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“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.

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doctor i have a cough quiz

“Doctor I have a cough” QUIZ

Dr Elfrieda Power

GP VTS2

September 2012

slide2

1. Pulmonary Embolism

  • How many patients present with the classical triad of dyspnoea, pleuritic chest pain and haemoptysis?
    • 80%
    • 50%
    • 20%
    • <10%
slide3

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

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

1 pulmonary embolism1

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 embolism3

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

2. Lung Cancer

  • How many of those diagnosed with lung cancer had a normal CXR in primary care?
    • 1%
    • 5%
    • 10%
    • 20%
2 lung cancer1

2. Lung Cancer

  • How many of those diagnosed with lung cancer had a normal CXR in primary care?
    • 1%
    • 5%
    • 10%
    • 20%
2 lung cancer2

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

2 lung cancer3

Cough

Dyspnoea

Chest signs

Haemoptysis

Hoarseness

Chest/shoulder pain

Clubbing

Weight loss

Cervical/supraclavicular lymphadenopathy

Any features suggestive of metastases

2. Lung Cancer

  • 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 cancer4

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

2. Lung Cancer

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

3 copd1

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

3 copd3

Grade severity Objectively and Subjectively

  • All must have post-bronchodilator FEV1/FVC <0.7

3. COPD

Must also be symptomatic

MRC Dyspnoea score

3 copd4

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

3 copd5

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

3. COPD

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

4 asthma1

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 asthma2

*** 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

4 asthma3

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

4 asthma4

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

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

5 dyspepsia1

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

5 dyspepsia2

Which of the following drugs does not cause dyspepsia?

  • Calcium channel blockers
  • Nitrates
  • Bisphosphonates
  • Statins
  • NSAIDSs
  • Corticosteroids

5. Dyspepsia

5 dyspepsia3

Which of the following drugs does not cause dyspepsia?

  • Calcium channel blockers
  • Nitrates
  • Bisphosphonates
  • Statins
  • NSAIDSs
  • Corticosteroids

5. Dyspepsia

5 dyspepsia4

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

5 dyspepsia5

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

5. Dyspepsia

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

6 acute bronchitis1

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

6. Acute bronchitis

7 pnuemonia

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 pnuemonia2

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.
7 pnuemonia3

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

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 failure1

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 failure2

BNP is affected by ischaemia, tachycardia, hypoxaemia, COPD, diabetes, cirrhosis, renal failure, old age, sepsis, obesity and drugs

  • NYHA Classification of heart failure:

8. 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

9 tuberculosis1

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

9 tuberculosis3

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

9. Tuberculosis

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

10 sarcoidosis1

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

10. Sarcoidosis

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

11 bronchiectasis1

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

11. Bronchiectasis

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

12 miscellaneous1

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

12. Miscellaneous