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INSTRUCTIONS FOR THE DOCTOR

This is a long case.

Please take a history and conduct an appropriate clinical examination. Outline to Andrew your differential diagnosis and plans for initial management.

Scenario

Mr Andrew Bond is a 65-year-old man who has not been to the surgery for a while. He is usually well. You spent time with him a year ago when he was giving up smoking. You are not sure why he has booked this appointment with you today.

The following information is on his summary sheet:

  • Past medical history

  • Vasectomy aged 42

  • Medication

  • Nil

  • Allergies

  • Nil

  • Immunisations

  • Up-to-date

  • Social history

  • Retired bus driver

  • Gave up cigarette smoking last year—was 20 per day for 40 years.

INSTRUCTIONS FOR THE PATIENT, ANDREW BOND

You are a 65-year-old retired bus driver who gave up cigarette smoking last year. The final spur to giving up was when your older brother was diagnosed with lung cancer. Like you, he had smoked since leaving school. You had a bit of a cough for the weeks after you gave up but then you were fine and felt better than you had for years.

You have developed a new cough in the last three to four weeks. It is worst first thing in the morning. You have coughed up some blood but mostly it is a dry cough. You have lost weight and your appetite is not so good. You get puffed more easily than you used to but you are still managing to do the wood-turning you enjoy.

At the back of your mind is the thought that this might be cancer. You are not going to tell the GP that this is your concern but will talk about it if the GP mentions it.

Clinical examination findings

Height 1.7 m

Weight 67 kg (weight five years ago 73 kg)

BMI 22.1 kg/m2

No abnormal clinical findings.

The following information is on your medical record:

  • Past medical history

  • Vasectomy aged 42

  • Medication

  • Nil

  • Allergies

  • Nil

  • Immunisations

  • Up-to-date

  • Social history

  • Retired bus driver

  • Gave up cigarette smoking last year—was 20 per day for 40 years.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Open-ended questions to establish Andrew’s ideas, concerns and expectations.

Specific questions

Cough

Haemoptysis

Sputum

Pain

Shortness of breath

Fever

Family history

Social history

  • — Confirm smoking history

  • — Occupational history—exposure to asbestos

  • — Travel

Systems review—to include weight loss/appetite/energy/sleep

Request permission to examine.

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