“Doctor I have a cough” QUIZ Dr Elfrieda Power GP VTS2 September 2012

1. Pulmonary Embolism How many patients present with the classical triad of dyspnoea, pleuritic chest pain and haemoptysis? 80% 50% 20% <10%

1. Pulmonary Embolism How many patients present with the classical triad of dyspnoea, pleuritic chest pain and haemoptysis? 80% 50% 20% <10%

BMJ suggests we should consider the diagnosis in patients with: 1. Pulmonary Embolism BMJ suggests we should consider the diagnosis in patients with: Dyspnoea, pleuritic chest pain and haemoptysis (this classical triad occurs in <10%) Any chest symptoms in a patient with clinical features of a DVT Dyspnoea or chest pain and a major risk factor for PE Unexplained dyspnoea or unexplained haemoptysis even if they have no RF for PE

1. Pulmonary Embolism If a diagnosis of PE is suspected, use a clinical prediction rule to assess pre-test probability and if needed use a D-dimer. Can you name the 7 risk factors that form the Well’s PE Scoring tool?

1. Pulmonary Embolism

1. Pulmonary Embolism If D-dimer is low and clinical probability is low (on Well’s score), then PE is ruled out, but if high clinical probability - send straight to hospital, a normal D-dimer does not rule out a PE. Confirmation by CTPA. Anticoagulation is continued for at least 3 months for both DVT and PE.

2. Lung Cancer How many of those diagnosed with lung cancer had a normal CXR in primary care? 1% 5% 10% 20%

2. Lung Cancer How many of those diagnosed with lung cancer had a normal CXR in primary care? 1% 5% 10% 20%

2. Lung Cancer 10% of those diagnosed with lung cancer, had a normal CXR in primary care. If the CXR was <90d old this reduced to 6%. No particular constellation of symptoms was more likely with a negative CXR

2. Lung Cancer Cough Dyspnoea Chest signs Haemoptysis Hoarseness Chest/shoulder pain Clubbing Weight loss Cervical/supraclavicular lymphadenopathy Any features suggestive of metastases The following are suspicious clinical features of lung cancer: Which statement about any of these symptoms would require an urgent CXR? Lasting more than 2 weeks Unexplained by another illness Lasting more than 2 weeks and unexplained by another illness Lasting more than 3 weeks or unexplained by another illness

2. Lung Cancer Any of these symptoms lasting more than 3w OR unexplained by another illness should have an urgent CXR. Urgent referral should be made (even without waiting fro the CXR result) if: Smoker/ex-smoker over 40yrs with persistent haemoptysis Stridor Signs of SVCO - What are these? Urgent referral if: Abnormal CXR Normal CXR but suspicion of cancer remains

Which of the following is False? 3. COPD Which of the following is False? A history suggestive of COPD includes over 35yrs, smoker/ex-smoker and symptoms including exertional breathlessness, chronic cough, regular sputum production, frequent winter bronchitis and wheeze. Stopping smoking has no impact on lung function Investigations required include post-bronchodilator spirometry, CXR, FBC and BMI c. Diagnosis is confirmed if post-bronchodilator FEV1/FVC is <0.7

Which of the following is False? 3. COPD Which of the following is False? A history suggestive of COPD includes over 35yrs, smoker/ex-smoker and symptoms including exertional breathlessness, chronic cough, regular sputum production, frequent winter bronchitis and wheeze. Stopping smoking has no impact on lung function Investigations required include post-bronchodilator spirometry, CXR, FBC and BMI c. Diagnosis is confirmed if post-bronchodilator FEV1/FVC is <0.7

3. COPD Fletcher-Peto Curve

MRC Dyspnoea score 3. COPD Grade severity Objectively and Subjectively All must have post-bronchodilator FEV1/FVC <0.7 Must also be symptomatic MRC Dyspnoea score

3. COPD True or False? SABAs (eg. Salbutamol) are associated with an increased cardiovascular risk Inhaled steroids are associated with reduced exacerbations but an increased risk of pneumonia Spireva respimat should not be used in those with known cardiac rhythm abnormalities Triple therapy is required before stepping up to oral therapy If cumulative lifetime steroid dose >1g consider DXA scanning or rx with bisphosphonate

3. COPD True or False? SABAs (eg. Salbutamol) are associated with an increased cardiovascular risk F Inhaled steroids are associated with reduced exacerbations but an increased risk of pneumonia T Spireva respimat should not be used in those with known cardiac rhythm abnormalities T Triple therapy is required before stepping up to oral therapy F If cumulative lifetime steroid dose >1g consider DXA scanning or rx with bisphosphonate T

4. Asthma From April 2012 OF required GP’s to record asthma control using the Royal College of Physicians 3 Questions. What are the RCP 3 Questions?

4. Asthma DAY NIGHT ADLs Used to help monitor morbidity, take action if YES to any of these questions using BTS step-wise guidelines.

4. Asthma *** IMPORTANT *** Long-acting beta-agonists must always be used with inhaled steroids in asthmatics. Use of LABA alone has been associated with increased mortality (although it’s fine in COPD).

4. Asthma In acute exacerbations oral steroids are used much earlier, in preference to doubling of inhaled steroids. Name 5 systemic side effects of frequent oral steroid use in adults and children:

4. Asthma In acute exacerbations oral steroids are used much earlier, in preference to doubling of inhaled steroids. Name 5 systemic side effects of frequent oral steroid use in adults and children: Raised BP Diabetes Osteoporosis Reduced growth in children Cataracts

5. Dyspepsia 5% of adults/yr see their GP about dyspepsia. 1% will go on to have an endoscopy. Of these - 80% will have reflux or non-ulcer dyspepsia - 13% will have a peptic ulcer - <3% will have a malignancy What are red flag symptoms that require referral for endoscopy?

5. Dyspepsia Red Flag Symptoms: Chronic GI bleeding Progressive dyspepsia Progressive unintentional weight loss Persistant vomiting Iron deficiency anaemia Epigastric mass Refer for endoscopy anyone >55 yrs with unexplained and persistant (>4-6wks) recent onset dyspepsia even without red flags

5. Dyspepsia Which of the following drugs does not cause dyspepsia? Calcium channel blockers Nitrates Bisphosphonates Statins NSAIDSs Corticosteroids

5. Dyspepsia Which of the following drugs does not cause dyspepsia? Calcium channel blockers Nitrates Bisphosphonates Statins NSAIDSs Corticosteroids

5. Dyspepsia True or False? There is no differences between test and treat or treat and test H. Pylori eradication regime lasts 14 days An H. Pylori eradication regime includes full dose PPI + Amoxicilln + Clarithromycin NICE advises stopping PPI’s and H2RA 4 weeks before endoscopy

5. Dyspepsia True or False? There is no differences between test and treat or treat and test T H. Pylori eradication regime lasts 14 days F An H. Pylori eradication regime includes full dose PPI + Amoxicilln + Clarithromycin T NICE advises stopping PPI’s and H2RA 4 weeks before endoscopy F

6. Acute bronchitis True or False? There is no evidence for cough mixtures or beta-agonists in acute bronchitis The cough with bronchitis lasts, on average 3 weeks. Antibiotics do not make the cough get better more quickly CRP and CXR are helpful

6. Acute bronchitis True or False? There is no evidence for cough mixtures or beta-agonists in acute bronchitis T The cough with bronchitis lasts, on average 3 weeks T Antibiotics make the cough get better more quickly F CRP and CXR are helpful F

The British Thoracic Society (BTS) defines pneumonia as: 7. Pnuemonia The British Thoracic Society (BTS) defines pneumonia as: Cough and at least one other lower respiratory tract symptom AND New focal chest signs on examination AND EITHER sweating, fevers, shivers, aches and pains OR fever >38 AND No other explanation for symptoms. The BTS recommends the CURB-65 score to assess severity and in particular to identify those who are likely to need admission. What is CURB 65?

7. Pnuemonia

In primary care CRP is unlikely to change managemnet 7. Pnuemonia True or false? In primary care CRP is unlikely to change managemnet Atypical pneumonia refers to Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella species. In primary care the CURB65 tool underestimates risk. Amoxicillin or erythromycin should be used first line. BTS recommends a 7 day course of treatment although evidence is emerging that shorter courses may be as beneficial.

In primary care CRP is unlikely to change management T 7. Pnuemonia True or false? In primary care CRP is unlikely to change management T Atypical pneumonia refers to Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella species. T In primary care the CURB65 tool underestimates risk. F Amoxicillin or erythromycin should be used first line. T BTS recommends a 7 day course of treatment although evidence is emerging that shorter courses may be as beneficial. T

8. Heart Failure True or False? a. SIGN recommend that patient self- weigh and should report a more than 1.5-2kg weight gain to their GP b. BNP is reliable in all circumstances c. Diuretics improve prognosis d. If LVSD NICE advises offering both ACEI and beta- blockers e. Functional Capacity is classified according to the NYHA scoring.

8. Heart Failure True or False? a. SIGN recommend that patient self- weigh and should report a more than 1.5-2kg weight gain to their GP T b. BNP is reliable in all circumstances F c. Diuretics improve prognosis F d. If LVSD NICE advises offering both ACEI and beta- blockers T e. Functional Capacity is classified according to the NYHA scoring T

8. Heart Failure BNP is affected by ischaemia, tachycardia, hypoxaemia, COPD, diabetes, cirrhosis, renal failure, old age, sepsis, obesity and drugs NYHA Classification of heart failure:

9. Tuberculosis BCG Immunisation should be offered to: Neonates living in a low incidence area (<40/100000) Children at increased risk of TB All immigrants from high risk countries TB contacts Abattoir workers

9. Tuberculosis BCG Immunisation should be offered to: Neonates living in a low incidence area (<40/100000) F Children at increased risk of TB T All immigrants from high risk countries F TB contacts T Abattoir workers T/F

9. Tuberculosis What are risk factors for TB?

Don’t forget extra- pulmonary TB 9. Tuberculosis Risk factors: Born in high prevalence areas With HIV, diabetes, chronic renal failure, previous gastrectomy, lung disease, cancer, post-transplant. On immunosuppressants Who are homeless, institutionalized, or living in prison or overcrowded conditions. With alcohol problems, or who are intravenous drug users. Who have had previous (especially incomplete) treatment for TB. Who have had close contacts of someone with active TB Clinical features that may make you suspect active TB in high risk individuals: Weight loss
 Fever Night sweats
 Anorexia
 Malaise Don’t forget extra- pulmonary TB

10. Sarcoidosis True or False? More common in smokers Up to 50% may be asymptomatic Tissue biopsy confirms the diagnosis Prognosis is generally good Refer to opthalmology to look for cataracts

10. Sarcoidosis True or False? More common in smokers F Up to 50% may be asymptomatic T Tissue biopsy confirms the diagnosis T Prognosis is generally good T Refer to opthalmology to look for cataracts F

11. Bronchiectasis True or False? Key feature is a chronic productive cough Pathology involves abnormal thickening of bronchial walls and dilatation of bronchi, set up by a vicious cycle of inflammation and infection Always shows up on CXR Inhaled steroids are the mainstay of therapy May be mistaken for asthma/COPD

11. Bronchiectasis True or False? Key feature is a chronic productive cough T Pathology involves abnormal thickening of bronchial walls and dilatation of bronchi, set up by a vicious cycle of inflammation and infection T Always shows up on CXR F Inhaled steroids are the mainstay of therapy T May be mistaken for asthma/COPD T

12. Miscellaneous True or False? A NICE guideline on Idiopathic pulmonary fibrosis will become available in June 2013 A chronic cough occurs in up to 33% In whooping cough, the inspiratory whoop is attenuated in those who have been immunised The Lancet advice that the diagnosis of whooping cough is best made by pernasal swab Antibiotics are beneficial to the patient in whooping cough

12. Miscellaneous True or False? A NICE guideline on Idiopathic pulmonary fibrosis will become available in June 2013 T A chronic cough occurs in up to 33% T In whooping cough, the inspiratory whoop is attenuated in those who have been immunised T The Lancet advice that the diagnosis of whooping cough is best made by pernasal swab F Antibiotics are beneficial to the patient in whooping cough F

And the winner is… Thank you