Urgent Thoracic Assessment Proforma

Transcription

1 Urgent Thracic Assessment Prfrma Patient Addressgraph Patient Age: Date f Assessment: / / Trust: Clinician: Initial Assessment: Baseline Physilgy Bld Pressure: / Initial Assessment: G8 Questinnaire (Patients >=65yrs ld) Items Pssible answers Scre Pulse:...bpm Pulse: Regular Irregular Respiratry Rate:... 1 Has fd intake declined ver the pas 3 mnths due t lss f appetite, digestive prblems, chewing r swallwing difficulties? 0: severe decrease in fd intake 1: mderate decrease in fd intake 2: n decrease in fd intake 0: weight lss >3kg Oxygen Saturatins:...% Temperature:... 2 Weight lss during the last 3 mnths 1: des nt knw 2: weight lss between 1 & 3kgs 3: n weight lss All patients shuld have an ECG & rutine bld testing (FBC, U&Es, LFTs, Bne Prfile, Cltting) unless there is a specific reasn nt t. ECG perfrmed: Yes N Blds 3 Mrbidity 4 Neurphyschlgical prblems 0: bed r chair bund 1: able t get ut f bed/chair but des nt g ut 2: ges ut 0: severe dementia r depressin 1: mild dementia r depressin Taken: Yes N 2: n physchlgical prblems 0: BMI <19 Initial Assessment: Nutritin Height (cm):... Weight (kg):... BMI:... Unplanned weight lss in the last 3-6 mnths? Yes N % weight lss: <5% 5-10% <10% MUST SCORE:... Please see Nutritinal Care Pathway fr apprpriate interventins based n MUST scre Bdy Mass Index (BMI (Weight in kg) / (height in m 2) Takes mre than 3 medicatins per day In cmparisn with ther peple f the same age, hw des the patient cnsider his/her health status? 8 Age Ttal Scre between : BMI = 19 t BMI <21 2: BMI = 21 t BMI <23 3: BMI = 23 and > 23 0: yes 1: n 0: nt as gd 0.5: des nt knw 1: as gd 2: better 0: >85 1: : <80 A scre <=14 identifies patients that may benefit frm a Cmprehensive Geriatric Assessment Malnutritin Universal Screening Tl ( MUST ) Flwchart Step 1 BMI Scre Step 2 Weight Lss Scre Step 3 Acute disease effect scre Unplanned weight lss in past 3-6 mnths BMI/kg/m + % + 2 Scre If patient is acutely ill and there has been r is <20 (>30 Obese) = 0 Scre likely t be n nutritinal intake fr >5 days = 1 <5 = 0 <18.5 = = 1 Scre 2 >10 = 2 Step 4 Overall risk f malnutritin Add Scres tgether t calculate verall risk f malnutritin Scre 0 Lw Risk Scre 1 Medium Risk Scre 2 r mre High Risk

2 First presenting symptm and histry f presenting cmplaints: Presentatin: Symptmatic Asymptmatic First presenting symptm: Duratin f symptms (mnths): Past Medical Histry: Drug Histry: Anticagulants: Yes N Details:... Antiplatelets: Yes N Details:... Allergies: Yes N Details:...

3 Smking Histry: Smker? Current Frmer Never Hw lng frm waking d yu smke yur first cigarette? <30 mins >30 mins Duratin... Cigarettes n. per day... Oz/week... Year stpped... Asbests Expsure Yes N Occupatin... Age f expsure... Duratin f asbests expsure... Years since expsure... Details f asbests expsure: Family Histry: Family histry f lung cancer in a first degree relative? Yes N Age f first degree relative at diagnsis (yungest if multiple)... Additinal relevant family histry: Scial Histry: Exercise tlerance: WHO Perfrmance Status Tick MRC Dyspnea Scale Tick 0 Fully active, able t carry n all pre-disease perfrmance withut restrictin 1 Nt trubled by breathlessness except n strenuus exercise Restricted in physically strenuus activity but ambulatry and able t carry ut wrk f a light r sedentary nature, e.g., light huse wrk, ffice wrk. Ambulatry and capable f all selfcare but unable t carry ut any wrk activities. Up and abut mre than 50% f wrking hurs Capable f nly limited self care, cnfined t bed r chair mre than 50% f waking hurs Cmpletely disabled. Cannt carry n any self care. Ttally cnfined t bed r chair Shrt f breath when hurrying r walking up a slight uphill Walks slwer than cntempraries n level grund because f breathlessness, r has t stp fr breath when walking at wn pace Stps fr breath after walking abut 100m r after a few minutes n the level grund T breathless t leave the huse, r breathless when dressing/undressing

4 Examinatin: General Clubbing? Lymphadenpathy? Harse vice? Signs f SVCO? Hearing aids? Hearing impairment? Respiratry Abdmen Cardivascular Murmur? Neur Investigatins CXR Perfrmed: Yes N Nrmal: Yes N Findings: ECG Perfrmed: Yes N Nrmal: Yes N Findings: CT Thrax T Stage: N Stage: Emphysema? Yes N Cmments: M Stage: Overall Stage: Frmal reprt? Yes N Other relevant investigatins: Stair climb assessment:... flights f stairs Starting saturatins:... % Finishing saturatins:... %

5 Which disease pattern is present n the CT scan? 0 Grup 1: Peripheral tumr & nrmal hilum/mediastinum, n metastases 0 Grup 2: Central tumur r N1 disease and nrmal mediastinum, n metastases 0 Grup 3: Discrete mediastinum lymph nde enlargement, n metastases 0 Grup 4: Cnglmerate, invasive ndal disease, n metastases Grup 1 GROUP 1: Peripheral tumur with nrmal hilar and mediastinum n staging CT with n distant metastases Including: slid pulmnary ndules 5mm diameter / 80mm3 vlume and BROCK risk 10% and persistent sub-slid ndules fr 3mnths and slid cmpnent 5mm Excluding: pure grund glass ndules, and sub-slid ndules with slid cmpnent <5mm Diagnstic tests Physilgy tests Ntes and guidance Spirmetry and diffusing capacity Percutaneus image-guide bipsy OR radial EBUS brnchscpy Shuttle walk r stair climbing test Peripheral tumur = psitined in the uter 2/3 f the thrax based n axial CT image (blue area): Cardiac examinatin Factrs favuring radial EBUS: Presence f a brnchus sign ± central psitin ± high risk f pneumthrax frm percutaneus apprach e.g. severe emphysema. ECG Creatinine clearance / egfr Request echcardigram if: Age 70 0 Grup 5: Distant metastases Heart murmur Abnrmal ECG Knwn ischaemic heart disease / valvular disease 0 Nne f the abve, desn t fit int these grups Grup 2 Pssibility f pneumnectmy Example f a brnchus sign If any psitive hilar / mediastinal ndes n PET request staging EBUS. Mandatry dataset fr MDT discussin: results Perfrmance status, FEV1 and DLCO, pst-perative predicted FEV1 and DLCO Grup 3 GROUPGROUP 2: 2: Central Central tumur tumur r N1 lymphadenpathy r N1 lymphadenpathy with nrmal with nrmal mediastinum mediastinum n staging n staging CT withct n with distant n distant metastases metastases GROUP 3: Primary tumur and discrete mediastinal lymphadenpathy n staging CT with n distant metastases PET-CT has apet-ct 15% false haspsitive a 15% false rate and psitive 25%rate falseand negative 25% false rate negative fr N2/3 disease rate fr N2/3 in thisdisease categry, in this categry, therefre EBUS therefre is required EBUS regardless is required f regardless PET findings f PET findings PET-CT has a 15% false psitive rate and 25% false negative rate fr N2/3 disease in this categry, therefre EBUS is required regardless f PET findings Prevalence f N2/3 disease is this categry is 60% Prevalence fprevalence N2/3 disease f N2/3 in thisdisease categry in this is 20-25% categry is 20-25% DiagnsticDiagnstic tests tests If bipsy is cnsidered high risk r prbability f malignancy is brderline it may be apprpriate await PET results prir t bipsy. Brnchscpy Brnchscpy & Staging EBUS & Staging EBUS Staging EBUS Staging definitin: EBUS definitin: PhysilgyPhysilgy tests tests Ntes and Ntes and guidance guidance Spirmetry and Spirmetry diffusing and capacity diffusing capacity Central tumur Central = psitined tumur in = the psitined inner in the inner 1/3 f the thrax 1/3 based f the thrax n axial based CT image n axial CT image Shuttle walk r Shuttle stair climbing walk r stair test climbing test (red area): (red area): Cardiac examinatin Cardiac examinatin Systematic examinatin Systematic f examinatin all N3, N2 f all N3, N2 ECG ECG fllwed by N1 fllwed ndes and by N1 sampling ndes and f any sampling f any Creatinine clearance Creatinine / egfr clearance / egfr nde 5mm, targeting nde 5mm, a minimum targetingfa3minimum f 3 lymph nde statins. lymph nde statins. Request echcardigram Request echcardigram if: if: Age 70 Diagnstic tests Physilgy tests Spirmetry and diffusing capacity Staging EBUS Shuttle walk r stair climbing test Cntrast enhanced brain imaging (CT r MR) Cardiac examinatin ECG Creatinine clearance / egfr Staging EBUS definitin: Request echcardigram if: Systematic examinatin f all N3, N2 fllwed by N1 ndes and sampling f any nde 5mm, targeting a minimum f 3 lymph nde statins. Age 70 Heart murmur Heart murmur Age 70 Heart murmur Abnrmal ECG Abnrmal ECG Abnrmal ECG If staging is negative EBUS (including is negative N1 (including N1 Knwn ischaemic Knwn heart ischaemic diseaseheart / disease / If staging EBUS ndes) and nndes) pathlgy and n frm pathlgy frm valvular disease valvular disease brnchscpybrnchscpy then percutaneus then percutaneus image image Pssibility f pneumnectmy Pssibility f pneumnectmy bipsy may be bipsy required may be required Knwn ischaemic heart disease / valvular disease Mandatry dataset Mandatry fr MDT dataset discussin: fr MDT discussin: results, EBUS results, pathlgy EBUS results pathlgy results and DLCO, and DLCO, pst-perative predicted FEV predicted FEV1 and DLCO Perfrmance Perfrmance status, FEV1status, FEV1pst-perative 1 and DLCO Greater Manchester Greater Manchester Cancer Cancer Ntes and guidance Discrete mediastinal lymphadenpathy has well defined brders allwing easy measurement and is nt cnglmerate with ther lymph nde statins. It is nn-bulky (<3cm). Pssibility f pneumnectmy Mandatry dataset fr MDT discussin: results, EBUS pathlgy results, brain-imaging results Perfrmance status, FEV1 and DLCO, pst-perative predicted FEV1 and DLCO, renal functin Grup 5 Grup 4 GROUP 5: Distant metastases n staging CT GROUP 4: Cnglmerate and invasive ndal malignancy n staging CT with n distant metastases Fllw this algrithm in cases where there is clear evidence f stage 4 disease n CT. In cases f uncertain findings there may need t additinal clarificatin tests e.g. liver USS/MR, triple phase adrenal wash ut CT r PET-CT. Radilgy is cnsidered diagnstic fr malignancy and pathlgical cnfirmatin nly required Prevalence f N2/3 disease is this categry is 100% Diagnstic tests Physilgy tests Spirmetry and diffusing capacity Diagnstic EBUS Creatinine clearance / egfr Cntrast enhanced brain imaging (CT r MR) Ntes and guidance Invasive mediastinal lymphadenpathy has prly defined brders and cannt be easily measured. It frms cnglmerate disease with ther ndal statins. Cnsider: Diagnstic EBUS definitin: Pleural aspiratin ± Medical thracscpy if symptmatic pleural effusin. Targeted sampling f ndal disease fr pathlgical cnfirmatin, tumur sub-typing and mlecular pathlgy. results, EBUS pathlgy results, brain imaging results Physilgy tests Creatinine clearance / egfr Wrkup f ligmetastatic disease Definitin f ligmetastatic disease = single metastases in a single rgan In patients that may be suitable fr a high grade palliative apprach request the fllwing investigatins in additin t thse perfrmed fr Grup 5 (request simultaneusly): PET-CT Aviding bne bipsy (lacking a significant sft tissue cmpnent) given time fr decalcificatin and inability t d mlecular pathlgy. Cntrast-enhanced brain imaging Ensure nn-mdt clinicians perfrming bipsies are infrmed abut tissue requirements fr targeted therapy. Shuttle walk r stair climbing test Staging EBUS Spirmetry and diffusing capacity Echcardigram Mandatry dataset fr MDT discussin: Mandatry dataset fr MDT discussin: Perfrmance status, FEV1 and DLCO, renal functin Diagnstic tests Chse mst apprpriate sampling technique t yield adequate pathlgy fr tumur sub-typing and targeted therapy assessment: Pathlgy results Perfrmance status, renal functin

6 Opinin at first assessment: Investigatins required: 0 PET-CT 0 Image-guided bipsy - lung 0 Radial EBUS 0 Staging EBUS 0 Diagnstic EBUS 0 Cntrast enhanced MR brain 0 USS-guided neck ndule bipsy 0 Image-guided bipsy - ther Details:... 0 Serum EGFR testing 0 Spirmetry and diffusin studies 0 Shuttle walk test 0 Echcardigram Cmments: Interventins required: 0 Smking Cessatin Advise smkers that the best way t treat tbacc addictin is with medicatins and supprt. Offer referral t cessatin services. Prescribe medicatins if required using the CURE Tbacc Addictin Treatment Guidance Overleaf. Prvide patient infrmatin leaflet 0 Prehabilitatin Cnsider referral t lcal exercise prgrammes thrugh ERAS referral frm fr Manchester, Tameside, Stckprt and Salfrd patients. Cnsider alternative pathways e.g. pulmnary rehabilitatin. 0 Nutritinal Interventins Prvide interventins guided by the Nutritinal Care Pathway in this dcument Infrmatin given t patient: Macmillan Lung Cancer Specialist Nurse (key wrker) in clinic? Yes N Written recrd f cnsultatin ffered t the patient? Yes N

7 THE CURE PROJECT Curing Tbacc Addictin in Greater Manchester Treatment Pathway fr Tbacc Addictin Lw level addictin Optins are given belw. MAX ne reach fr prduct per patient 10 Cigarettes/day Prescribe a shrt acting nictine replacement ( reach fr nictine) Discuss the fllwing ptins with the patient (tick which ne prescribed): Nictine Inhalatr 15mg sl therapy max 6 cartridges in 24hrs Advise patients nt t inhale but t puff n the inhalatr and the nictine is absrbed thrugh the lining f the muth. Aim t use the inhalatr little and ften. Mre frequent uses gives better results. Cartridge lasts 40 mins f cnstant use. Nictine gum 2mg sl therapy max 15 pieces in 24hrs Advice patients t chew the gum until there is a ht/peppery taste then rest the gum between the lip and gum chew and park. Excessive chewing may cause indigestin & hiccups. Aim t have ne piece n the hur every hur. 2mg sl therapy max 15 lzenges in 24hrs Aim t suck a lzenge n the hur every hur. If indigestin and hiccups ccur try resting the lzenge in the side f the muth. Mderate level addictin Optins are given belw. MAX 1 patch and 1 reach fr prduct per patient Cigarettes/day Prescribe a lng acting nictine patch AND CONSIDER adding a shrt acting reach fr nictine replacement, the ptins are given belw. Advise patients t use a clean & hairless area f skin t apply the patch. Skin irritatin can ccur but is generally mild. Discuss the fllwing ptins with the patient (tick which ne prescribed): Nictine inhalatr 15mg sl therapy max 6 cartridges 3 in cmbinatin therapy/24hrs Nictine gum 2mg sl therapy max 15 pieces 7 in cmbinatin therapy/24hrs Nictine lzenge 2mg sl therapy max 15 lzenges 7 in cmbinatin therapy/24hrs Nictine Patches 14mg/24hur (smkes within 30 minutes f waking) Nictine Patches 15mg/16hur (des NOT smke within 30 minutes f waking) 24 hur patches are ideal fr patients that smke within 30 minutes f waking but can cause sleep disturbance. Discuss ptins, preferences and previus experiences with patient. High level addictin Optins are given belw. MAX 1 patch and 1 reach fr prduct per patient 20 Cigarettes/day Prescribe a lng acting nictine patch AND a shrt acting reach fr nictine replacement, the ptins are given belw. Discuss the fllwing ptins with the patient (tick which ne prescribed): Nictine inhalatr 15mg sl therapy max 6 cartridges 3 in cmbinatin therapy/24hrs Nictine gum 2mg sl therapy max 15 pieces 7 in cmbinatin therapy/24hrs Nictine lzenge 2mg sl therapy max 15 lzenges 7 in cmbinatin therapy/24hrs Nictine Patches 21mg/24hur (smkes within 30 minutes f waking) Nictine Patches 25mg/16hur (des NOT smke within 30 minutes f waking) 24 hur patches are ideal fr patients that smke within 30 minutes f waking but can cause sleep disturbance. Discuss ptins, preferences and previus experiences with patient. VARENICLINE (CHAMPIX) Varenicline prevents the feeling f pleasure during smking by reducing dpamine release in the brain triggered by nictine. This als prevents the subsequent drp in dpamine that triggers cravings and withdrawal. Varenicline is cmmenced 1-2 weeks prir t stpping smking althugh Nictine Replacement Therapy and/r e-cigarettes can be used alngside varenicline in this initial perid. 0.5mg nce daily Day mg twice daily day 4-7 1mg twice daily day 8 end f treatment (12 weeks) One third f patients suffer nausea minimise by having varenicline with a glass f water and fd. Patients can suffer strange dreams but it is safe fr use in patients with a Mental Health diagnsis wh are n stable treatment (i.e n dsage changes r cmmencement f new medicatins in the last 3 mnths) E-CIGARETTES E-cigarettes cntain 95% less harmful chemicals than cigarettes and therefre represent a significant risk reducing behaviur cmpared t smking. It may be a ptential methd f risk reductin fr thse that are nt ready t stp smking. Equally, e-cigarettes can help thse trying t stp smking. E-cigarettes are nt withut risk and still cntain 5% f the harmful chemicals f cigarettes. E-Cigarettes can be used in cmbinatin with ther tbacc addictin therapies including nictine replacement and varenicline. E-cigarettes cannt be prescribed and their use cannt be permitted n hspital grunds.

8 Nutritinal Care Pathway Assess risk f malnutritin MUST Scre 0 = Lw Risk N actin needed MUST Scre 1 = Mderate Risk Prvide Patient Infrmatin Leaflet Eating t be Strnger Cnsider dietician referral and ral nutritinal supplements (2xONS/day) MUST Scre 2 = High Risk Prvide Patient Infrmatin Leaflet Eating t be Strnger, refer t Dietician Team & cmmence ral nutritinal supplements immediately (2xONS/day) Patients can be prvided with a starter pack f Oral Nutritinal Supplements whilst waiting frmal dietician assessment: Fdlink Cmplete Sachets with Fibre: 7 x 63g Sachets, 385kcal per serving (made with 200ml whle milk), added 5g fiber Altrasht: 4 x 120mls, 420kcal, 6g prtein Flavurs: Vanilla, Chclate, Strawberry, Banana, Natural Bth starter packs can be rdered fr free by healthcare prfessinals via an nhs address at the website: