionals only for a few hours a year at most. Healthy lifestyle forms the basis of the prevention and treatment of the majority of the chronic diseases – a suitable diet, sufficient physical activity, not smoking, sufficient rest, and the maintenance of mental health in various ways. A health care professional can assist in guiding these self-care methods. Some diseases require various types of measurements – weight, blood sugar, blood pressure, or PEF tests. All of these measurements and tests can be done at home or at a health centre’s self-care point. Actual laboratory tests or imaging services are needed more rarely and they are always scheduled patient-specifically.

The follow-up of chronic diseases is always based on a treatment plan. We aim to ensure that all patients have their own treatment plan that is drawn up together with the patient and that can be accessed by the patient either electronically via the Kanta service or in paper form. If you do not have your treatment plan yet, please request that one be made at your next visit when booking your next appointment. The treatment plan includes the diseases that require follow-up, challenges, goals and the patient’s self-care plan and goals and the duties of the professional. It also includes the date and contact person for the next appointment, in case the patient has questions before the next appointment.

Good self-care and recording it enables good treatment. A health care professional is not a psychic. In order to be able to assess matters related to your health, we need your self-care results. Always fill in the self-care form before your appointment. Some diseases require other monitoring as well, please see below for more information. Remember that we want to help you to take care of yourself, so collaboration and openness are the keys to a good patient relationship.

Follow-up visits in chronic diseases take place at a nurse’s appointment. Should any challenges arise that require the assistance of a physician, the nurse will consult a physician or you will be booked an appointment with a physician.

Diabetes

It is very important that you are well prepared when you arrive at the appointment. Bring along your sugar level monitoring chart, if you have one. During the week preceding your appointment, take measurements more frequently than usual, especially so-called pair measurements, i.e. measure your blood sugar before the meal and 2 hours after the meal. Fill in the Self-care form. Fill in the medication list of the form with all medication and supplements you are using. Conduct Monitoring of blood pressure for a period of one week and MEAL-PAIR-MEASUREMENT FOR DIABETICS for a period of at least 5 days. Weigh yourself at home or at the self-care point of the health centre. Think in advance about which challenges and hopes related to your disease you would like to discuss during the appointment. The matters evaluated in the appointment include your condition, blood sugar balance, blood lipids, blood pressure, kidney function, foot condition, sites of injection, development of weight, lifestyle, and functional capacity. It is also checked that fundus photography is conducted as agreed and that there is a special compensation granted for the medications if Kela’s criteria are met. Fill in Own plan for diabetics before the appointment.

Cardiovascular diseases, such as hypertension, coronary artery disease, long-term arrhythmias, cerebral circulation disorders

Cardiovascular diseases include a wide variety of diseases which put two of our vital organs – the brain and the heart – at risk. Lifestyle is key in their prevention and treatment. At least 80% of coronary artery diseases could be prevented with healthy lifestyle: with physical activity, not smoking, and by following a heathy diet. These diseases often do not show any symptoms before something sudden, such a myocardial or cerebral infarction, occurs. Sudden illness often changes life fundamentally. Peer support is available at Sydänliitto.

Prepare for your appointment by filling in the Self-care form and its medication list and Monitoring of blood pressure. Weigh yourself at home or at the self-care point of the health centre. Think in advance about which challenges and hopes related to your disease you would like to discuss during the appointment. At the appointment your condition, blood lipids, blood pressure and heartbeat, weight development, lifestyle habits and functional capacity will be evaluated. If you are using Marevan (a blood-thinning medication), its alternatives can be discussed as well.

Lung diseases

Asthma and COPD (Chronic Obstructive Pulmonary Disease) are common chronic lung diseases. Physical activity, not smoking and proper self-regulation of medical treatment are in key positions in the treatment. Patient organisations, such as Hengitysliitto and Allergia- ja astmaliitto can provide help as well.

Evaluation of the treatment balance of chronic respiratory diseases at regular intervals is important. Evaluation is usually conducted annually in connection with the renewal of prescriptions. The Oma Lääkärisi health clinics hope patients will phone when they need to renew their prescriptions. The nurse will chart the condition of the patient on the phone. If everything is ok, the physician will be requested to write an electronic prescription. If necessary, the patient will be booked an appointment with a pulmonary nurse for a more detailed charting of the situation. Before the appointment, the patient is usually requested to conduct PEF tests at home (PEF monitoring and electronic PEF monitoring). Weigh yourself at home or at the self-care point of the health centre. The appointment includes evaluating the command of self-regulated medical treatment, checking the technique of taking the medication, listening to the lungs, measuring oxidation with a finger-prick test, and conducting PEF tests. The nurse provides instructions for the regulation of the medication and lifestyle choices that support the treatment of chronic respiratory diseases.

Rheumatic diseases

Medications used in the treatment of rheumatic diseases can affect the formation of blood cells and the condition of the liver or the kidneys. The medication is started in specialised health care, but is often monitored in basic health care. Instructions for the laboratory test monitoring usually come from specialised health care. Contact us when the follow-up of your rheumatic disease is transferred to a health centre and we will draw up a treatment plan for you and program the follow-up plans specified in the specialised health care into our system.

Cancer follow-up

Follow-up plans for cancer are always made in specialised health care. Contact us when the follow-up of your cancer is transferred to a health centre and we will draw up a treatment plan for you and program the follow-up plans specified in the specialised health care into our system.