NT-proBNP Guidelines for Heart Failure Diagnosis

NICE guidelines provide clear instructions for the interpretation of NT-proBNP levels in the diagnosis of heart failure. An NT-proBNP level above 2000ng/litre indicates a poor prognosis and requires urgent referral for specialist assessment and echocardiography within 2 weeks. For levels between 400 and 2000 ng/litre, referral should be made within 6 weeks. However, an NT-proBNP level less than 400 ng/litre makes a diagnosis of heart failure less likely. It is important to keep in mind that certain factors such as obesity, Afro-Caribbean family origin, and medication use can reduce the reading. Therefore, careful consideration of these factors is necessary when interpreting NT-proBNP levels. By following these guidelines, healthcare professionals can ensure timely and accurate diagnosis of heart failure.

Distal Intestinal Obstruction Syndrome in Cystic Fibrosis Patients

Distal intestinal obstruction syndrome (DIOS) is a common complication in 10-20% of cystic fibrosis patients, with incidence increasing as they age. It is caused by the loss of CFTR function in the intestine, leading to the accumulation of mucous and fecal material in the terminal ileum, caecum, and ascending colon. DIOS is usually diagnosed through a plain abdominal radiograph, which shows faecal loading in the right iliac fossa, dilatation of the ileum, and an empty distal colon. Ultrasound and CT scans can also be used to identify an obstruction mass and show dilated small bowel and proximal colon.

Treatment for mild and moderate episodes of DIOS involves hydration, dietetic review, and regular laxatives. N-acetylcysteine can be used in moderate episodes to loosen and soften the plugs. Severe cases may require gastrograffin or Klean-Prep, and surgical review should be obtained if there are signs of peritoneal irritation or complete bowel obstruction. In resistant cases, phosphate or gastrograffin enemas can be used, or colonscopy with installation of gastrograffin.

In summary, DIOS is a common complication in cystic fibrosis patients that can be diagnosed through radiographs, ultrasound, and CT scans. Treatment options vary depending on the severity of the episode, but hydration, dietetic review, and regular laxatives are often used for mild and moderate cases. Severe cases may require more aggressive treatment and surgical review.

Assessment and Severity of Acute Asthma

Assessment and severity of acute asthma are common topics in exams. The British Thoracic Society provides clear guidance on the assessment and management of acute asthma, which should be familiar to healthcare professionals.

Indicators of acute severe asthma include a peak expiratory flow rate of 33-50% of the patient’s best or predicted rate, a respiratory rate of 25 or greater, a heart rate of 110/min or greater, or the inability to complete sentences in one breath. Oxygen therapy should aim to maintain SpO2 levels between 94-98%.

It is important to note that increasing symptoms is not a marker of an acute severe attack, but rather denotes a moderate asthma exacerbation. Additionally, there is no fixed numerical peak flow rate for all patients to determine the severity of their asthma. It depends on their personal best or predicted peak flow reading.

If a patient’s actual peak flow is 33-50% of their personal best or predicted rate, it is a marker of an acute severe attack. If any of the indicators of an acute severe asthma attack persist after initial treatment, admission is advised. A simple rule of thumb is that if the peak flow remains at <50% predicted or best after initial treatment, admission is recommended.

Diagnosis of Panic Attack

The ECG and pulse oximetry tests were normal, and the clinical context and examination findings all point to the diagnosis of a panic attack. It is appropriate to explain the diagnosis to the patient and provide reassurance.

Psychological symptoms of an anxiety state include irritability, intolerance of noise, poor concentration/memory, fearfulness, apprehensiveness, restlessness, and continuous worrying thoughts. On the other hand, physical symptoms of an anxiety state include dry mouth, difficulty in swallowing, chest pain, shakiness, diarrhoea, urinary frequency, paraesthesiae, and hot flashes. Physical signs of an anxiety state include tenseness, sweating, shaking, pallor, restlessness, and sighing.

It is important to recognize the symptoms and signs of a panic attack to provide appropriate care and support to the patient.

Harmful Levels of Paracetamol

When it comes to harmful levels of paracetamol, patients are divided into two groups: those who have taken an acute overdose and those who have taken a staggered overdose, which includes patients who may have taken therapeutic excess over a period of time. Surprisingly, even modest amounts of paracetamol can be harmful, especially for frail elderly patients.

According to the British National Formulary, a staggered overdose involves ingesting a potentially toxic dose of paracetamol over more than one hour, with the possible intention of causing self-harm. Therapeutic excess is the inadvertent ingestion of a potentially toxic dose of paracetamol during its clinical use. In these cases, patients who have taken more than 150 mg/kg of paracetamol in any 24-hour period are at risk of toxicity and should be commenced on acetylcysteine immediately, unless it is more than 24 hours since the last ingestion, the patient is asymptomatic, the plasma-paracetamol concentration is undetectable, and liver function tests, serum creatinine and INR are normal.

It’s important to note that there is no set number of tablets that can cause toxicity as it depends on the patient’s weight. Rarely, toxicity can occur with paracetamol doses between 75-150 mg/kg in any 24-hour period, and clinical judgement of the individual case is necessary to determine whether to treat those who have ingested this amount of paracetamol. For small adults, this may be within the licensed dose, but ingestion of a licensed dose of paracetamol is not considered an overdose. The doctor may not be informed until after the event, so familiarity with the timescales is also important.

Guidelines for Identifying Acute Severe and Life-Threatening Asthma

Guidelines from the British Thoracic Society suggest that certain symptoms may indicate acute severe asthma, including an inability to complete sentences, a tachycardia above 110 bpm, a respiratory rate above 25/minute, and a PEFR of 33-50% of the predicted value. It is important to note that the threshold for pulse is higher than expected at 110 bpm.

In contrast, life-threatening asthma is characterized by more severe symptoms such as a silent chest, bradycardia, hypotension, and hypoxia. These symptoms require immediate medical attention and intervention to prevent further complications. By recognizing the signs of acute severe and life-threatening asthma, individuals can seek appropriate medical care and potentially prevent serious health consequences.

Severity of Ulcerative Colitis and the Truelove-Witts Criteria

Severe flare-ups of inflammatory bowel disease can lead to serious complications such as toxic megacolon, perforation, sepsis, and severe bleeding. Hospital admission and inpatient treatment are necessary in such cases. Severe ulcerative colitis is characterized by significant systemic upset and severe lower gastrointestinal symptoms. Blood investigations can provide further information on disease severity.

The Truelove-Witts criteria are a validated way of stratifying disease severity. According to these criteria, acute severe ulcerative colitis is defined as bowels open more than six times daily plus one or more of the following: haemoglobin less than 105 g/L, ESR greater than 30 mm/hr, pulse rate greater than 90 bpm, and temperature greater than 37.8°C.

If a patient presents with bloody diarrhea and systemic unwellness (fever and/or tachycardia), immediate hospital admission for in-patient assessment is necessary. Approximately half of severe ulcerative colitis attacks occur as a first attack in a patient without a previous diagnosis.

Moderate disease is classified as four to six stools a day (with or without blood) with minimal systemic disturbance. Mild disease is classified as less than four stools a day (with or without blood) with no systemic unwellness (no fever or tachycardia) and a normal ESR.

It is important to note that anti-diarrheal agents such as loperamide should be avoided as they have not been shown to reduce stool frequency in ulcerative colitis and have been associated with an increased risk of toxic megacolon. Studies from the 1950s show that untreated severe ulcerative colitis had a mortality rate of almost 25%, but with the use of corticosteroids and expert surgical input, this figure has been reduced to less than 1%.

Severity of Ulcerative Colitis and Hospital Admission

Severe flare-ups of inflammatory bowel disease require hospital admission and inpatient treatment due to potential complications such as toxic megacolon, perforation, sepsis, and severe bleeding. In the case of ulcerative colitis, disease severity can be determined using the Truelove-Witts criteria, which includes symptoms such as bowel movements more than six times a day, along with low hemoglobin levels, high ESR, elevated pulse rate, and fever.

A patient presenting with severe symptoms such as bloody diarrhea and systemic unwellness should be admitted immediately for in-patient assessment. The tachycardia should alert the clinician to systemic upset and prompt hospital admission to initiate treatment to guard against the development of complications. Studies have shown that untreated severe ulcerative colitis had a mortality rate of almost 25%, but with the use of corticosteroids and expert surgical input, this figure has been reduced to less than 1%.

It is important to note that approximately half of severe ulcerative colitis attacks occur as a first attack in a patient without a previous diagnosis. Moderate disease is classified as four to six stools a day (with or without blood) with minimal systemic disturbance, while mild disease is classified as less than four stools a day (with or without blood) with no systemic unwellness (no fever or tachycardia) and a normal ESR. Overall, the severity of ulcerative colitis should be carefully assessed to determine the appropriate level of care and treatment needed for the patient.

Hospital Admission Necessary for Patient with Asthma and Pneumonia

There are several indicators that suggest hospital admission is necessary for this patient. Despite already taking preventative measures for his asthma with Beclomethasone diproprionate 100 mcg/Formetorol fumarate 6 mcg, his usage of salbutamol has increased and he has a productive cough with fevers, indicating a potential bacterial infection. Additionally, his oxygen levels are low, requiring oxygen therapy and monitoring of his oxygen saturations. He is also febrile with evidence of a focal infection and tachycardic. His CRB-65 score of 2, due to his blood pressure being <60 diastolic and his age being >65, further supports the need for hospitalization. Furthermore, his peak flow is less than 50%, indicating both pneumonia and an acute asthma attack.

While other options may be reasonable, such as adjusting his medication or providing home care, this patient requires intravenous antibiotics, oxygen therapy, and monitoring of his oxygen saturations and steroids, all of which can only be provided in a hospital setting.

Emergency Treatment in Primary Care

Potentially life-threatening situations are rare in primary care, but prompt action by a vigilant GP can save lives. Both NICE/CKS and the BNF are reference sources for the AKT exam, and they recommend admitting the person to the hospital as an emergency by calling 999. Treatment should not delay transfer to the hospital, and a single dose of parenteral benzylpenicillin should be administered as soon as possible, provided that it doesn’t delay urgent transfer to the hospital.

Emergency treatment is a crucial topic for the exam, and candidates have performed poorly in the past. It is essential to have benzylpenicillin, a suitable diluent, needles and syringes, and to be familiar with the correct doses for the age range. It is also crucial to ensure that the medicines in the emergency drug bag have not expired and to know who pays for them. More general GP admin and management issues appear to be a weak area for Registrars. If you are unsure about any of the questions posed, ask your trainer who pays for emergency drugs and whether the cost can be claimed back.