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

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

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

4. 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

5. 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?

6. 1. Pulmonary Embolism

7. 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.

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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 3. COPD
Fletcher-Peto Curve

16. 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

17. 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

18. 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

19. 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?

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

21. 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).

22. 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:

23. 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

24. 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?

25. 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

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

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

28. 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

29. 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

30. 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

31. 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

32. 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?

33. 7. Pnuemonia

34. 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.

35. 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

36. 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.

37. 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

38. 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:

39. 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

40. 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

41. 9. Tuberculosis
What are risk factors for TB?

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. And the winner is…
Thank you