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Management of Common Presenting Complaints Using NICE Guidelines History Taking and Safety Netting TOPICS A to E Assessment COVERED NEWS Score TODA Y Anticoagulation Record (Yellow Book) CURB 65/ Wells Score/ PESI BTS vs NICE Guidance for Asthma/COPDCase 1 55M presents to A&E with whilst lifting boxes as he was moving house. Chest pain is described as central and burning. Has been having similar episodes for the last 6 months. What should you do first to manage this patient? 1 2 3 4 5 Call the cath lab Further history Send off a Diagnose the Obtain an ECG as this patient is about patient’s troponin and patient with panic having a STEMI chest pain triage to attacks and Cardiology SpR propanololtartingComponents of a Good Clinical HistoryCase 1: Additional History and Labs • not radiate. Settles after 15 minutes. Isoes present only after exertion. No pain at rest. • PMH - Hypertension, High cholesterol, • activity, poor diet cig/day, no physical • 98% on air, RR 14, pulse 90, Temp 37.5, Sats • additional sounds, HS I + IIr entry, no • Blood test: Pending • Troponin: PendingPutting the Pieces Together for The Patient • Chest pain - likely cardiac pain, still awaiting the blood test for your heart, tracing of your heart appears normal currently • If blood test positive will need to stay in to be monitored and repeated , if negative I will have discuss with my senior but we may be able discharge you. • GP, GTN spray , Aspirin + statin, Beta blocker for the chest pain on exertion • In the mean time, we shall wait on the blood results (or repeated if needed) If worsening chest pain, similar sx occur please inform the nurse ASAP . • F2s can’t discharge a cardiac chest pain without senior discussionCase 2 55 M, PMH previous MI 5 years ago. Presented admitted with worsening SOBOE and lower limb swelling. Nurse asks you to see him for a NEWS of 6. How Would Y ou Initially Manage This Patient? 1 2 3 4 5 Give 40mg Obtain a CXR Conduct an Escalate to Obtain an ECG furosemide A-E is unwell patient IV STAT assessmentNational Early Warning Score (NEWS)National Early Warning Score (NEWS)NEWS of 5 1. respiration rate: 22 2.oxygen saturation: Saturating 97% on 4L NC 3.systolic blood pressure:114/87 4.pulse rate: 92 5.level of consciousness or new confusion: Alert 6.Temperature:36.5 • Airway: Patent and patient speaking to you • Breathing: Equal chest expansion and rise. Respiratory rate is 22. On auscultation chest has bilateral crackles at lung bases. Patient is saturating on 97% on 4L NC Assessment • Circulation: No evidence of peripheral cyanosis, CRT<2s, Pulse 94 and regular, BP 114/87, Raised JVP present, increased additional heart sounds or murmurso • Disability: Patient is alert, BM-7.5 • Everything: Peripheral oedema up to the level of the mid thigh which is 3+pitting in natureManagement • Diagnosis - likely heart failure • Treatment – Diuretics, oxygen, echo,cardio input, Monitor closely (daily weight, daily U&Es, ins and outs) • Sit up, oxygen, consider vasodilators (GTN) and then IV diuretics • Advise will be reviewed by specialist heart failure nurse to organise cardiac rehab and clinic follow up once leaving hospitalHeart Failure Service A set of community nurses that help to bridge the gap between primary and hospital care for the follow up of patients with heart failure that are symptomatic but do not require hospital level treatmentCase 3 68 F presented to A&E has been getting theme on and off for the last 2 weeks but today it started 2 hours ago and she is feeling light headed. No chest pain. Stable BP . How Would Y ou Manage This Patient? 1 2 3 4 If this patient is If this patient is If the patient is If the patient is haemodynamically haemodynamically haemodynamically haemodynamically stable, cardiovert unstable, unstable, start a stable, start a beta this patient anticoagulate this beta blocker blocker immediately patient immediately immediately immediatelyCommunication with the Patient Explanation of atrial fibrillation in simple to understand terms Explanation of management going forward Explanation of the benefit of medication and the increased risk of bleeding If starting on warfarin, explain the yellow book and the need for frequent follow up with anticoagulation clinic and warfarin nursesCase 4 75 M, Attended A&E with SOB and productive cough for the last 7 days. RR:28 saturating 96% on 4L NC, BP 96/64, HR 88 and T 38. Green sputum production.Labs: CRP 2 WCC 9.8 Hb 120 Neutrophils 7.8 Urea 4.3 mmol/L What Is The Most Likely Diagnosis? 1 2 3 4 5 Bronchitis Exacerbation Pneumonia Pulmonary pulmonary of COPD Embolism oedemaLabs: CRP 187 WCC 13.0 Hb 120 Neutrophils 16.3 Urea 8.3 mmol/L What Is The Most Likely Diagnosis? 1 2 3 4 5 Bronchitis Exacerbation Pneumonia Pulmonary pulmonary of COPD Embolism oedemaWhat Is The CURB65 Score For This Patient? 1 2 3 4 5 Always Follow Trust Antimicrobial Antibiotic Guidelines First As Usually Made Choice? Based on Local Resistance Patterns Oral vs IV Antibiotic Choice Using Sputum to Guide Your ManagementCase 5 42 F presents to GP . Has had a dry cough for the coughs up blood as well.lly Associated with weight loss, fatigue and decreased appetite. History of frequent traveling abroad and significant smoking historyWhat Are Some Differential Diagnoses for this Presentation?DifferentialsWhat Are Some Investigations to HelouY Narrow Down The Pathology?CXR is done which is highly suspicious for a diagnosis of lung cancer and a CT chest has been advised by RadiologyCase 6 35 F presented to referred from GP with unilateral lower limb swelling up to knee. Reddening and tenderness of the calf. Taking OCP . Mother has a history of PE. What is the most likely diagnosis 1 2 3 4 5 Cellulitis DVT Venous erythema compartment eczema migrans syndrme What Can Help Us Assess the Risk of A Patient Actually Having a DVT or PE? 1 2 3 4 TIMI Risk ScorePESI Score Well’s ScoreCHA₂DS₂-VASc ScoreContraindications to Anticoagulation 1. Active Bleeding 2. Haemorrhagic Stroke 3. Major bleeding (gastrointestinal, intracranial, intraocular, retroperitoneal) 4. Bleeding Disorders (haemophilia, thrombocytopenia, other bleeding disorders) 5. Peptic Ulcer 6. Oesophageal Varices 7. Aneurysm 8. Proliferative Retinopathy 9. Recent Major Surgery 10.Recent Major TraumaCase 7 18 F. BIBA worsening Struggling to talk in full sentences. PMH Asthma since childhood. She has been using her blue inhaler like usual but she is not feeling any better. An A-E Assessment is Done. Which of the Following Features Would Make You Concerned About Life Threatening Features? 1 2 3 4 Completey to Respiof 24y Rate PaO2 of 8.5kPa P5.2kPaf Sentences in A Single BreathHANDOVER TO ITUChronic Asthma Management BTS vs NICE GuidelinesReferences • NICE UK Guidelines • NHS Website • Gram Project (AF Guidelines Schematic) • GREPMed (CURB 65 Schematic) • CXRs from radiopaedia.org • British Thoracic Society • NHS University Hospital Sussex on Life Threatening Asthma