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