Cardiorespiratory conditions in general practice: differential diagnosis

Cardiorespiratory symptoms are non-specific. All general practice nurses may be faced with patients presenting with new or acute symptoms, requiring them to draw on their understanding of disease presentations so that they are able to respond appropriately and safely

General practice is under pressure to provide care for an increasing number of conditions to an increasing number of people, while, at the same time, the recruitment and retention of staff is becoming ever more challenging.¹ The number of general practitioners is decreasing and as a result, more general practice nurses (GPNs) and other health care professionals, such as pharmacists and paramedics are moving into general practice to fill the gap.² GPNs are developing and implementing advanced skills in assessing, triaging and managing people who present with acute ‘on the day’ illness. The recent drive to develop training and education for apprentice advanced clinical practitioners (ACPs) is another way of addressing the issue of staff shortage, but there are, as yet, inadequate numbers of ACPs to deal with the increasing workload, and nursing recruitment in general is falling.³

As more GPNs extend their role into acute, ‘same day’ care, critical decision making skills with regard to diagnosis and management, are becoming increasingly important. Those nurses who do not officially work in an extended role may still be faced with patients who present with new symptoms during so-called routine consultations, requiring the nurse to draw on her or his understanding of disease presentations, signs and symptoms and immediate and ongoing management.

In this article, we consider the challenges of differential diagnosis in the general practice setting, focusing on chronic obstructive pulmonary disease (COPD) and coronary heart disease (CHD).

PICTURE THE SCENE

As the respiratory nurse in the practice you are carrying out a COPD review on a patient, Sam. On arrival, Sam looks unwell and informs you that he has been feeling under the weather all morning. He thinks he may be suffering from an exacerbation of his COPD and wonders whether he might need to start his rescue pack of antibiotics and steroids. However, as he was already booked in with you, he thought he would come along anyway and see what you thought.

STRUCTURED ASSESSMENT

Although Sam has offered you a ready-made diagnosis, there is potential danger in accepting this at face value and it is essential to consider other possibilities. Several conditions can present with breathlessness, cough and/or chest pain so the history and assessment can help to narrow down the likely diagnosis. This is where a structured approach is essential. Careful history taking and observations should be recorded and documented. Negative findings, as well as positive signs, should be noted.

Initial assessment

There are several key areas that should be covered in the initial assessment and there are tools available that can act as an aide memoire to ensure that clinicians, who choose to use them, are covering all of these key areas. One tool, which I have developed for myself, is ‘Careful Preparation Finds Medical Issues Swiftly’ with the first letter of each word acting as a reminder about what should be assessed and recorded:

• Current history – what is the history of the presenting complaint?
• Is there any Past medical history that may be relevant?
• What about Family history? Any clues there?
• Medication provides lots of clues – prescribed, bought over the counter, via health stores or online.
• Have they any Ideas about what might be going on or what should happen? (More on this below).
• Is there any Social history that might need to be considered? Has the individual recently moved house or changed their job or started smoking, for example? Are they suffering from low mood or anxiety which may be related to, or complicate their current state of health?

With respect to the ‘ideas’ section above, the ‘ICE’ consultation model can be implemented here: does the patient have any Ideas about what might be going on, any Concerns that should be shared and any Expectations of what might be needed to improve the situation.⁴

Another example of structured assessment is SOAPIER:⁵

• S – subjective i.e. what the patient is feeling
• O – objective i.e. what the clinician observes
• A – assessment of the patient
• P – plan for what to do
• I – implementation of the plan
• E – evaluation of progress
• R – revision of the plan based on response.

In Sam’s initial presentation, only ‘SOAPI’ will be used as the ‘ER’ aspects will come later. However, safety netting will include aspects of evaluation and revision so it is important to explain to Sam how you would expect his recovery to progress and what action he should take if this is not what happens or indeed, if he gets worse.

Symptoms

Specific questions can also be asked about symptoms, unless these have already been offered up by the patient during the initial discussion. Tools which are often used to assess specific symptoms include PQRST, OLDCART and SOCRATES.⁶ These tools broadly cover the same areas so it is only necessary to become familiar with one. (Boxes 1-3)

Examination

Once the history has been taken, a thorough examination should be carried out and, irrespective of the level of expertise that the GPN may have in cardiac or respiratory nursing, all should be able to do a basic assessment of temperature, heart rate, respiratory rate, blood pressure and oxygen saturations.

It may also be prudent to record an electrocardiogram (ECG) and this becomes even more achievable with the advent of new portable devices such as the AliveCor (https://www.alivecor.com/), which can instantly record an ECG without the patient having to lie down and undress.

Depending on the nurse’s expertise and the patient’s problem, further assessment can be carried out using the skills of inspection, auscultation, palpation and percussion.

SAM’S STORY

Sam is 63 years old and tells you that he has a history of COPD and currently takes a long acting B2 agonist to relieve breathlessness. This morning he awoke with a tight chest and increased breathlessness and a productive cough with green sputum. He can feel the cough deep in his chest, and coughing also hurts his throat and his abdomen. Sam has a recent diagnosis of type 2 diabetes and takes ramipril 2.5mg for hypertension. His last blood pressure reading, 2 months ago, was 152/89mmHg.

Today Sam’s blood pressure is 162/93mmHg, his temperature is 37.9° and he has a regular pulse of 95bpm and a respiratory rate of 22. His oxygen saturations are 94%, lower than his normal 98%.

Sam tells you that he thinks this is an exacerbation of his COPD because he has had two exacerbations in the past year, which felt the same. He is worried that his new e-cigarette might have contributed to this flare up of symptoms and is anxious because his father, who suffered from ‘bronchitis’ died after developing pneumonia during an exacerbation. He says that he believes that a course of antibiotics is what he needs, along with his usual short course of oral steroids.

Overall, then, Sam’s story and examination findings all correlate with an acute exacerbation of COPD. NICE has produced guidance on whether or not to prescribe antibiotics for acute exacerbations of COPD and in Sam’s case they would be indicated.⁷ Local guidelines should be followed with respect to which antibiotic but NICE’s recommendations are either amoxicillin 500mg tds or doxycycline 100mg, but in both cases NICE recommends they should only be prescribed for 5 days. Similarly, GOLD recommends that oral corticosteroids should only be prescribed for 5 days in acute exacerbations, at a dose of 40mg daily.⁸ This will simplify Sam’s regime so that both drugs will be completed in 5 days’ time, at which point Sam should be reviewed (or sooner if he is not improving).

ALTERNATIVE PRESENTATION

In an alternative presentation, however, Sam’s story would be different. For example, Sam may have said that when he got out of bed this morning he felt breathless and his chest felt tight. He stopped to rest and the pain subsided a little, only recurring when he went for a wash and shave. He had not noticed a cough and there was no change in his usual sputum production. Sam says that although he has had a few exacerbations of his COPD in the past year, this feels different and he is worried that his usual approach, which is to start one of his COPD rescue packs, is not what is needed today. On examination, he is apyrexial but his heart rate and respiratory rate are both raised and his oxygen saturations are abnormal at 92%.

Taking into account all of this information and bearing in mind his history of diabetes, hypertension and smoking, Sam is at high risk of a cardiovascular event. A decision should be made as to whether Sam is suffering from a new presentation of CHD and whether he needs urgent referral or even admission.⁹ If Sam had described an increase in sputum production and described the sputum as frothy, he could also be at risk of heart failure as he has a history of COPD and diabetes, both of which are linked to an increased possibility of heart failure.¹⁰

Careful history taking and assessment can help to differentiate all of these potential diagnoses and set the scene for a referral – either into the acute services or to a GP colleague for further input, depending on the level of expertise of the GPN carrying out the initial review. If acute coronary syndrome is suspected, aspirin, GTN spray and even morphine may be indicated, with supplementary oxygen as Sam is hypoxic.¹¹ In acute heart failure, a loop diuretic can relieve symptoms and an echocardiogram will be needed to identify what type of heart failure Sam has in order to manage it effectively.¹⁰

ONGOING CARE

Sam was diagnosed as having an acute exacerbation of COPD and was initially treated with doxycycline and prednisolone for 5 days. At his review, a week later, it was noted that he had made a good recovery but that this was his third exacerbation in a year. Based on guidance from GOLD and NICE, it was agreed that Sam would benefit from a dual bronchodilator to improve his symptoms and potentially reduce the risk of future exacerbations.^8,12 However, the possibility of using triple therapy was mentioned if Sam had a further exacerbation.¹²

At the same time, lifestyle and pharmacological interventions were optimised to improve his diabetes, lipid and blood pressure control and reduce his cardiovascular risk in the future. After discussion, Sam opted to attend for smoking cessation support to look at different ways to help him to quit smoking. A pulmonary rehabilitation referral was completed with Sam’s agreement.

SUMMARY

GPNs are extending their role to reflect the needs of the population and meet the challenges presented by difficulties with the recruitment and retention of general practice staff. However, all nurses working in the primary care environment may come into contact with people who present with signs and symptoms that may be associated with significant illness. Although GPNs should only work within their area of competency, and should not attempt to assess and diagnose inappropriately, all nurses should be able to carry out a thorough assessment based on history taking and basic examination before referring on appropriately.

REFERENCES

1. Institute for Government. Performance tracker: General Practice; 2019.

2. NHS Employers. Advanced Clinical Practice; 2019. https://www.nhsemployers.org/your-workforce/plan/workforce-supply/education-and-training/advanced-clinical-practice

3. Buchan J, Charlesworth A, Gershlick B, Seccombe I. A critical moment: NHS staffing trends, retention and attrition; 2019. https://www.health.org.uk/sites/default/files/upload/publications/2019/A%20Critical%20Moment_1.pdf

4. Matthys J, Elwyn G, Van Nuland M, et al. Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract 2009;59(558):29–36. doi:10.3399/bjgp09X394833

5. Eckman M (ed.) The Portable RN: the all in one nursing reference, 4th edition. Philadelphia; Lippincott, Williams and Wilkins: 2011

6. Nuttall D, Rutt–Howard J. Handbook of non-medical prescribing. Chichester; John Wiley & Son: 2019

7. NICE NG114. Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing; 2018. https://www.nice.org.uk/guidance/NG114

8. GOLD. Global Strategy for Prevention, Diagnosis and Management of COPD. 2019 https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf

9. NICE. NICE pathways: Chest pain overview; 2019. https://pathways.nice.org.uk/pathways/chest-pain#path=view%3A/pathways/chest-pain/chest-pain-overview.xml&content=view-index

10. NICE NG106. Chronic heart failure in adults: diagnosis and management; 2018. https://www.nice.org.uk/guidance/ng106

11. NICE. NICE pathways: Assessment and immediate management of suspected acute coronary syndrome; 2019 https://pathways.nice.org.uk/pathways/chest-pain/assessment-and-immediate-management-of-suspected-acute-coronary-syndrome#content=view-node%3Anodes-immediate-management-of-suspected-acute-coronary-syndrome

12. NICE NG115. Chronic obstructive pulmonary disease in over 16s: diagnosis and management; 2019 https://www.nice.org.uk/guidance/ng115

13. Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018 http://diabetologia-journal.org/wp-content/uploads/2018/09/EASD-ADA.pdf