Dr Chrissy Gray Sessional GP, GP Support Unit and Ambulatory Care

Dr Chrissy Gray
Sessional GP, GP Support Unit and Ambulatory Care
Wednesday 12th March 2014
Learning Objectives
 To know when to consider primary care management
of acute medical problems that previously required
admission and/or referral including:
 Chest pain
 PE
 Cellulitis,
 Acute diabetic problems
 GI bleeds
 To be able to manage these acute medical problems
safely in primary care
Case 1
 64yr M
 2/52 post achilles tendon decompression
 3/7 R pleuritic CP and SOBOE
 Slight dry cough, feeling bit hot, not unwell
 No PMH of note.
 O/E – T38.4, p96, BP 137/80, SaO2 95%, RR 20
 Chest clear
 Calves SNT, L=37cm, R=38.5cm
 ECG – SR, nil acute
Clinical Scoring Tools
TIMI
ABCD2
Wells
PERC
Rockall
CURB-65
Blatchford
Level 2
Wells
Geneva
Clinical Scoring Tools
TIMI
ABCD2
Wells
PERC
Rockall
CURB-65
Blatchford
Level 2
Wells
Geneva
Level 2 Wells / PERC Assessment for ?PE
(excludes pregnancy)
Score
(if
'yes')
Level 2 Wells Score
Clinical Criteria
Clinical signs of deep vein thrombosis (minimum leg swelling or
pain on palpation)?
3
An alternative diagnosis is less likely than pulmonary embolus?
3
Heart rate >100 beats per minute?
1.5
Immobilisation for more than 3 days or surgery in the previous 30
days?
1.5
Previous deep vein thrombosis or pulmonary embolism?
1.5
Haemoptysis ?
1
Malignancy (on treatment, treated within the last 6 months or
palliative)?
1
TOTAL SCORE
Additional
PERC
Criteria
...if score = 0 then use following criteria
Age <50
O2 sats >94%
No exogenous oestrogen
If all answers NO then no d-dimer required as ultra low risk PE
Y/N
Geneva score:
same clinical
features,
different scoring
system
Case 1
 64yr M
 2/52 post R achilles tendon decompression
 3/7 R pleuritic CP and SOBOE
 Slight dry cough, feeling bit hot, not unwell
 No PMH of note
 O/E – T38.4, p96, BP 137/80, SaO2 95%, RR 20
 Chest clear
 Calves SNT, L=37cm, R=38.5cm
 ECG – SR, nil acute
Case 1
 Bloods
 WCC 17, Nt 12.5, CRP 126, D-dimer 2976, trop <14
 CXR
 Patchy basal consolidation R>>L
 CTPA
 Bilateral PEs and likely middle lobe infarct
 Outpatient management
 Rivaroxaban 6/12, no further Ix
Pulmonary Embolus
• Diagnostic dilemmas
– Radiation exposure, VOMIT syndrome, overdiagnosis
• Inpatient V outpatient management
• Treatment options & duration
• Warfarin, Rivaroxaban, Heparin. 3-6/12 +
• Investigation
• Unprovoked – cancer screen, ?thrombophilia screen
Chest pain ?cardiac
 NICE Risk stratification rather than scoring tool
 Low or High (DM, smoking & TC >6.4)
 Typical, Atypical or Non-anginal chest pain




Typical
 Constricting discomfort -chest/neck/shoulder/arm
 Exertional
 Relieved by rest/GTN
Atypical = 2 of above
Non-anginal = 0-1 of above
Unlikely stable angina if: continuous/very prolonged, nonexertional, pleuritic, assoc with palpitations, dizziness,
tingling or difficulty swallowing
Chest pain ?cardiac
 If not able to confirm stable angina clinically:
 Estimated CAD 10-29%  CT calcium scoring
 Estimated CAD 30-60%  functional imaging
 Estimated CAD 61-90%  angiography
 Estimated CAD >90% & typical angina  treat angina, no Ix!?
 Treadmill exercise testing for known CAD only
 NO investigation for shaded area!
NICE applied – RACPC summary
 High risk & typical/atypical symptoms or low risk &
typical/?atypical symptoms  RACPC
 Identify and modify RF – meds, lifestyle +++
 Start primary prevention – aspirin, bisoprolol 2.5mg (if
p>60 bpm), GTN
 Refer RACPC to access investigations
 Non-anginal pain or low risk & ?atypical symptoms
consider alternative diagnoses
 Further cardiac investigations rarely needed
Case 2
 52M
 T2DM, Smoker, HT
 3/12 L sided sharp chest pain, some tingling L chest
when severe
 Initially only with climbing stairs and hills, now
occuring walking 400m on flat at a pace
 Relieved by rest
Case 3
 64F
 Smoker
 1/52 central chest ache/pressure
 Occuring at rest, several hours a day
 No change with exertion
Case 2
 52M
 T2DM, Smoker, HT
 3/12 L sided sharp chest pain, some tingling L chest
when severe
 Initially only with climbing stairs and hills, now
occuring walking 400m on flat at a pace
 Relieved by rest
= High risk, atypical
Start aspirin, GTN, ?bisoprolol
RACPC
Case 3
 64F
 Smoker
 1/52 central chest ache/pressure
 Occuring at rest, several hours a day
 No change with exertion
= Low risk, non-anginal chest pain
Consider alternative causes
Lifestyle advice and review of modifiable RF
Acute Chest Pain
 Unstable angina/ACS
 Aspirin 300mg
 GTN
 ?Oxygen - ONLY if SaO2 <94% (caution in COPD)
 ECG



Don’t delay admission/999 for this
Can alter where patient taken – eliminate delays
Normal ECG doesn’t exclude ACS
 Late presentation

?Troponin - >6hrs, doesn’t exclude UA, grey area?!
ECG changes, no IHD?!
 Abnormal ECG suggestive of ischaemia eg LBBB
 No hx suggestive of cardiac event
Do echo – often due to HT, LVH etc
Don’t send to RACPC!
Case 4
 32yr M
 F&W
 3/7 hx R thigh pain, 2/7 rigors, 1/7 erythema spreading
down to calf
 Intermittent headache, no vomiting, E&D ok
 O/E – T38.1, p96, BP 95/62, SaO2 98%, RR 16
 R leg – hot, red area R shin, tracking up medial aspect
of leg to thigh
 WCC 19.7, neut 17.7, CRP 274, eGFR 81
Cellulitis
 Seen by Dr Richard Brindle, Micro Consultant
 Home on PO flucloxacillin 500mg qds 1/52
 NO marking of erythema margin
 Strep A, toxins released with cell lysis  local
inflammation  worsening oedema/erythema and
?blistering (like sunburn), tracking - lymphatic
drainage
 No benefit in adding/changing abx/prolonged course
if systemically well
Cellulitis
 Red flags – think necrotising fasciitis, ?IV abx if
vomiting ++ or no systemic response 2-3/7
 Exceptions – DM, IVDU, animal/human bite, ?face
 Microbiology advice (BRI) – 0117 342 2539
 Clindamycin 4 Cellulitis trial – 0117 342 3253
 www.bristolcellulitis.org
Case 5
 47yr F, Afro-Carribean
 F&W. FHx - T2DM (mother)
 2/52 unwell, tired, polyuria, polydipsia, intermittent
blurred vision
 E&D normally, no vomiting, drinking lots of water
 O/E – Well, alert, p60, tongue sl dry, CBG 30.2, blood
ketones 0.8
Case 5
 10 units Insulatard S/C stat
 FU with DSN mane
 Flatbush diabetes
 Primarily in Afro-caribbean population
 Sudden onset high CBG, ?DKA
 No β-cell antibodies
 Often overweight, Fhx T2DM
 Short-term insulin, then ?diet control alone
New onset T1DM
 OP Management
 Well, no co-morbidities or intercurrent illness
 Urine ketones ≤ ++ or serum ketones ≤ 1.5mmol/L
 E&D, no vomiting
 Mobile, social support etc
 Insulatard 10units SC bd (10-12hrs apart)
 Hypo symptoms decr by 2 units bd
 CBG >13 + ketones incr by 2 unit bd
 Advice: reg meals, avoid sugary food/drink, no
strenuous exercise
Mild DKA
 CBG >11, ketones >1.5 (urine ++), pH 7.2-7.3
 Reversible precipitant
 Well – E&D, no vomiting
 Aim = resolution within 4 hrs
 Fluids IV/PO, insulin bolus (10-20% total daily insulin
dose), bloods/monitoring
 DSN input (BRI) – 0117 342 2892
Case 6
 42yr F
 Coffee-ground vomit once daily last 3/7
 No malaena
 No RF
 F&W, no meds
 O/E – T36.1, p62, BP 123/86, SaO2 98%, RR 16
 Epigastric tenderness
Clinical Scoring Tools
TIMI
ABCD2
Wells
PERC
Rockall
CURB-65
Blatchford
Level 2
Wells
Geneva
Clinical Scoring Tools
TIMI
ABCD2
Wells
PERC
Rockall
CURB-65
Blatchford
Level 2
Wells
Geneva
GI bleed – Risk Scoring
 Blatchford Score – Low risk criteria
 P<100, SBP >110
 Absence of malaena, syncope, co-morbidities
 Normal Hb and Urea
 Rockall score
 Age (<60y =0, 60-79y = 1, >80y = 2)
 Shock (p>100 & SBP>100 = 1, SBP<100 =2)
 Co-morbid (CCF, IHD, sig other =1, RF/LF/malig = 3)
 Pred mortality 0=0.2%, 1=2.4%, 2=5.6%, 3 =11%
Case 6
 Bloods normal
 Same day OGD – normal
 Discharged home with PPI for symptomatic treatment
 No clear guidelines for OP Mx of UGI bleed
 Case dependent, Dr dependent, hospital dependent!
CAP: CURB-65





C = Confusion mental test score 8 or less
U = Urea > 7mmol/l
R = Respiratory Rate ≥ 30/min
B = BP Systolic < 90 mmHg +/- Diastolic ≤ 60 mmHg
65 = age ≥ 65 years
 <2 = mild CAP (Amox 500-1g tds or Clarithro 5/7)
 2 = moderate CAP (Amox and Clarithro 5/7 PO)
 3 = severe CAP  IV Abx
TIA: ABCD2 score
 Age >60
 BP at presentation >140 syst or >90 diast
 Clinical features (unilat weak =2, speech disturbance
alone =1)
 Duration >60mins = 2, 10-59 mins = 1
 Diabetes
 ABCD2 score ≥ 4 or >1 episode in 7d or TIA on
warfarin  TIA clinic review w/n 24 hrs
Questions?
References
 When a test is too good: how CT pulmonary
angiograms find pulmonary emboli that do not need
to be found. BMJ 2013;347:f3368
 CG95 Chest pain of recent onset: NICE guidelines
24 March 2010
 CG141 Acute upper GI bleeding: NICE guidelines
13 June 2012
 Acute Medicine Guidelines, BRI
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