Hoarseness – Take-home points

 

Red flag symptoms are persistent hoarseness for more than three weeks, difficulty or pain on swallowing, haemoptysis, earache with normal otoscopy, weight loss, and heavy smoking or alcohol intake

Urgent chest x ray is needed if hoarseness persists for more than 3 weeks (especially if the patient is a heavy drinker, smoker, or over 50 years old)

If the x ray is positive, refer urgently for suspected lung cancer. If it's negative, refer urgently for suspected head and neck cancer

Routine ENT referral is advised for recurrent but non persistent (<3 weeks) hoarseness with no red flag symptoms

Advise patients to stop smoking, reduce alcohol intake, and improve vocal hygiene

Treat any exacerbating conditions such as oral thrush, asthma, or rhinitis 

5 Minutes of General Practice from BMJ

Incidental finding of lymphocytosis in an asymptomatic patient -- Grove et al. 338: b2119 -- BMJ

Causes of lymphocytosis

Reactive (secondary) lymphocytosis

Normal morphology

• Chronic smoking
• Acute hypoxia (transient):

  Acute asthma

  Pulmonary embolus

  Myocardial infarction

• Acute stress (transient)
• Bordetella pertussis

Atypical morphology

• Viral infections:

  Most common—Epstein-Barr virus; cytomegalovirus

  Less common—herpes simplex, influenza, mumps, HIV, dengue haemorrhagic fever; hepatitis A or B

• Bacterial infections:
• • Rickettsial infections
• Drug hypersensitivity

Neoplastic (primary) lymphocytosis

• Chronic lymphocytic leukaemia—most common
• Less common neoplasms:

  Hairy cell leukaemia

  Prolymphocytic leukaemia

  Leukaemic phase of non-Hodgkin lymphoma

Summary of the article

• Lymphocyte morphology can often distinguish between reactive and neoplastic causes of lymphocytosis
• If "atypical lymphocytes" are present, an infectious mononucleosis screening test and viral serology are indicated
• If the lymphocytes have normal morphology and the cause of lymphocytosis is uncertain, repeat the blood count and film in 2-4 weeks
• When lymphocytosis is persistent and unexplained, lymphocyte phenotyping may provide insight into the aetiology

Incidental finding of lymphocytosis in an asymptomatic patient -- Grove et al. 338: b2119 -- BMJ

‘ABCDE’ Mnemonic for Secondary Causes of Hypertension (after American Family Physician, 2003)

A
Accuracy
Alcohol
Apnea
Aldosteronism
Are the blood pressure readings accurate? Could chronic alcohol use be playing a role? Does the patient have obstructive sleep apnea? Does the patient have hypokalemia or other suggestions of primary hyperaldosteronism?

B
Bruits
Bad kidneys
Is there an abdominal bruit suggestive of renovascular hypertension? Does the patient have renal parenchymal disease (which can be cause or a consequence of hypertension)?

C
Catecholamines
Coarctation
Cushing's
Is the patient having palpitations, tachycardia, diaphoresis, headaches, and/or paroxysmal hypertension suggestive of pheochromocytoma? Are there decreased or delayed femoral pulses, or rib notching on chest x-ray suggestive of coarctation of the aorta? Any weight gain, hirstuism, amenorrhea, striae, or moon facies suggestive of Cushing's syndrome?

D
Drugs
Diet
Any use of sympathomimetics, corticosteroids, NSAIDs, oral contraceptive pills, MAOIs, or other drugs that can elevate blood pressure? Are excess dietary sodium or obesity contributing?

E
Endocrine
Erythropoietin
Is there untreated thyroid disease or hyperparathyroidism? Is there another disorder (COPD) leading to increased erythropoietin levels?

Abbr.: NSAID, non-steroidal anti-inflammatory drug; MAOI, monoamine oxidase inhibitor; COPD, chronic obstructive pulmonary disease

Primary Aldosteronism—Changing Concepts in Diagnosis and Treatment (2003)

In patients with suspected primary aldosteronism, screening can be accomplished by measuring a morning (preferably 0800 h) ambulatory paired random PAC and PRA. This test may be performed while the patient is taking antihypertensive medications and without posture stimulation. Spironolactone is the only medication that will absolutely interfere with interpretation of the ratio.

Endocrinology -- Young 144 (6): 2208 Figure 1

JAMA -- A Simplified Approach to the Management of Non-ST-Segment Elevation Acute Coronary Syndromes

While outcomes of controlled studies support a comprehensive approach in the management of patients with NSTE-ACS, many physicians perceive existing guidelines as lengthy and complex. After risk stratification to identify those patients most likely to benefit from an early invasive vs early conservative strategy, a comprehensive management plan can be assembled through an "ABCDE" approach. The elements of this include "A" for antiplatelet therapy, anticoagulation, angiotensin-converting enzyme inhibition, and angiotensin receptor blockade; "B" for beta-blockade and blood pressure control; "C" for cholesterol treatment and cigarette smoking cessation; "D" for diabetes management and diet; and "E" for exercise.

JAMA -- A Simplified Approach to the Management of Non-ST-Segment Elevation Acute Coronary Syndromes, January 19, 2005, Gluckman et al. 293 (3): 349

ScienceDirect - The Lancet : Phaeochromocytoma

 

Presence of phaeochromocytoma

---

Unlikely
Possible
Likely

Urine tests

Catecholamines (HPLC)

Norepinephrine (nmol/24 h)
<500
500–1180
>1180

Epinephrine (nmol/24 h)
<100
100–170
>170

Fractionated metanephrines (HPLC)

Normetanephrine (nmol/24 h)
<3000
3000–6550
>6550

Metanephrine (nmol/24 h)
<1000
1000–2880
>2880

Total metanephrines (spectrophotometry)

Total of normetanephrine and metanephrine (μmol/24 h)
<6
6–12·7
>12·7

VMA (spectrophotometry)

VMA (μmol/24 h)
<40
40–55
>55

Blood tests

Catecholamines (HPLC)

Noradrenaline (nmol/L)
<3·00
3·00–7·70
>7·70

Adrenaline (nmol/L)
<0·45
0·45–1·20
>1·20

Free metanephrines (HPLC)

Normetanephrine (nmol/L)
<0·60
0·60–1·40
>1·40

Metanephrine (nmol/L)
<0·30
0·30–0·42
>0·42

ScienceDirect - The Lancet : Phaeochromocytoma 2005

Ventricular ectopic beats treatment – Heart 2006

 

Treating patients with ventricular ectopic beats: key points

• Ventricular ectopic beats (VEBs) are frequently seen in daily clinical practice and are usually benign

• Presence of heart disease should be sought and, if absent, indicates good prognosis in patients with VEBs

• There is no clear evidence that caffeine restriction is effective in reducing VEB frequency, but patients with excessive caffeine intake should be cautioned and appropriately advised if symptomatic with VEBs

• Unifocal VEBs arising from the right ventricular outflow tract are common and may increase with exercise and cause non-sustained or sustained ventricular tachycardia. Catheter ablation is effective and safe treatment for these patients

• β blockers may be used for symptom control in patients where VEBs arise from multiple sites. It should also be considered in patients with impaired ventricular systolic function and/or heart failure

• Risk of sudden cardiac death from malignant ventricular arrhythmia should be considered in patients with heart disease who have frequent VEBs. Implantable cardioverter-defibrillator may be indicated if risk stratification criteria are met

• VEBs have also been shown to trigger malignant ventricular arrhythmias in certain patients with idiopathic ventricular fibrillation and other syndromes. Catheter ablation may be considered in some patients as adjunctive treatment

Treating patients with ventricular ectopic beats -- Ng 92 (11): 1707 – Heart, 2006

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