COPD should be suspected in an older adult (at least 35 years old but typically more than 45 years old) who presents with symptoms such as breathlessness, wheeze, cough and sputum production and has one or more risk factors, typically current, or a past history of, cigarette smoking. A diagnosis should also be suspected when an individual with a risk factor develops a lower respiratory tract infection requiring treatment. COPD is far more common in smokers of heroin and crack cocaine, in whom it occurs at a younger age.

Cigarette smoking is overwhelmingly the most important risk factor for COPD. In some cases, other factors such as occupation, passive exposure to inhalants and fetal nutrition/low birthweight are also important. The diagnosis should be suspected in symptomatic patients with risk factors, usually cigarette smoking, aged 40 years or above, albeit a majority of people with COPD present when considerably older. The 2017 GOLD guideline recommends that management should be focused on two objectives. First, to relieve symptoms of breathlessness (assessed using the MRC dyspnoea scale) and improve quality of life (assessed by the COPD Assessment Test). Second, to reduce risk assessed by the number of exacerbations and hospitalisations in the previous year.

Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especially when they arise on the ears or lips. Patients with one non-melanoma skin cancer (NMSC) have a higher risk of developing another NMSC and of malignant melanoma.

End stage renal disease can be defined as the requirement for kidney transplantation or dialysis therapy. In the UK in 2016, of the 63,162 people receiving renal replacement therapy 53% were renal transplant recipients, 41% were on haemodialysis and 6% were on peritoneal dialysis. Dialysis should be started when: symptoms of uraemia impact on day to day living; the need is indicated by biochemical measures or uncontrollable fluid overload or at an eGFR of 5-7 ml/min/1.73 m² in the absence of symptoms. The choice of dialysis modality is influenced by the individual’s functional status, social circumstances and confidence.