wales medical undergraduate conference case presentation - a dangerous cough
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A Dangerous CoughPresented by Abhishek Chitnis4th Year Medical StudentKeele [email protected]
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Demographic Data 48-year-old Male Caucasian Obese Presented to GP
Presented with a 4 week history of a persistent cough
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History of the Presenting Complaint First noticed cough 4 weeks ago whilst gardening Cough
Persistant Loud & brassy Non-productive No haemoptysis No chest pain / pleuritc pain Dyspnoea
No orthopnoea or PND No exacerbating / alleviating factors
No wheeze / stridor / hoarseness No fever / history of recent foreign travel No loss of appetite, fatigue or weight loss
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Differential Diagnosis?
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Differential Diagnosis
Cough??
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Past Medical History Scoliosis Spondylosis Hypertension Asthma
No significant family history
Family History
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Drug History Ramipril – 2.5mg Amlodipine – 5mg Bendroflumethiazide – 2.5mg Terazosin – 1mg
Salbutamol – 4mg Beclomethasone – 200mcg
Paracetamol – 500mg
No known drug allergies 6
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Differential Diagnosis?
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Differential Diagnosis
Cough??
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Social History Lives with wife 20 pack-year smoking history Minimal Alcohol (1-2 units p/w) Ex-potteries worker Now retired
Only visited today because a television advert he saw stated that anyone with a persistent cough lasting for three weeks or more should visit their GP
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Differential Diagnosis?
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Differential Diagnosis
Cough
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Vital Signs Airway
Patent
Circulation BP - 115/62 Pulse - 76 Warm Peripherals Temperature - 36.4 °C
Breathing RR - 20 SaO2 – 99%
Disability GCS – 15 Talking in full sentences
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Respiratory Examination Patient appeared comfortable at rest and in no resp. Hands
Clubbing and nicotine staining Face
Slight pallor of conjunctiva Neck
No apparent lymphadenopathy Chest
Inspection – No scars, swellings or distensions Palpation – Apex beat palpable, symmetrical lung expansion Percussion – Dullness on percussion over left lower lobe Auscultation – Reduced air entry and diminished breath sounds
over left chest11
distress
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Plan….
1) Urgent CXR2) Bloods
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CXR…. Changes indicative of COPD Pleural thickening
bilaterally Scaring and calcification
right apex
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Left lower lobe - large speculated mass projecting through the left heart border
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CT Thorax and Abdomen with contrast
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Bronchoscopy…. Mouth, larynx and laryngeal area visualised – normal Carina – sharp and clear Right upper, middle and lower lobe bronchi with their
subsegments inspected – normal Left upper and middle lobe bronchus with their
subsegments inspected – normal Left lower lobe bronchus – mass seen at bifurcation
between the left B7 and B8 bronchi Transbronchial lung biopsy - cytology, pathology and culture
Non-small-cell adenocarcinoma – T1N1M0
Plan to review patient at MDT15
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How Does Lung Cancer Present? Second most common cancer in the UK In 2009, 41,428 people were diagnosed with lung cancer in
the UK - that’s more than 113 people every day Cancer with highest mortality Over 8/10 lung cancer cases occur in people aged ≥60 Smoking is the cause of more than 8/10 lung cancers Around 1/8 people with lung cancer have never smoked Presents with:
Cough (80 %)Haemoptysis (70 %)Dyspnoea (60 %)Chest pain (50%)
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Lung cancer screening in the uk Population screening programme for lung cancer by CXR not
recommended by UK National Screening Committee due to: Low sensitivity Low number of cancers that would be found High costs involved Risks of screening
Trials looking at fluorescence bronchoscopy, spiral CT scans and blood tests: Trial in Scotland for those who have smoked for 20 pack years Blood test looks for antibodies against tumour related antigens ->
high antibody levels will be referred for a CT scan Aim to reduce 5 year mortality of lung cancer by earlier detection 17
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Be Clear on Cancer Campaign National campaign set up by DoH to promote earlier diagnosis
of lung cancer Campaign run on TV, radio, print and online media has a simple
message – recommends that people with persistent coughs for three weeks or more visit their GP
Follows an awareness-raising pilot in the Midlands last year – showed improved knowledge of lung cancer and increased confidence in recognising the symptoms
Previously only 1/10 people realised that a persistent cough could be a key symptom of lung cancer
Consequently lead to a 23% increase in attendance to primary care and increase in referrals for CXR and CT scans
94% of the public and 87% of GP agreed its importance18
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Be Clear on Cancer Campaign Campaign fully launched in May 2012 and is aimed at >55 Also targeted at lower lower socio-economic groups as
they tend to delay seeing their GP (Macleod et al, 2009) Hoped that the campaign will help save around 1,300
lives a year Aims to reduce 5 year mortality of lung cancer from 93%
after detection at a late stage to 20% when diagnosed at a much earlier stage
Backed by celebrities including Sir Alex Ferguson, Ricky Gervais and Duncan Bannatyne
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Take Home Messages Bronchial carcinoma can present at any age, including in
those who are under 50 years of age Healthcare advertising is important in encouraging
patients to identify and investigate serious illnesses at an early stage
A fairly innocent presentation can later turn out to be a more sinister pathology
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References http://1.bp.blogspot.com/_-Uzu0xg5lh0/R5kOODkhs3I/AAAAAAAAAIE/
a77WgkwEgzk/s1600-h/Differential_Diagnosis_of_Cough.jpg http://www.cancerresearchuk.org/cancer-info/cancerstats/keyfacts/lung-
cancer/ Longmore M, Wilkinson IB, Davidson EH, et al. Oxford Handbook of Clinical
Medicine. 8th ed. New York: Oxford University Press; 2010. http://www.cancerresearchuk.org/cancer-help/type/lung-cancer/about/
lung-cancer-screening http://www.cancernetwork.com/lung-cancer/content/article/
10165/2056846 http://www.cancerresearchuk.org/cancer-info/spotcancerearly/naedi/
beclearoncancer/lung/lungcancercampaigninformation/
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