A Dangerous CoughPresented by Abhishek Chitnis4th Year Medical StudentKeele Universityv0z55@students.keele.ac.uk

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??

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

Differential Diagnosis?

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Differential Diagnosis

Cough??

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

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

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

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

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

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

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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