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A technical update - Nov 2014 v 1.1

Having gone to the bother of taking notes at local CPD events it seems a shame not to
share them, so here is our first CPD Bog Blog featuring YG Grand Round & local GP CPD.

Diagnosing cancer earlier!


Professor Richard Neal, to Ynys Mon Medical Society - 25th Nov 2014 !

! Our gatekeeping GP system is a problem when it comes to early diagnosis of cancer - one year cancer

survival rates are lower in countries where GPs gate-keep investigations and specialty referrals. !
Patients without NICE-qualifying red flags take longer to be diagnosed!
Top Ten Tips
1 Iron deficiency anaemia is
abnormal & needs Ix

Mild anaemia seems to carry


worse prognosis

6 Low-risk but not no risk


symptoms need vigilance

2 Haematuria needs a
reason and Ix

Including dipstick +ve.


Womens urological cancers
are diagnosed later than
mens.

7 Dont lose patients who are


undergoing diagnostic work up

Safety net!

3 Have a low threshold for


In lung cancer, 20% have
CXR & repeat if symptoms normal initial CXR
persist

8 Don't get gate-keeping get in


way of finding a cancer

Your personal
responsibility for health
service austerity must
not affect clinical
decisions

4 Abnormal LFTs/globulins
need a reason and Ix

Raised globulins may be


only sign of myeloma before
renal damage occurs

9 Undertake an SEA for each new


cancer diagnosis

Is in this years QOF for


bowel and lung
malignancies

5 Lower your thresholds for


ix and referral for
suspicious symptoms

Use risk assessment tools

10 Keep cancer as a possibility in


your mind at all times

Snippets from some recent YG Grand Rounds


1. Crohns in a young patient
with learning disability !

- Symptoms attributed to
anorexia then coeliac disease!
- Px with learning disabilities
are at risk of delayed
diagnosis of many illnesses!
- Beware of diagnosing coeliac
disease in absence of
supporting serology (atrophic
changes on biopsy can be
patchy) !

2. Weird symptoms in an
elderly patient on warfarin for
an aortic valve replacement !
!
- Cefuroxime can cause
neutropenia!
- Amyloid angiopathy is a
specific diagnosis that incases
risk of ICH both on and off
warfarin - but it needs
specialised MRI techniques to
find signs of previous bleeds. !

3. Thoracic aortic dissection !

- Only 15% have pulse


differences, 22% have normal
mediastinum on CXR, and
19% have no chest pain!
- Beware neurological features!
- D-dimer may have a role in
ruling out!
- There are new European
Society of Cardiology
guidelines on thoracic aortic
dissection !

Feedback to this Bog Blog? Contact Linda Dykes (Consultant in EM & occasional locum GP!) !
Email Linda.Dykes@wales.nhs.uk - www.mountainmedicine.co.uk !

! Presented to GP with multiple vague symptoms

!66% of very young MI patients,

4. MI in the very young patient!

4. Lady in her 60s with renal vasculitis !

and funny foot pain!


smoke, but 23% have no
Treated conservatively initially but then worrying
conventional risk factors !
features developed such as unexplained
-Usually inferior MI and single
presume irons-deficiency anaemia!
vessel disease !
After many months of investigations chasing a
- Consider differential diagnosis of coronary
presumed malignancy, with various -ologist
dissection (especially if female, pregnancy, under
referrals, her deteriorating renal function and
50 years)!
microcytic haematuria gave the clue to the real
- Also consider cocaine use and pro-coagulable
diagnosis!
states !
Did you know you can get petechiae in swollen
- Recent paper by Rick Body in Manchester found
legs due to venous stasis?!
clinical assessment for ?MI to be
fair (ROC 0.76) but combined with
troponin and ECG, ROC is much better
Errors in Clinical Reasoning !
(1.0) !

!
4. Abscess in a lumbar facet joint in a
diabetic patient in early 20s!
! Took many weeks of IV antibiotics to
-

settle!
- Oedema (visible on MRI) persists for
months, and so does the pain, even after
successful treatment!
- Spinal infections getting more common,
especially in IVDUs!
- try to biopsy/aspirate before Abx if
possible!
- Also watch out for tumours, haematomas
(beware warfarin), fractures, aneurysms
& caudal equina/cord compression!
- Traditional red flags have recently been
reviewed by Cochrane team and found to
be pretty useless in isolation!
- The problem is that the vast majority of
back pains turn out to be nothing (70% of
the population will experience back pain
and theres no specific diagnosis in 85%) !
- However, 2 to 5% of patients presenting
to primary care with back pain have
serious pathology. !
- Recent RCT showed that paracetamol is
ineffective for back pain!
- Dont forget TB.!

Ian Scotts 2009 BMJ paper [http://www.bmj.com/content/338/


bmj.b1860] explores the causes and remedial
strategies of clinical error, and quotes
rates of miss/delayed diagnosis in 5-14%,
with 50% having errors of reasoning of
decision quality. Being older and more
experienced does not necessarily help. !

Theres been a lot of interest in the past few


years about the psychology behind our clinical
decision making - if you dont yet know about
System One and System two thinking, you
really do need to do some catch-up reading. Most people
recommend Daniel Kahnemans Thinking Fast & Slow but
personally I found it almost unreadable. Why We make
Mistakes (Joseph T Hallinan) is much more readable, or do
some googling - http://www.improvediagnosis.org/?
ClinicalOverview has many resources !

Then there are cognitive predispositions to respond which can really damage your ability to reach the correct
diagnosis or decision without you realising. Read about them
at http://lifeinthefastlane.com/ccc/cognitivedispositions-to-respond/ !

If youre interested in knowing more, Pat


Croskerry is the Emergency Medicine guru
in all this, and his tome Patient Safety in
Emergency Medicine has much of note for
all specialties. Ask us very nicely and we
may lend you one of our copies! !

See our conference reports: www.scribd.com/BangorED


taster of

A taster of
Another #FOAMEd production by

OUR CPD

Another #FOAMEd production by

YOUR CPD

OUR CPD

MEd
#FOA

v1.1 - 7th July 2014


minor corrections &
new urology links in
this edition

YOUR CPD

OUR CPD

v1.0 - 4th Sept 2014

YOUR CPD

OUR CPD

MEd
#FOA

MEd
#FOA

YOUR CPD

MEd
#FOA

Another #FOAMEd production


by

OUR CPD

YOUR CPD

MEd
#FOA

CEM 2014

CEM 2014

Conference

Conference

10th & 11th September

Tuesday 9th September

Exeter Cathedral

Mostly Paediatrics

College of Emergency Medicine


Spring CPD Event 2014 - Day 1

College of Emergency Medicine

The unofficial report

DAY ONE

DAY 2 & 3

Toxicology & Trauma

Compiled from the lecture notes made on


the day by our intrepid reporters:

Dr Alison Walker

Exeter Cathedral

Consultant in EM, Harrogate

Dr Helen Salter
Consultant in EM, Bangor, North Wales

OUR CPD

YOUR CPD

MEd
#FOA

OUR CPD

Sharing the learning...


Brought to you by the intrepid reporters of
Team Bangor EM and friends from across
the UK - viva la #FOAMEd!

Sharing the learning...

YOUR CPD

MEd
#FOA

Sharing the learning...


Brought to you by the intrepid reporters of
Team Bangor EM and friends from across
the UK - viva la #FOAMEd!

Topics include:
Legal highs
Crystal Meth
Carbon Monoxide
GHB & GBL
Head, spinal, burn and urological injuries

Edited & designed by Dr Linda Dykes


v 1.0 - 22nd Nov 2014

www.mountainmedicine.co.uk

Edited & designed by Dr Linda Dykes

Compiled, designed & edited by


Dr Linda Dykes, Consultant in EM, Bangor
v 1.0 - 13th Oct 2014

Spring CPD Event March 2014 - Day 3

Sharing the learning...


Another #FOAMEd production
by

The unofficial report


Day 3 topics include:

HIV in the ED
Paediatric major trauma imaging
Atrial Fibrillation
Paediatric CNS tumours (and how
not to miss them in the ED)
Paediatric Acute Severe Asthma
Urological emergencies

Another #FOAMEd production by

www.mountainmedicine.co.uk

College of Emergency Medicine

The unofficial report


Day 2 topics include:

Compiled from the lecture notes


made on the day by our intrepid reporters:

Dr Helen Salter
Consultant in EM, Bangor, North Wales

Dr Alison Walker
Consultant in Emergency Medicine, Harrogate

www.mountainmedicine.co.uk

Sports Medicine, innovation


& controversies

Spring CPD Event March 2014 - Day 2

www.mountainmedicine.co.uk
Compiled, designed & edited by
Dr Linda Dykes, Consultant in EM, Bangor

Concussion in sport
Cardiac problems in athletes
Ankle injuries: beyond Ottawa
Diagnosing PE
Training in trauma management
A field hospital for city-centre drunks
Your ED and your coroner

Sharing the learning...


Another #FOAMEd production
by

Compiled from the lecture notes


made on the day by our reporter

Dr Alison Walker
Consultant in Emergency Medicine, Harrogate

www.mountainmedicine.co.uk
Compiled, designed & edited by
Dr Linda Dykes, Consultant in EM, Bangor

The 2013 EMS Expo:


Conference Catch-Up

Highlights from

Topics include:
Cardiac Arrest: the pitstop
concept & airway management
Drowning
Airway positioning
Community paramedicine
Opiate overdose
Spinal immobilisation
Hypovolaemic shock
Leadership
The Flipped classroom
.... and much more

Sharing the learning...

Las Vegas
September 2013

Sharing the learning...


A totally unofficial report of the EMS World Expo 2013 lectures
attended by two conference delegates from the UK:
Another #FOAMEd production
by

Dr Linda Dykes

Consultant in Emergency Medicine, North Wales

Dr Alison Walker

Consultant in Emergency Medicine, Yorkshire

www.mountainmedicine.co.uk

A totally unofficial report of key learning points noted by conference delegate

Dr Kate Clayton
Clinical Fellow in Emergency Medicine & PHEM
Ysbyty Gwynedd
Bangor, North Wales, UK
PLUS a flavour of the Twitter coverage from the event

www.mountainmedicine.co.uk
Compiled, edited & designed by Dr Linda Dykes

Compiled, designed & edited by


Dr Linda Dykes, Consultant in EM, Bangor

Feedback to this Bog Blog? Contact Linda Dykes (Consultant in EM & occasional locum GP!) Email Linda.Dykes@wales.nhs.uk !