Oxford summary 6 Flashcards
Acute Abdomen Hx & Exam
SOCRATES Temperature, pulse, BP, anemia, Jaundice Guarding/ rebound tenderness Rectal/ vaginal examination Urine dipstick/ finger prick blood glucose testing
Acute Abdomen DDx
Renal causes
Gynaecologic
GI
Other
Acute Abdomen
Ruptured spleen Hx
History of trauma
Blood loss: tachycardia, hypotension, pallor
Peritoneal irritation: guarding, rigidity, shoulder tip pain
Paralytic ileus: distention, no bowel sounds
RUQ pain DDx
liver
gallbladder
duodenum
right lung
R Flank pain DDx
R kidney
colon
ureter
MSK
RIF pain DDx
caecum appendix R ovary R fallopian tube ureter
suprapubic pain DDx
bladder
uterus
rectum
epigastric pain DDx
oesophagus
stomach
duodenum
heart
LUQ pain DDx
stomach
spleen
L lung
L Flank pain DDx
L kidney colon ureter AAA MSK
Central pain DDx
small bowel
appendix
Meckel’s diverticulum
LIF pain DDx
colon
L ovary
L Fallopian tube
ureter
Abdominal Pain Hx + Exam
Hx: Socrates
Examination
• Temperature, pulse, BP, RR, anemia, jaundice signs
• Abdominal, rectal, genitalia exam
• Urine dipstick/ finger prick blood glucose testing
Anal/ perianal pain
Fissue, haemorrhoids, naematoma, abscess, fistula Pilonidal sinus Skin infection FunRUQctional pain- proctalgia fugax Carcinoma
tenesmus DDx
IBS
Proctitis
IBD
tumour
Constipation Sx
Straining at defecation ≥25% of time
Tenesmus ≥25% of time
≤2 bowel movements / week
Lumpy/ hard stools ≥25% of time
Constipation Tx
o FBC, ESR, U&E, Cr, LFTs, TFTs, serum glucsose
o Colonoscopy or CT colography if >6weeks
o Lifestyle advice
o Osmotic or bulk- forming laxative- ispaghula, sterculia ± stimulant laxative
o Long- term stimulant laxative: c- danthrustate in very old
o If laxatives not working- try rectal measures. For soft stool- bisacodyl suppositories, if hard stool- glycerin suppositories
Organic causes of constipation
Colonic: cancer, diverticular disease, CD, stricture, intussuption, volvus
Anorectal: ant mucousal prolapse, fissure, abcess, proctitis
Pelvic: ovarian ca, uterine ca, endometriosis
Endocrine: Ca2+, hypothyroid, DM + autonomic neuropathy
Drugs: opioids, antacids + calcium/ aluminum, antidepressants, Fe2+, anti-PD, anticholinergic, anticonvulsants, antihistamine, calcium antagonists
Other: pregnancy, immobility, fluids
Dyspepsia causes
GORD, PU – both 15%
Stomach cancer- 2%
Non-ulcer dyspepsia aka “functiona”- 60%
Oseophagitis
Dyspepsia PC
Retrosternal or epigastric pain
heartburn
Fullness
bloating
wind
N &V
H pylori Tx
Healthy eating, weight loss
Stop smoking, alcohol, caffeine, chocolate, fatty food
omeprazole 20mg bd 4/52 + amoxicillin 1g bd + clarithromycin 500mg bd 1/52
Metronidazole 400mg bd can be used instead of amox
Endoscopy
H. Pylori Dx:
serology,
urea breast test,
faecal antigen test
Gastritis drug causes
Ca antagonists Nitrates Theophyllines Bisphosphonates Corticosteroids, NSAIDs SSRIs
Barret’s oesophagus
Metaplasia into intestinal cell type
Risk of adenocarcinoma
Tx: long-term omeprazole 20-40mg od ± laser ± resection
Acute gastritis
def
types
tx
Mucosal inflammation without ulcer
Type A: entire stomach, a/w pernicious anemia, pre-malignant
Type B: antrum ± duodenum, a/w H.pylori
Type c: due to irritants- NSAIDs, alcohol, bile reflux
Treat cause
Acid suppression with rantidine, nizatidine or PPI 4-8wk
Endoscopy
Gastro-esophageal malignancy upper 2/3
Squamous cell carcinoma
• Smoking, alcohol
• Low fruit and veggies
Gastro-esophageal malignancy lower 1/3
Adenocarcinoma
• Smoking
• Low fruits and veggies
• GORD, obesity
Gastro-esophageal malignancy risks
Previous mediastinal RT
Plummer- Vinson sundrome
Tylosis- inherited. Also hyperkertosis of palms
Gastro-esophageal malignancy PC
Short hx rapidly progressive dysphagia ± weight loss ± regurgitation of food and fluids, hoarsness, cough
Retrosternal pain is late feature
Gastro-esophageal malignancy Tx
endoscopy
CT
RT palliative with stenting tube
Stomach cancer 95% what type age Risks Px: Management:
adenocarcinoma
>55 yo
- Japan, SES
- Blood group A, smoking
- Pernicious anemia, H.pylori, atrophic gastritis
- Adenomatous polyps, previous partial gastrectomy
dyspepsia, weight loss, anorexia, early satiety, V, dysphagia ± GI bleed
endoscopy, total/ partial gastrectomy
Post gastrectomy syndromes
• Early satiety ± weight loss • Bilious vomiting: o Metoclopromide or domperidone • Dumping: distention, colic and vasomotor disturbance after meal= rapid gastric emptying. • Diarrhea: loperamide, codeine • Anaemia: B12 and iron deficiency • Stomach cancer
Colorectal Cancer screening test
faecal occult blood test every 2 years to 60-74years
Colorectal Cancer FHx
risk 2-3x
Refer for colonscopy: 2x first degree or 1x first degree <45
FAP: cancer <40
Juvenile polyposis
Peutz- Jegher syndrome- AD. Benign intestinal polyps with dark freckes on lips, oral mucosa, face, palm and soles
HNPCC: ≥3 relatives with ≥2 generations and ≥1 developed <50
MMR oncogene
Previous hx colorectal cancer
colonoscopy 5 yearly until 70years
Colorectal cancer Risks
Obesity, diet, alcohol, exercise Meds that : HRT, COCP, statins, aspririn Hx gallbladder disease/ cholecystectomy T2DM UC/ Crohns Disease
Colorectal cancer Px:
Bowel habit: D ÷ mucous, constipation or alternating, Tenesmus
Obstruction: pain, distention, absolute constipation ± V
PR bleeding: occult or bright red
Perforation: generalized peritonitis fistula
Systematic
Colorectal cancer Examination and investigation:
General: cachexia, jaundice, anemia
Abdominal mass, hepatosplenomegaly, ascites
Rectal exam
Colorectal cancer Tx:
resection ± chemotherapy
Hemorrhoids “piles”
Def
Risks:
Types
Distention of submucosal plexus of veins at 3,7, 11 o’clock
constipation, Fhx, VV, pregnancy, anal tone, pelvic tumour, portal hypertension
1st degree: piles in anal canal
2nd degree: prolapse out of anal verge but spontaneously reduce
3rd degree: prolapse out of anus and need digital reduction
4th degree: permanently prolapsed
Hemorrhoids “piles”
Px:
Tx
Complications
Discomfort, discharge ± PR bleeding, Tenesmus, pruitius ani
Protoscopy ± sigmoidoscopy if >40 and not visable
Soften stool- bran ispaghula husk
Topical analgesia- lidocaine 5%
Strangulation –> intense pain + anal sphincter spasm
Thrombosis –> pain/ anal sphincter spasm
Perianal haematoma (thrombosed external pile)
Ruptured superficial perianal vein causing subcut haematoma
Px:
Tx:
sudden onset of severe perianal pain
Tender, 2-4mm “dark blueberry” under skin near anus
analgesia, spontaneously settles over 1 week
Rectal prolapse
Young or >60yrars
Px: mass coming from anus ± discharge
Types
Mucosal: 3rd degree- bowel musculature remains in position but redundant mucosa prolapses from anal canal
Complete: decent of upper rectum- weak pelvic floor fro childbirth. Bowel wall inverted and passed
Anal fissure
Torn anal mucosa- posteriorly>
Px:
Management:
Px: pain on defecation ± constipation, PR bleed
Visible as “sentile pile”= bunched up mucosa at base of tear
Rectal examination tender bc muscle spasm
Tx
ispaghula husk, lidocaine 5%, can add glycerol trinitrate 0.4% bd- pain and spasm but can cause headache or 2% topical diltiazem cream bd
Anal ulcers causes
Crohn
Syphilis
Tumour
Anal cancer SCC
Risks
Px:
Tx:
anal sex, syphilis, warts
PRB, pain, anal mass/ulcer, pruritus, stricture, BH change
RT ± CT- if fails then abdominoperineal resection
Irritable bowel syndrome def
Chronic relapsing and remitting condition. No cause. Symptoms: abdominal pain, bloating, change BH
Irritable bowel syndrome dx
dx of exclusion
<40: FBC, ESR, TTG/ EMA- Ig to exclude coeliac
>40: exclude colorectal cancer
TFT, stool sample for infection, endocervical swab for chlamydia, colonoscopy, laproscopy for endometriosis
Irritable bowel syndrome Sx
abdominal pain or discomfort that is relieved by defacation or altered bowel frequency/ form + ≥2:
Altered passage- straining, urgency, incomplete
Bloating, distention, tension, hardness
Passage of mucouse
Worse with eating
Irritable bowel syndrome Tx
Diet: water, caffeine, alcohol, high-fibre food, for D- avoid sorbitol
Probiotics- 4week trial
Fibre/ bulking agent: ispaghula husk or laxatives if constipation
Antispasmodics- mebeverine, peppermint oil
Antidiarrhael loperamide- avoid codeine phosphate bc dependence
Antidepressants- low dose amitriptyline 10mg nocte, SSRI less effective
Psychotherapy and hypnosis
Causes of SOB
Cardiac disease
Acute: LVF, arrythmis, shock
Subacute: arrhythmia, subacute bacterial endocarditis
Chronic: CCF, MS, AS, congenital heart disease
Causes of SOB
Lung disease
Acute: pneumothorax, acute asthma, PE, pneumonitis
Subacute: asthma, infection, COPD exagerbation, effusion
Chronic: COPD, CF, ILD, mesothelioma, cancer
Causes of SOB
Other causes
Hyperventilation
Foreign body inhalation
GB syndrome, MG, thyrotoxicosis, MND, MS, kyphoscoliosis
Polio
Anaemia, ketoacidosis, musculoskeletal chest pain
Hyperventilation: >20 breaths/min or deep (TV)
Can result in palpitations, dizziness, faintness, tinnitus, chest pain, perioral and peripheral tingling due to Ca2+
Caused by: anxiety, PO, PE, hyperthyroid, fever, lymphangitis
Kaussmal respiration: deep, sighing seen in met acidosis
Neurogenic hyperventilation: due to stroke, tumour, CNS infection
Hypoventilation causes:
Respiratory depression: opioid, anoxia, trauma
Neurological: GB disease, polio, MND, syringobulbia
Lung disease: pneumonia, collapse, pneumothorax, effusion
Resp muscle disease: MG, dermatomyositis
Limited chest movement: kyphoscoliosis
Combined chest pain + SOB DDx
MI, pericarditis, chest infection, dissecting aneurysm
PE, pulmonary ca
Esophageal pain, MSK pain
Increased RR causes
- Lung- asthma, pneumona
- Heart- LVF
- Metabolic- ketoacidosis
- Drugs- salicylate overdose
- Psychiatric- hyperventilation
Decreased RR causes
CNS- CVA
drugs- opioids
Acute cough <3 weeks Tx
CXR if marked focal chest signs, foreign body, cancer
Abx- amoxicillin 500mg tds/ clarithromycin 500mg bd/ doxycycline 100mg od if:
Systemically unwell Co-morbidity high risk of complications >65 with ≥2 of following or >80 with ≥1 of following: • Hospitalized in previous year • CCF • Use of oral glucocorticoids • DM
Haemoptysis DDx
- Infection, bronchiestasis, lung cancer, PE
- Violent cough, foreign body, tubation, trauma
- Cardiac: acute LVF, MS
- Idiopathic, aspergillioma, good pastures, PAN, Wegners
Haemoptysis Tx
Admit if bleeding/ shock
Urgent CXR
Cancer risk if: persistant with normal CXR, >40 + smoker, ex-smoker- if terminal tx with IV morphine + midazolam
Chronic cough >3 weeks DDx
- Post nasal drip, post viral, ear wax
- COPD/ asthma, lung cancer, PPO, bronchiesctasis, smokers cough
- Pertussis, TB
- Foreign body, vocal cord palsy
- GORD, LVF, ACEI
Chronic cough management:
CXR
Treat cause
Bronchiectasis: recurrent/ persistent infections –> dilated bronchi
Causes
Px mild:
Px severe:
Congenital: CF, kartagener syndrome
Post infection: TB, pertussis, measles, pneumonia
Obstruction, aspergillosis, hypogammaglobinaemia, aspiration
Px mild: asymptomatic with winter exagerbation- fever, cough, purulent sputum, pleuretic pain, SOB
Px severe: persistant cough + sputum, haemoptysis, clubbing, crackles and wheeze
Bronchiectasis
Dx:
Tx:
CXR, sputum- M,C&S, spirometry, HR CT
respiratory referral, physio, aBx, bronchodilators, influnenza/ pneumo vaccine, surgery
Pneumonia in Adults PC
Acute LRTO: cough ± purulent sputum ± pleurisy
New focal chest signs: consolidation, decreased air entry, coarse crackles, pleural rub
Systemic features: fever, sweating, shivers, aches, temp ≥38°C
Pneumonia in Adults Causes
Pneumococcus
H. influenza- elderly
Influenza A and B- annual epidemics
M. pneumonia, gram –ve enterics
Pneumonia in Adults prevention
influenza and pneumococcal vaccine
Pneumonia in Adults Dx
Pulse oximetry: ≤92% saturation= need admission
CXR:
Sputum culture: not responding to tx, TB signs
Bloods: FBC, WCC, ESR, Ig titres
CURB 65
Confusion
RR ≥30 breaths/ min
BP: systolic <90 or diastolic ≤60mmHg
≥65 years
0: likely for home treatment
1-2: consider hospital referral
3-4: urgent admission
Pneumonia in Adults Management
Home vs admission
No smoking, rest, increase fluids
Amoxicillin 500mg-1g tds, doxycycline 100-200mg od or clarithromycin 500mg bd
Treat pleuritic pain with Paracetamol 1g qds
Review 48hrs- no improvement/ deterioration= CXR/ admit
Pneumonia in Adults Comp
Pleural effusion, respiratory failure
Lung abscess: px with swinging fever + worsening pneumonia
Septicemia, jaundice
Metastatic infections
Pneumonia in Adults Comp
Pleural effusion, respiratory failure
Lung abscess: px with swinging fever + worsening pneumonia
Septicemia, jaundice
Metastatic infections
Common cold Complications
Exacerbation of asthma/ COPD
Secondary infection: bronchitis, pneumonia, conjunctivitis, OM, sinusitis, tonsillitis
Common cold
acute, afebrile, RTI
Causes: Rhio, picorna, echo, coxsackie
Spread: droplet infections
Management: fluids, Paracetamol. Symptoms resolve <1.5wks
Acute bronchitis
inflammation of major bronchi
Follows viral URTI
Symptoms: cough ± sputum, SOB, wheeze
Signs: wheeze and scattered coarse crepitations
Acute bronchitis Tx
self limiting <3wks.
o Bronchodilators if wheeze hard
o Abx to shorten symptoms vs abx resistance, extra meds
Systemically unwell
Symptoms of serious illness/ complication- pneumonia
Co-morbidity so risk of complications
>65 + acute cough + ≥2 or >80y + acute cough +≥1: hospitalization in last year, CCF, oral steroids, DM
Risk for severe disease with influenza
≥65 years or
≥1 of: chronic respiratory disease, CVD, immunosuppression, CRD, DM
Influenza
Sporadic, during autumn and winter
Causes: influenza A, B, D
Spread: droplets, person- to person contact, contaminated items
Influenza Px
Common cold symptoms + myalgia, arthrylagia
Headache, sore throat, cough ± coryza
Acute symptoms last <5d- weakness, sweating, fatigue- longer
Secondary chest infection with S.aureus/ S.pneumonia
Influenza Management
Rest, fluids, Paracetamol
Tx complications- penumona, exacerbation of asthma/ COPD
Antivirals: zanamivir 10mg bd 5/7 inhaled and oseltamivir 75mg bd 5/7- shorten symptoms and complications. Use when risk of complications and when prevalent in community
Zanamivir- can cause bronchospasm- avoid in asthma
Influenza Prevention
Influenza vaccine
≥65, pregnant
Chronic renal, lung, liver, cardiovascular disease
Immunocompromised and DM
Health professionals, carers of patients with disabilities
Oseltamivir in high risk >13: 75mg od for 7- 10 days
Lung Cancer urgent referral if
o Persistent haemoptysis
o CXR with pleural effusion, slowly resolving consolidation
o Asbestos exposure + SOB, pain, systemic symptoms
Lung Cancer urgent CXR if
o Haemoptysis
o >3 wks: cough, chest/ shoulder pain, SOB, weight loss, chest signs, hoarseness, clubbing, lymphadenopathy, met?
Lung Cancer types
Small cell lung cancer: ~25%
Disseminated on dx to liver, bones, brain, adrenals
NSCLC: adenocarcinoma or SCCC. Not always due to smoking
Lung Cancer prevention
Smoking cessation- 90% lung cancers due to smoking
Diet: fruit, carrots, green veggies
Lung Cancer PC
>90% have symptoms Cough- 56% Chest/ shoulder pain- 37% Haemoptysis- 7% SOB, hoarseness Weight loss, malaise, clubbing, met Incidental on CXR
Lung Cancer Pancoast syndrome
Apical lung cancer + isilateral horners
Causes: invasion of cervical sympathetic plexus
Can have shoulder/ arm pain (invasion C8-T2), hoarseness, bovine cough- unilat recurrent laryngeal N palsy + VC paralysis
Lung Cancer neoplastic syndrome
SCLC • Ectopic ACTH • SIADH • Hypercalcaemia • Hypercoagulability
Asthma in Adults
Signs/ symptoms of severe attack
PEFR 33-50% predicted/ best
O2 saturation ≥92%, cant talk in sentences
Intercostal recession, RR ≥25 breaths/ min, HR ≥110bpm
Asthma in Adults
Life-threatening signs
PEFR <33% predicted/ best
O2 saturation <92%
Arrhythmia, hypotension, cyanosis
Exhaustion, poor resp effort, silent chest, altered consciousness
Asthma in Adults Definition
paroxysmal, reversible airway obstruction with:
- Airflow limitation- reversible spontaneously or with meds
- Airway hyper-responsiveness to wide range of stimuli
- Inflammation of bronchi
Asthma in Adults Dx
symptoms/ sings in absence of alternative explanation
• Wheeze, SOB, chest tightness, cough
• Worse at night/ early morning, exercise, allergen/ cold air, after aspirin, β-blockers,
• PMH atopy, unexplained eosinophilia, Fhx
• Unexplained low FEV1 or PEFT
• Tests: spirometry*
Asthma in Adults DDx
Airflow obstruction = FEV1/ FVC <0.7
• COPD, bronchiectasis, obliterative bronchiolitis
• Inhaled foreign body
• Large airway stenosis, lung cancer, Sarcoidosis
No airflow obstruction
• Chronic cough syndrome, hyperventilation syndrome
• Vocal cord dysfunction
• Rhinitis, GORD, HF, pulmonary fibrosis
Asthma in Adults Tx
- Mild intermittent: inhaled short acting β2 as needed
- Regular preventer therapy: +inhaled steroid 200-800mcg
- Add- on therapy:
o + LABA ± inhaled steroid to 800mcg
o LABA not working: stop, use only inhaled steroid 800mcg
o Consider leukotriene R antagonist or SR theophylline - Persistent poor control: inhaled steroid 800mcg
o ± LRA, SR theophylline, β2 agonist tablet - Continuous or frequent use of oral steroid
Action based on probability of asthma
High:
inhaled beclometasone 200mcg bd for 6-8 weeks, review inhaler technique doesn’t work try oral prednisolone 30mg od for 2 week
Action based on probability of asthma
Intermediate:
o FEV1/ FVC <0.7: try trial of treatment/ reversibility testing
o c >0.7: further investigations
Action based on probability of asthma
Low:
consider alternate dx
• Consider CXR if atypical/ additional symptoms
• Exhaled nitrous oxide testing, eosinophil count
Reversibility testing: when suspect airflow obstruction
Check FEV1 or PEFR before + after 400mcg inhaled salbutamol via MDI and spacer
If uncertain/ no response to salbutamol: inhaled beclometasone 200mcg bd or oral prednisolone 30mg od for 14days
> 400mL in FEV1= asthma
Asthma Tx
Inhaler device: try to use MDI. Educate on technique
Short- acting β2 agonist: salbutamol- quick and SE. Use prm.
• Poor control: ≥2 cannisters/ month or >10-12puffs/day
• Budesonide/ formoterol combo as alternative
Inhaled corticosteroids
• Consider if exacerbation in last 2y needing steriords, βw agonist use ≥3x/wk or symptomatic ≥3x/wk or ≥1 night/wk
LABA: salmeterol- don’t use without inhaled steroids
Leukotriene receptor agonist: montelukast- exacerbations
Theophylline: SE common
Onamlizumab: binds to IgE- subcut every 2-4 weeks
If allergy factor in asthma, on high-dose steroid + LABA and if frequent exacerbations
COPD def
Slowly progressive disorder characterized by airflow obstruction
COPD causes
- Smoking
- Genetic: bronchial hyperresonsiveness, α1α- antitrypsin def
- Poor diet and LBW
COPD Dx
• SOB on exertion- using MRC scale • Chronic cough + regular sputum • Frequent winter bronchitis • Wheeze • Spirometry shows airflow obstruction if: a) FEV1/ FVC <70% and b) FEV1 <70% predicted and c) <15% response to reversibility test * little variability in PEFR
COPD signs
• Hyperinflated chest ± poor expansion on inspiration
• cricosternal distance
• Hyperresonant chest with dullness
• Wheeze/ quiet breath sounds
• Paradoxical movement of lower ribs
• Use of accessory muscles, tachypnea, pursed lips on expiration
Peripheral oedema, cyanosis, JVP, cachexia
COPD other investigations
- CXR: exclude other dx
- FBC: polycythaemia or anaemia
- BMI
- α1- antitrypsin- early onset COPD or fhx
- ECG/ echo: if cor pulmonale suspected
- Sputum culture
COPD management
Lifestyle: smoking cessation, vaccinations, exercise, weightloss Drug therapy SABA LABA LAMA
`MRC dysponea scale
- SOB on exertion
- SOB when hurrying or walking up hill
- SOB when flat or walking on own pace
- SOB after 100m or few minutes
- SOB on minimal effort
Stage 1 COPD:
mild FEV1 ≥80%
Cough, little SOB, no abnormal signs
Stage 2 COPD:
moderate FEV1 50-80% predicated
SOB, wheeze on exertion, cough ± sputum
Some abnormal signs
Stage 3 COPD:
severe FEV1 30-49%
SOBOE, marked wheeze/ cough
Other signs, frequent exacerbations/ admissions
Stage 4 COPD:
very severe FEV1 <30% or <50% + respiratory failure
Same as 3 but more SOB and severely restricted everyday
COPDReversibility testing: when suspect airflow obstruction
Check FEV1 or PEFR before + after 400mcg inhaled salbutamol or beclometasone 200mcg bd or oral prednisolone 30mg od for 14days
If FEV1 and FEV1/FVC return to normal, not COPD
COPD Long-term O2 therapy:
FEV1 <30%, O2 saturation ≤92% breathing air
Cyanosis, peripheral oedema, polycythaemia, JVP
COPD Acute exacerbation Px:
worsening of symptoms
COPD Acute exacerbation Causes
Infections: viral URTI/ LRTI and bacterial LRTI
Pollutants- nitrous oxide, sulphur dioxide, ozone
COPD Acute exacerbation Investigations
Pulse oximetry to assess severity. ≤92%= hypoxemia- admit?
CXR
Sputum culture
COPD Acute exacerbation
Management:
home vs admission
• Ability to cope at home, support
• SOB, general condition, level of activity
• Cyanosis, worsening peripheral oedema, level of consciousness
• LTOT, co-morbidity, change in CXR
COPD Acute exacerbation
Home treatment
bronchodilators
broad spectrum abx- clarithromycin 500mg bd or doxyxycline 100mg od/bd if purulent sputum/ pneumonia signs/ consolidation on CXR
Oral corticosteroids: prednisolone 30-40mg/day for 1-2wks ± bisphosphonate
COPD Acute exacerbation
Follow up:
Reassess: deterioration = admit. If >2 wks and no improvement = CXR and referral.
If discharged, assess ability to cope at home
Inhaler technique
Need to LTOT and/or home nebulizer
Check FEV1
Lifestyle modification
