Common Clinical Conditions in General Practice - I Dr. Brendan O’ Shea

Common Clinical Conditions in
General Practice - I
Dr. Brendan O’ Shea
Department of Public Health and Primary Care
Conditions Covered
• Session 1
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Hypertension
Ischaemic heart disease / Angina / MI
Diabetes mellitus
URTI / LRTI
• Session 2
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Asthma
COPD
Low back pain
Arthritis / Joint pain
Thyroid disorders
General Approach to CCCs
• Each condition needs to be considered
in terms of:
• Your Diagnosis and how to make it
– Definition and Prevalence
– Actions at diagnosis
– Follow up / management
– Prevention & screening
Terminology
• Chronic Disease - CDM
• Long Term Condition – ‘LTCs’
• Common Clinical Conditions
Your Diagnosis……..
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How to make it
Understanding the natural history
Understanding the implications of Dx.
Steps and Interventions at diagnosis
Good follow up
Effective continuing care
Common LTCs – 80 patients
Hypertension 42 Renal Failure 5
(Malignancies 8)
ICHD 26
Anxiety 4
Breast 3
Cholesterol 26
Asthma 3
Gastric 1
Thyroid 17
Dementia 3
Prostate 1
Depression 12
TIA 3
Bladder 1
Osteoporosis 12
Alcohol 2
Myeloma 1
Diabetes 11
Cardiomyopathy 2
Myeloprolif 1
A fib 9
Epilepsy 2
COPD 7
Haemochromatosis 2
PVD 7
Uterine prolapse 2
CCF 7
CVA 6
Gout 5
Comment: data garnered from POMR + Drugs
Common Clinical Conditions
• Large Volume of Data
• System of learning.....
Clinical Approach – Talk to / Examine Patients
Programme of Active Reading
Texts
Web Based Resources
Hypertension
• Moderate Incidence / High Prevalence
25% Adults (50% of > 60 yrs) NICE
Hypertension
• Case Study
– 49 y.o. Caucasian Irish male with a LRTI; 1st visit in
3 years
– Opportunistic screening shows BP 167/98
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What is the next step?
What are the important things to cover in the Hx
What investigations should he have?
What treatment would you advise?
What if he was 65 y.o?
Hypertension
• Case Study
– 49 y.o. Caucasian Irish male with a LRTI; 1st visit in
3 years
– He returns 3 months later for f/up:
– BP 152/92. He still smokes 30/day, alcohol 28 upw
• What now?
Hypertension
• Case Study
– 49 y.o. Caucasian Irish male with a LRTI; 1st visit in
3 years
– He returns 3 months later for f/up:
– BP 152/92. He is still smoking 30/day
• What now?
• He is reluctant to take further medication or give up
smoking. How would you approach this problem?
Hypertension
• Definition
– Level of blood pressure above which there is a benefit
from investigation and treatment
• Prevalence
– Dramatically underestimated
– >30% undiagnosed (conservative)
– Approx 50% in 60 + yr age-group
Hypertension
 Why Treat?
 Major risk factor for cardiovascular disease (not just
MI and stroke – retinal, renal, PVD)
 Clear evidence that controlling BP reduces that risk
 HOPE study (ramipril), ALLHAT, Blood Pressure Lowering Treatment
Trialists’ Collaboration
 Screening
 ‘Opportunistic’ or Organised Screening
 All adults: check routinely every 5 yrs to age 80 y.o.
 Annual checks if “high normal,” or hx of abnormal BP
Hypertension
• Classification
– Essential HTN (95%) – cause unknown
• Isolated systolic HTN – elderly patients (5% at 60 y.o.)
– Secondary HTN (5%) – responds less easily to Rx
• Renal disease
– 75% intrinsic renal disease (GN, PAN, polycystic kidney disease,
chronic pyelonephritis)
– 25% renovascular disease
• Endocrine disease – Cushing’s / Conn’s syndrome,
phaeochromocytoma, acromegaly, hyperPTH
• Others – coarctation, pregnancy, steroids, COCP, alcohol
Hypertension
 Classification of BP Levels (BHSoc)
 Category
 Blood Pressure
 Optimal
 Normal
 High Normal
 Hypertension
 Grade 1 (mild)
 Grade 2 (moderate)
 Grade 3 (severe)
 Isolated Systolic Hypertension
 Grade 1
 Grade 2
Systolic BP (mmHg)
Diastolic BP (mmHg)
< 120
< 130
130 – 139
< 80
< 85
85 – 89
140 – 159
160 – 179
≥ 180
90 – 99
100 – 109
≥ 110
140 – 159
≥ 160
< 90
< 90
Hypertension
• Diagnosis
– Proper procedure and equipment (BHSoc)
– If > 140/90 proceed to 24 Hr ABPM
– Assess absolute 10 yr risk of cardiovascular disease
• Ambulatory BP Monitoring
– Suspect white coat HTN (10%)
– Wide variations in BP measurements
– HBPM – seated, BD, 4-7 days, calculate average.
Hypertension
• History / Symptoms and Signs
– Usually asymptomatic, maybe headache / visual disturbance
– Symptoms of end-organ damage – e.g. LVH, TIA, CVA, MI, angina, PVD, renal
impairment
– Contributory factors
• Obesity, excess alcohol intake, excess salt, lack of exercise, environmental stress,
medications, illicit drugs
– Cardiovascular risk factors
• Smoking, DM, hypercholesterolaemia (esp total chol:HDL ratio), FHx
• Examination
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General: BMI, abdominal circumference,
CVS: BP, pulse, heart size, heart sounds, heart failure
Renal: bruits, palpable kidneys, dipstick urine
Fundoscopy (hypertensive retinopathy)
24 Hr ABPM
Hypertension
Investigations
24 hr ABPM
– Dipstick urine and send for microalbuminuria
• 30% pts with HTN have microalbuminuria, one of the strongest markers
for complications in untreated HT
– U+E (consider LFT’s if likely to start a statin)
– Fasting blood glucose
– Fasting lipid profile
– ECG – Sokolow Lyon ; LVH – predictor of complications
– CXR (if suspect cardiomegaly)
Management of Hypertension
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Entry on Disease Register
Communicate on care
Ascertain expectations
Educate re the long haul- Planned
Management
• Explain system of care
• Recalls – 2-3 per annum initially
• Specialist referral if high risk Score > 20%
End Organ
Management of Hypertension
• Web based knowledge resource www.patient.co.uk
‘RAPRIORS’
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Reassure
Advise
Prescribe
Recall
Investigate
Other opinion
Refer
Second opinion
Management of Hypertension
• Lifestyle Interventions
– All patients with HTN / high normal BP
– Grade 1 HTN and no complications – 6 month trial
– Reduce BP and pre-empt rise of BP with age (DASH
diet)
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Maintain a normal BMI
Reduce salt intake to <100 mmol/day (<6g NaCl)
Limit daily alcohol consumption to 15/ 21 upw (F: M)
Regular aerobic exercise ≥30 mins most days
Eat five portions fresh fruit and vegetables per day
– Reduce risk of CVD
• Smoking cessation**
• Reducing intake of total / saturated fats, replacing saturated fats with
Management of Hypertension
• Thresholds for Drug Treatment
– Grade 1 HTN if
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Any complications of HTN
Any end-organ damage
Diabetic
Estimated 10 year risk of CVD ≥20% despite lifestyle advice
If not treated, monitor BP annually as 10-15% will reach
threshold for tx within 5 years, and CVD risk also increases
with age
– Sustained Grade 2 HTN or higher
Choice of Antihypertensive
Under 55
ACE/ARB II
CCB
Over 55
CCB
D (Chlorthalidone/Ind)
ARB II
CCB
D (Chlorthalidone/Ind)
+ Spironolactone
Management of Hypertension
 Increasing Efficacy of Drug Treatment
 All drug classes produce BP reductions of usually 4 to
8% for systolic and diastolic
 70% of patients require tx with a combination of
drugs
 Initiate therapy with a low dose and add small dose
of a second drug, rather than increasing the original
dose
 Give an interval of 4 weeks to observe full response, if
possible
 Long acting single dose 24 hr formulations preferred
The drugs you choose...
 Know 4-6 anti hypertensives in detail
 They are part of your 30-40 drug formulary...
4-6 Anti hypertensives
3-4 stepped Analgesics
2-4 first line Antibiotics
Inhaled beta 2 agonist, anticholinergic,
steroid
Short / LA Benzodiazepine, SSRI Ads X 2.
OHGs X 3, Statins X 2, Steroid creams / PO
Ongoing Management
• BP Target (Monitor 6 monthly when stable)
– Aim 140/85 (but <150/90 gives a major reduction in
CV events)
– Diabetic patients / Chronic renal disease / established
CVD aim <130/80
• Cholesterol / Alcohol / Tobacco / Ex / Wt Targets
– Total cholesterol
• Lower by 25% / aim <4.0 mmol/L, whichever is greater
– LDL cholesterol
• Lower by 30% / aim <2.0 mmol/L, whichever is greater
Management of Hypertension
• Additional Drug Therapy
– Aspirin 75mg OD
• Primary Prevention
– ≥50 y.o. with controlled BP <150/90 AND target organ damage /
10 year CVD risk ≥20%
– Diabetic patients
• Secondary Prevention – all patients unless CI
– Statins
• Primary Prevention
– If 10 year CVD risk ≥20% - titrate dose to reach targets
• Secondary Prevention
– Use sufficient doses to reach targets if total chol >3.5 mmol/L
Malignant Hypertension
• Definition
– Severe HTN (>200/130 mmHg) in conjunction with
bilateral retinal haemorrhages / exudates /
papilloedema
• Presentation
– Headache, visual disturbance
– May ppt fits, encephalopathy, renal failure, heart
failure
• Management
– Untreated 90% die within 1 year
NICE
 Related NICE guidance
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Chronic heart failure. NICE clinical guideline 108 (2010). Available from
www.nice.org.uk/guidance/CG108
Hypertension in pregnancy. NICE clinical guideline 107 (2010). Available
from www.nice.org.uk/guidance/CG107
Prevention of cardiovascular disease at population level. NICE public
health guidance 25 (2010). Available from
www.nice.org.uk/guidance/PH25
Type 2 diabetes. NICE clinical guideline 87 (2009). Available from
www.nice.org.uk/guidance/CG87
Medicines adherence. NICE clinical guideline 76 (2009). Available from
www.nice.org.uk/guidance/CG76
Ischaemic Heart Disease
• Case Study
– Our previous patient is now 58 y.o. He never
managed to give up the cigarettes. His 60 y.o.
brother recently had a CABG.
– Medications:
• Coversyl Plus (perindopril+indapamide)
• Pravastatin 20mg nocte
• Nu-Seals Aspirin 75mg OD
– He presents complaining of recurrent chest
pain
Ischaemic Heart Disease
• Case Study
– What questions will you ask him in the history?
– If you can only do one investigation, what
should it be?
– What medication(s) can you offer him for
symptom relief?
Ischaemic Heart Disease
• Case Study
– His stress test his positive and angiography
confirms significant atherosclerosis. He is
placed on the waiting list for a CABG.
– 5 months later (while languishing on a waiting
list, and having had his admission for surgery
cancelled twice) he has an MI.
– He returns to you after his discharge from
hospital.
• What medication would you expect him to be on?
• When can he return to his job as a taxi-driver?
Ischaemic Heart Disease
• Prevalence
– Cardiovascular disease is the commonest cause of
death in Ireland – 32% (CSO 2011)
Malignancy - 30%
Respiratory – 12.6%
www.cso.ie
Angina
• Definition
– Central chest tightness / heaviness brought on by
exertion and relieved by rest (+/- radiation)
– Caused by myocardial ischaemia
• Atheroma (usually) / anaemia / aortic stenosis / tachyarrhythmias /
HOCM, thyrotoxicosis
• Prevalence
– Affects 2% of population (UK)
• Unstable Angina
– Angina that occurs with increasing frequency /
severity, especially if on minimal exertion or at rest
How are you getting on today ?
Those pills you put me on are making
me feel really lousy
Gosh, I’m really sorry to hear that...
Really ?
Angina
• Diagnosis
– Typical history
– Relieved with GTN
• Investigations
– Bloods
• FBC, ESR (exclude arteritis), fasting lipids and glucose, TFT’s
– Resting ECG (usually normal)(?)
• Evidence of old MI, ST depression, flat / inverted T waves
– Stress ECG
• CI: Symps uncontrolled by max medical tx, MSSK, physically unfit – refer
Cardiology for dx +/- angiography
Angina
 Management
 Cardiovascular risk factor modification
 Secondary prevention – aspirin 75mg OD (↓ mortality by
34%)
 Occupational advice – may need to change to less
physical job; inform driving insurer
 Symptom control (see next slide)
 Cardiology referral – anyone who’s fit enough for
angiography +/- stenting (i.e. most patients); elderly pts
with AS
 PTCA gives symptom improvement in 70%, ?↓ mortality?
 Stenting improves symptom control and relapse rate
 Drug-eluting stents reduce restenosis
 CABG ↓ mortality over 10 yrs and ↓ symps in 80-90%
Angina
 Drug Treatment
 GTN spray – 1-2 puffs PRN (symptom relief)
 β-blockers – 1st line tx
 symptom control and prevents events
 check adequately blocked (resting <60 bpm, post-exercise <90 bpm)
 CI: LVF, asthma
 Verapamil – use if β-blockers not tolerated
 Other Ca++ Channel blockers
 All effective for symp control, but no evidence that cardioprotective
 Nitrates (e.g. isosorbide mononitrate)
 PO / transdermal preparations; start with low dose and increase as
tolerated. SFx – headache, postural hypotension, dizziness
Myocardial Infarction
 Presentation
 Sustained severe, central chest pain, not relieved with
GTN
 +/- collapse, sweating, SOB, nausea, referred pain etc.
 Emergency Management – Call ambulance
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ABC’s if collapsed
Give oxygen / GTN
Aspirin 300mg PO – patient should chew it
IV access
IV analgesia: 2.5 – 5mg morphine repeated PRN (max 15
mins)
 IV antiemetic: metoclopramide 10mg
 GTN spray if SBP >90mmHg and pulse <100 bpm
Myocardial Infarction
• Medication Post-MI
– Secondary prevention
• Statin and aspirin for all unless contraindicated
• Β-blocker for all unless CI – estimated that prevents 12
deaths/1000 treated/yr – benefit in the first year post MI
• ACE inhibitor for all - ↓ myocardial work and ↓ mortality
long-term (and w/in 1 month of MI by 5 per 1000 treated);
fx greater if heart failure at presentation
Myocardial Infarction
 The Role of the GP Post-MI
 Ongoing follow up and monitoring of risk factors (?)
 Support and advice after discharge:
 Gradual increase in activity: @ 2wks post-MI – stroll in the garden; 4 wks
– ½ mile per day; increase gradually up to 2 miles/day at 6 wks; from 6
wks on, increase speed. (Cardiac rehab imps outcome sig..)
 Sexual activity can resume from 6 wks
 Depression – 50% at 1/52, 25% at 1 year
 Work after uncomplicated MI : sedentary work at 4-6 wks; light manual
work at 6-8 wks; heavy manual work at 3 months.
 Driving – nil X 1 mth. HGV / Bus drivers may need driving assessment
 Flying – not for 2 weeks
Diabetes
Diabetes Mellitus
• Case Study
– KC is a 62 y.o. Irish lady who presents for a
repeat prescription of bendrofluazide 2.5mg,
which she takes for HTN. She is well.
– Her BP is 138/88
– On questioning, she has never had her
cholesterol or blood sugar checked.
– You send her for fasting lipids and glucose and
a U+E
Diabetes
• Then and now.....
1400’s
1600’s
1900’s
2012 NICE (2002 / 2008)
Take a somewhat scholarly interest.....
Pop. Prevalence 5 %; > 80% of 80 yr olds
Diabetes Mellitus
• Case Study
– Her fasting blood sugar is 7.9mmol/L
• What does this mean?
– She tells you that her sister has diabetes.
– What other questions do you want to cover in
the history?
– What is the next step?
Diabetes Mellitus
• Case Study
– OGTT with 75g glucose load
(??)
• Fasting blood sugar = 7.3 mmol/L
• 2 hr PP = 12.3 mmol/L
• FBG > 7, or HbA1C > 48 mmol/mol (IFFT)
– She comes back for the results.
– What will you tell her about diabetes?
– What medication should she be started on?
Diabetes Mellitus
• Case Study
– She has been stable on metformin 850mg TID
– She attends for her 6 monthly review.
• HbA1c = 70 mmol/mol
• BP 129/80
• Total cholesterol 5.4, LDL 3.4, HDL 1.0, TG 1.4
– What should be covered at the 6 monthly
review?
– What medication changes should be made?
Diabetes
Cover
Insight
Tobacco
Exercise
Alcohol
Diet
Compliance
BP, BMI, Bloods,
Fluvax / Pneumovax
Dietician / Opthalmology
ECG
Medication
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Add Glicazide
CE or ARB
Statin (Rosuvastatin)
? Antiplatelet Rx
 Planned Review
 Disease Register
 ? Diabetic Referral
Diabetes
• Definition
– Syndrome of increased blood sugars and abnormalities
of carbohydrate and lipid metabolism
– Type 1 (IDDM)
• Usually <35y.o.
• Acute onset due to failure of insulin production – so need insulin
replacement from diagnosis
• Islet cell Ab’s may be present
• Prone to profound weight loss and ketoacidosis
– Syndrome X (Metabolic Syndrome)
• Insulin resistance + other metabolic d/o’s of ↑ CVD risk: visceral
adiposity, HTN, dyslipidaemia (↑TG, ↓HDL), hyperinsulinaemia, obesity,
Diabetes
 Type 2 (NIDDM)
 80-90% of patients;
M:F = 3:2
 ½ have complications at dx
 Insidious onset d/t impaired insulin secretion and
insulin resistance in liver, adipose tissue and skeletal
muscle
 Life expectancy ↓ by 30-40% in 40-70 y.o. (loss of 810 yrs)
 Risk Factors:
 Age >65 y.o.
Obesity
+FHx (100% concordance in MZ twins)
 Ethnicity (South Asians, Afro-Caribbean, Hispanic)
 PMHx of gestational DM or baby >4kg
 Prevalence (Type 1 and 2 DM)
Diabetes
• Presentation
– Asymptomatic – opportunistic / routine screening
– Subacute – weight loss, polydipsia, polyuria, lethargy,
irritability, infections (esp candida, skin infxns, ulcers),
genital itching, blurred vision
– Acute
• Ketoacidosis (Type 1)
• HONK (Type 2)
– Complications – neuropathy, nephropathy, CVD, retinal
disease
• Screening
Diabetes
• Diagnosis
– ADA / WHO criteria (need 2 abnormal readings)
• Fasting venous plasma glucose ≥ 7.0 mmol/L
• 2 hr PP / Random venous plasma glucose ≥11.1 mmol/L
• HbA1C > 44 mmol/mol
• Pre-Diabetes
– Impaired fasting glucose (IFG)
• Fasting glucose ≥ 6.1 and < 7.0mmol/L (check OGTT)
– Impaired glucose tolerance (IGT)
• Fasting glucose < 7.0 and 2hr PP glucose 7.0 – 11.1mmol/L
– Screen annually, as 4% per year will develop diabetes
Management of Type 2 Diabetes
 Initial
 Patient Education
 Diabetes knowledge, complications, need for lifelong tx, aims of
management, long-term illness scheme
 Home monitoring of blood glucose
 Diet – similar to DASH diet; high fibre, low fat; ideal weight
 Exercise – ↑ insulin sensitivity, ↓ BP and lipids
 Smoking cessation
 Driving – ok if not on insulin, should inform insurer, caution for HGV etc
 Employment – most jobs ok if not on insulin
 Psychological problems
 Immunisations – influenza and pneumococcal vaccines
 Modification of CVD Risk Factors
 Statin, ACE inhibitor / ARB (even if BP normal), antiplatelet Rx.
Management of Type 2 Diabetes
• Initial
– Patient Education – most N.B. component
– 3 month trial of diet alone for most patients
• Medication (Oral Hypoglycaemic Agents)
– Biguanides (Metformin)
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•
•
1st line tx for obese pts
↓ gluconeogenesis, ↑ peripheral utilisation of glucose
Only work if some endogenous insulin production
Side Fx: N/V, abdo cramps, lactic acidosis
Management of Type 2 Diabetes
 Medication (cont.)
 Sulphonylureas (e.g. Gliclazide (Diamicron),
glimepiride (Amaryl), glibenclamide)
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1st line tx for non-obese patients (can cause weight gain)
Augment insulin secretion – so need some residual insulin
Modified release – taken before breakfast, last 24 hours
Risk of hypoglycaemia, esp if miss meals
 Repaglinide (Novonorm)
 Very short-acting OHA, usually used with metformin
 Taken before meals and omitted if don’t eat – helps PP glucose only
 Thiazolidinediones (e.g. rosiglitazone (Avandia))
 Cause ↑ insulin sensitivity and ↑ insulin secretion; improve lipid profile
 Used with metformin (2nd choice sulphonylurea), but only if metformin
sulphonylurea combo failed)
 Need to monitor LFT’s; can’t be used with insulin
 Recent concern re this class of drugs: double the rates of heart failure
(class effect) and 42% increased risk of MI (rosiglitazone)
Management of Type 2 Diabetes
• Ongoing
– Routine review (every 3-6 months)
• Continuing Patient Education – most N.B. component
• Glycaemic control, weight, BP, lipids, foot care, set targets
– Annual Review
• Screening for complications (neuropathy, retinopathy, renal
disease (microalbuminuria, U+E), CVD, PCD), foot care, set
targets
• Ophthalmology
– annual slit lamp examination
– 20-40% type 2 diabetics have retinopathy at diagnosis
• Specialist Referral
Diabetes (Conclusions)
 Primary Care Issues
 Practice Registers
 Recall and review systems
 Special diabetic clinics (often nurse-led)
 Shared Care
 Studies
 UKPDS - Tight glycaemic contol reduce microvascular
complications only – NNT 196/yr – no effect on mortality;
Tight BP control  complications and all-cause mortality –
more useful than glycaemic control; beware the U shaped
curve tho’
 HOT trial - tight BP control more effective in DM patients
LTC Management
• Definition of a CD / LTC ; likely to be present at
6 months
• Multimorbidities
• Features of good LTC Management
Clear, earliest consistent Dx
Ongoing practice management
Detailed, standard driven care
Disease register, recall system
Information: Enfranchised, enabled patients
Extended Team (1 & 2 Care, plus Social)
LTC Management
‘Make everything as simple as you can,
........but not simpler.’
Chronic Disease Management
Problems Un co-ordinated care
Disorganised care
Patients do not fully co operate
Cost – in the broadest sense
The fallacy of cheating death
Resourcing
Complexity
Thoughts on LTC Management
 Cochrane Review on Combined Care
 Closer to home (Houlihan & Mitchell) 2010
- In Cycle 1 (MODDM) (n = 70)
- Only 48 patients (68%) were on ACE /
ARB
- 22/70 patients were not on either (32%)
How could this happen ?
How could this happen ?
•
•
•
•
Non systematic approach
Woolly thinking by GPs / NCHDs
Inadequate input by Specialists
Failure of joined up thinking
Respiratory Tract Infections
• Acute RTI
– 25% of GP workload
– 90% viral – aetiological agent rarely identified
– Diagnosis
• Short history of upper and lower respiratory symptoms
• Multiple mucous membranes involvement => likely viral
• Common Cold (rhinovirus, adenovirus, picornavirus)
– Av. Person has 2-3 per annum
– Symps resolve in 4-10 days
– Tx: paracetamol / ibuprofen, fluids, vitamin C, cough
suppressant, decongestant
Respiratory Tract Infections
 Tonsillitis / Pharyngitis
 Each GP sees approx 120 cases/yr
 70% viral, rest mostly group A β-haem strep – clinically indistinguishable
 90% patients recover within a week (consider glandular fever if
prolonged / severe sore throat in a young adult)
 Throat swabs unhelpful as 40% of population +ve for strep
 ABx reduce symptoms x 8 hours and reduce complications
 Penicillin V / erythromycin x 10 days (delayed)
 Referral for tonsillectomy




>5 attacks of acute tonsillitis causing school absence / yr, for 2 years
Airway obstruction d/t very large tonsils causing sleep apnoea
Recurrent quinsy
Chronic tonsillitis >3 months, + halitosis
Respiratory Tract Infections
 Otitis Media
 P/C: painful ear (often unilateral), deafness,
systemically unwell, pyrexia, perforation (assoc with
pain relief)
 Signs – fever; bulging, red TM / perforation
 Aetiology: clinically impossible to tell if bacterial /
viral
 80% resolve in <3 days without tx
 Tx: analgesia; ABx – symps resolve 24 hrs quicker, but
no diff in days off school; usually used if perforation
at presentation
 Advice parents re smoking cessation
 Sinusitis
 Usually post-URTI, but 10% dental origin
Respiratory Tract Infections
 Pneumonia (BTS Guidelines)
 90% in patients >65 y.o; 5% mortality; 10% need
hospitalisation
 Aetiology (UK)




60-70% Strep pneumoniae
4-5% Haemophilus influenzae
1-5% Staph aureus (esp assoc with influenza)
20% Atypical – e.g. Mycoplasma, influenza A virus, Chlamydia, Coxiella
burnetti
 Presentation
 Acute illness with cough, fever, purulent sputum +/- malaise, aches and
pains, vomiting, anorexia, pleuritic chest pain, dyspnoea
 Signs
 Fever, tachycardia, central cyanosis (esp COPD), consolidation, creps, +/-
CAP:
(BTS Guideline 2009)
For the purposes of these guidelines, CAP in the
community has been defined as comprising...
► Symptoms of an acute lower respiratory tract illness
(cough and at least one other lower respiratory tract
symptom)
► New focal chest signs on examination
► At least one systemic feature (either a symptom
complex of
sweating, fevers, shivers, aches and pains and/or
temperature of 38°C or more)
► No other explanation for the illness
Respiratory Tract Infections
• Pneumonia
– Investigations – usually diagnosed on clinical picture
• CXR if diagnosis in doubt; (esp smokers). X-ray changes should resolve in
6 weeks – refer if not
• Bloods – FBC, ESR, titres for atypical pneumonia
• Sputum – microscopy, C+S
– Management
• Analgesia and antipyretics, bed rest, fluids
• Antibiotics
– Amoxycillin 500mg – 1G TID x 1/52
– Erythromycin – can be used first-line as will cover atypicals too
– Complications – pleural effusion, lung abscess,
septicaemia, respiratory failure, jaundice, metastatic
Going Global – it’s the only way…..
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Gastroenteritis
Malaria
Malnourishment
Maternity / Post Partum related illness
Trauma
Tobacco related diseases
Infectious Diseases (other !)
Some Big Ideas
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The Prevention Paradox
The Inverse Care Law
Conventional ‘Western’ Medicine
Social Humane Medicine – Archie C.
‘For Profit’ Private Medicine
The fallacy of cheating death
Life, Death and individual Patients