NICE Clinical Knowledge Summaries...
Transcript of NICE Clinical Knowledge Summaries...
04/10/2016
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Identifying and Referring Patients with Suspected Cancer
Dr Nick Pendleton
NICE Clinical Knowledge Summaries (CKS)
• Cancer – suspected (NICE referral advice)
http://cks.nice.org.uk/#specialityTabnt
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Referral timelines
• Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary
• Urgent: the patient is seen within the national target for urgent referrals (currently 2 weeks)
• Non-urgent: all other referrals
Lesley Summers - 31
• Whilst I’m here can you check this mole on my arm?
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A B C D E Rule
ASYMMETRY
IRREGULAR BORDER
COLOUR – gaining, losing(?), multiple colours
Diameter greater than 6mm (1/4 inch)
Evolving
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Dermnet New Zealand
http://www.dermnetnz.org/topics/melanomafor-health-professionals/
Mr Schonberg, 66
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A Cutaneous Horn – 25% will have SCC at the base
Ricky, 15
« Coach said I should come and see you about my left leg –It’s interfering with my training. I play a lot of sport including football 3 times a week »
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Tell me more about it..
• I don’t remember injuring it, but I’ve not been able to run on it for a few weeks now
• It is sore and tender to press on
• It hurts even when I’m not walking about
• It’s more sore this week than a few weeks ago
• On examination: he’s limping, there is a bony and tender swelling below the knee
What is the Differential Diagnosis?
• Osgood-Schlatter Disease?
• A Primary Bone Tumour?
• Osteosarcoma most commonly presents between 10 and 24 years old
• This is an age when a lot of people take part in sports
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What should you do next?
• Patients with increasing, unexplained or persistent bone pain or tenderness, particularly pain at rest (and especially if not in the joint), or an unexplained limp should be investigated urgently ?Bone Tumour
• CKS Guidance recommends an immediate Xray and then if bone tumour is a possibility – refer urgently (2WW)
OSTEOSARCOMA (MALIGNANT BONE TUMOUR)
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Osgood-Schlatter Disease
Mrs Gladys Parker, 72
• Dysphagia and weight loss. Gastroscopy 1 month ago normal.
• Came with daughter. My mum is still losing weight and can’t swallow properly. The Doctor we saw last week gave her some ensure drinks but something’s not right!
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Re-referral for gastroscopy
Report: There is a circumferential stricture
seen with the appearances
of an advanced oesophageal
carcinoma…
The patient died 4 weeks later
Letter to Endoscopy Unit
Dear Sister X
I would like to enquire whether it
is possible for a tumour of this
advanced stage to appear with in
this short time scale and do you
have any video footage of the
previous exam?
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Response from GI Consultant
Thank you for your letter. No I do
not think this lesion could have
arisen in this short time scale. I
think it was missed during the
first examination. We will be
exploring this with the
endoscopist. We do not currently
video the examinations.
Mr Chandra, 46, IT Developer
• I have been passing blood from my back passage every time I go to the toilet for the last 3 days
• No change in bowel habit
• Its bright red
• Its after a motion
• It’s not painful
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Examination
• Abdomen examination normal, no mass
• PR examination normal
• What would you do next?
WHAT DOES THE CKS GUIDANCE SAY?
• In patients 40 years of age and older, reporting
rectal bleeding with a change of bowel habit
towards looser stools and/or increased stool
frequency persisting for 6 weeks or more, an
urgent referral should be made.
• In patients 60 years of age and older, with rectal
bleeding persisting for 6 weeks or more without a
change in bowel habit and without anal
symptoms, an urgent referral should be made.
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Mr Chandra, 46, IT Developer
• I have been passing blood from my back passage every time I go to the toilet for the last 3 days
• No change in bowel habit
• Its bright red.
• Its after a motion
• It’s not painful
WHAT DOES THE CKS GUIDANCE SAY?
• In patients with equivocal symptoms who
are not unduly anxious, it is reasonable to
use a period of 'treat, watch and wait' as a
method of management
• In men of any age with unexplained iron
deficiency anaemia and a haemoglobin of
110 g/L or below, an urgent referral should be made
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Timothy, 6 years old
• He’s got a lump on his neck! Its getting bigger
• 3 cm lymph node in posterior triangle
• Hard and irregular in shape
• Recent URTI/sore throat
• Pallor
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Causes of Neck Swelling in Children
LYMPHADENOPATHY (enlarged lymph nodes)
• LOCAL
• SYSTEMIC
LYMPHADENITIS (inflamed lymph nodes) or ABSCESS
NON-LYMPHADENOMATOUS NECK SWELLINGS
BMJ 2012;344:e3171
LYMPHADENOPATHY (enlarged lymph nodes)
• LOCAL • Viral or bacterial upper respiratory tract
• Ear infection, Oropharyngeal infection
• Headlice infestation, Dental abscess
• Cat scratch disease (gram –ve bacteria Bartonella Henselae or
Quintana)
• SYSTEMIC • Malignancy (lymphoma or leukaemia)
• Viral infections (Epstein-Barr virus, cytomegalovirus, rubella)
• Kawasaki disease
• Mycobacterial infection (tuberculous or non-tuberculous),
Sarcoidosis
• Systemic lupus erythematosus
• Juvenile idiopathic arthritis
BMJ 2012;344:e3171
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Lymphadenitis (inflamed lymph nodes) or abscess
• Bacterial lymphadenitis
• Mycobacterial lymphadenitis
• Abscess
BMJ 2012;344:e3171
Non-lymphadenomatous neck swellings
• Cystic hygroma
• Sternocleidomastoid swelling
• Thyroid gland enlargement
• Thyroglossal cyst
• Dermoid cyst
• Branchial cyst
• Mumps
BMJ 2012;344:e3171
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Features of High Risk Neck Lumps in Children
• Non-tender, firm or hard lymph nodes
• Progressively enlarging
• Lymph nodes in the supraclavicular area or axillary area
• Lymph nodes > 3 cm in size
• Lymph nodes in children with a history of malignancy
• Hepatosplenomegaly, Fever, Weight Loss
• Night Sweats
Clinical Otolaryngology, 31, 433 – 434
and GP Notebook (lymphadenopathy)
Timothy, 6 years old
• He’s got a lump on his neck!
• 3 cm lymph node in posterior triangle
• Hard and irregular in shape
• Recent URTI/sore throat, Pallor
• Clearly fits urgent referral criteria for a suspicious neck lump
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Mrs Sullivan, 50, unemployed
• I’ve got this ringing in my left ear!
• I can’t hear as well either
• I sometimes have a spinning sensation in my head
“IN MY RIGHT EAR”
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“IN FRONT”
Weber without
lateralization
Weber lateralizes left
Weber lateralizes
right
Rinne both ears
AC>BC
Normal/bilateral
sensorineural loss
Sensorineural loss in
right
Sensorineural loss in
left
Rinne left BC>AC Conductive loss in
left
Combined loss :
conductive and
sensorineural loss in
left
Rinne right BC>AC
Combined loss :
conductive and
sensorineural loss in
right
Conductive loss in
right
Rinne both ears
BC>AC
Conductive loss in
both ears
Combined loss in
right and conductive
loss on left
Combined loss in left
and conductive loss
on right
AC = Air Conduction BC = Bone Conduction
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Mr Sullivan, 50, unemployed
• I’ve got this ringing in my left ear!
• I can’t hear as well either
• I sometimes have a spinning sensation in my head
• Examination: sensorineural hearing loss
• Diagnosis – small acoustic neuroma (tumour of
vestibulocochlear nerve)
A Large Acoustic Neuroma
Can cause these additional symptoms:
• headaches with blurred vision
• numbness or pain on one side of the face
• problems with limb coordination on one side of the body
• less often, muscle weakness on one side of the face
• in rare cases, changes to the voice or difficulty swallowing
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Mrs Simpson, 52 « I am fed up with this, just look at
my belly its massive, I feel bloated, but I’ve got no appetite and when I do eat I’ve either got diarrhoea or can’t go at all. Also I keep having to urinate, I feel tired and my back hurts! »
OVARIAN CANCER
VERSUS
IRRITABLE BOWEL SYNDROME
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IRRITABLE BOWEL SYNDROME OVARIAN CANCER
Bloating Bloating
Abdominal Pain Pelvic or Abdominal Pain
Nausea/ Poor Appetite/Feeling Full/
Flatus/Belching
Trouble Eating or Feeling Too Full
Quickly
Constipation and/or Diarrhoea
Constipation
Urinary Symptoms eg. frequency Urinary Symptoms eg. frequency
Fatigue Fatigue
Upset Stomach/Heartburn Upset Stomach
Back Pain Back Pain
Abdominal Swelling (with Weight Loss?) Abdominal Swelling with Weight Loss
Muscle pains Pain During Sex
Menstrual Changes
It is uncommon for IBS to first develop in women over the age of 50
Investigating Ovarian Cancer Symptoms in Primary Care
• Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer
• If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis
• For any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound: assess her carefully for other clinical causes of her symptoms and investigate if appropriate
NICE CG 122 - OVARIAN CANCER
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Other Causes of a raised CA125 – Peritoneal trauma, disease, or irritation.
– Other cancers such as primary peritoneal cancer, lung cancer, and pancreatic cancer.
– Endometriosis.
– Pelvic inflammatory disease.
– Ovarian cyst torsion, rupture, or haemorrhage.
– Pregnancy.
– Heart failure.
• Ovarian Cancer Differential Diagnosis:
• http://cks.nice.org.uk/ovarian-cancer#!diagnosissub:1
Sally Smith, 39, Secretary
« My Sister is 45 and having treatment for breast cancer and I want to know if I am at risk »
« My Aunt died from Ovarian cancer 2 years ago »
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What is a Significant Family History? • One first-degree female relative diagnosed with breast cancer at
younger than age 40 years
• One first-degree male relative diagnosed with breast cancer at any age
• One first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years
• Two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age
• One first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative)
• Three first-degree or second-degree relatives diagnosed with breast cancer at any age
http://www.patient.co.uk/doctor/familial-breast-cancer
What is a Significant Family History?
• One first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative)
http://www.patient.co.uk/doctor/familial-breast-cancer
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Alternative Scenario
• Mother had breast cancer aged 50. No other family history.
• Offer information and reassurance, secondary care referral not indicated unless the family history contains:
• Bilateral breast cancer, Male breast cancer
• Ovarian cancer, Jewish ancestry
• Sarcoma in a relative younger than age 45 years
• Glioma or childhood adrenal cortical carcinomas
• Complicated patterns of multiple cancers at a young age
• Paternal history of breast cancer (two or more relatives on the father's side of the family)
http://www.patient.co.uk/doctor/familial-breast-cancer
Mr Jenkinson 71
• Telephone call: « I cannot tolerate this shoulder pain any longer. Surely I need an X-ray or something. The Drs have said there would be no point as it would just confirm arthritis, but it is getting worse and my arm is loosing muscle and strength! »
• XRAY request: 6 months of right shoulder pain now needing morphine
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PANCOAST TUMOUR AT RIGHT APEX
Identifying and Referring Patients with Suspected Cancer CLINICAL RECORD REVIEW
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Tony Frazer 36, National Account Manager (Sales)
• July 2014
• Dr A on-call
• Telephone triage encounter:
• Haematemesis fresh and dried (coffee bean) blood
• Abnormal weight loss, 3 stone in 7/12
Same day appointment with Dr B
• Heamatemesis after drinking excessive alcohol and vomiting
• 2 stone weight loss in 7 months
• Exam normal, weight 65kg (75kg Sept 12)
• Needs 2WW referral, upper GI poss mallory weiss tear but in combination with weight loss need to r/o malignancy.
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14 August – Dr C
• Gastroscopy normal, h.pylori -ve
• Very tired
• Intermittent diarrhoea
• No appetite, weight 63kg
• Mood OK – but a lot of stress in last year
• Blood tests requested to exclude coeliac
• Start omeprazole 20mg bd
Dr C – 22 August • Omeprazole caused dizziness
• TTG IgA test – normal
• c/o No appetite, mood ‘ok’, loss of concentration, memory disturbance, stressful life events
• Not open to possible depression
• Wanted to go private – GI consultant
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2nd October • Continues to lose weight - wt 59Kg
• Consuming 2000 calories in food from McDonalds and 2500 calories in supplements
• Upper GI consultant suggested the cause of his weight loss is depression and suggested starting him on mirtazapine (and arranges CT)
• Patient thinks this is wrong as he has a great life and everything to feel good about.
Weight Chart
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25 September – Dr D
• CT scan was normal
• Now feels too weak and tired to work
• Weight stable
• Feels frustrated and down in mood
• TATT, sleeping lots, buying own high calorie supplements
• Awaiting further GI consultant review. See in 3 weeks
25 November – Dr C • Gaining weight
• Taking mirtazapine
• Has seen consultant again who suggests Chronic Fatigue Syndrome (CFS) is the possible diagnosis
• Referred CFS Specialist for opinion
• In the meantime wants to try hydrotherapy to get some fitness back
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Weight Chart
7 February 2015
• Diagnosis of CFS confirmed by specialist
• 16 September 2015 – making progress with CFS therapy and a return to work is possible in early 2016
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15 September 2016
• Came for review 1 year later
• Went back in to work for but had to leave on Day 2 due to tiredness and inability to cope
• Weight static, Hopes to try work again soon
• Still being paid by employer and admits this is unusually generous
Principles of CFS management • Chronic fatigue syndrome (CFS) causes persistent
fatigue (exhaustion) that affects everyday life and does not go away with sleep or rest
• Affects 250,000 people in the UK
• Usually develops in early 20s to mid-40s. Children can also be affected, usually between the ages of 13 and 15.
• Mild, Moderate or Severe
http://www.nhs.uk/Conditions/Chronic-fatigue-
syndrome/Pages/Introduction.aspx
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Postulated Causes of CFS
• Viral or bacterial infection
• An immune system dysfunction
• Endocrine dysfunction
• Psychiatric – stress/emotional trauma
• Genes – more common in families
http://www.nhs.uk/Conditions/Chronic-fatigue-syndrome/Pages/Causes.aspx
Treatment of CFS • Cognitive Behavioural Therapy
• Graded Exercise Therapy
• Activity Management –setting individual goals and gradually increasing activity
• Medications – nil specific. Symptom relief eg. Analgesia for pain, antidepressants (amitriptyline)
• Pacing – balancing activity with rest
• Relaxing, avoiding stress, avoid excessive sleep, relapse management
• With treatment many people do improve with time
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Summary of the Session
• Melanoma, Cutaneous Horn
• Bone Tumour
• Dysphagia/Oesophageal Cancer
• Rectal Bleeding
• Neck Lump in a Child
• Acoustic Neuroma
• Ovarian Cancer and CA125
• Breast Cancer FH
• Abnormal Weight Loss – Case Review
DISCUSSION
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FOR (outcome of group work)
• Less DNAs, inappropriate/trivial appts
• Encourage use of other resources
• More time to consult and make decisions
• Saves money
• More appts for those who need them
• Less strain on A&E
• Happier Drs and staff – less stressed/busy
AGAINST (outcome of group work)
• Against principle of NHS and Drs
• Deterrent to consulting appropriately
• Poorer health – late presentations and poorer follow up
• Higher expectations, harder to address ICE
• Shifts burden to A&E and will end up shifting cost
• Damages Dr-patient relationship
• More consulting with multiple problems to get ‘value for money’
• Impact on working population
• Incentive for quantity over quality - unethical
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DVD Consultation Analysis
‘A Tingling Arm’
Upcoming Sessions
• 18th October 2016: Mental Health (NP)
• 1st November 2015: COPD (Michaela Bowden)