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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please read the following scenario. No further history or examination are required. Please discuss the results of your initial investigations with the patient and negotiate a management plan with him.

Scenario

Neil Dawson is a 61-year-old insurance broker who has spent most of his life avoiding doctors. His wife, worried about him, finally convinced him to come and see you last week for his first doctor appointment in at least a decade. She was worried about his increasing fatigue and his ankles that sometimes swell.

Your further history and systems review elicited no alarm symptoms. You established that Neil has had some psychosocial stressors (caring for his mother with dementia who passed away 12 months ago, plus some financial concerns regarding his home business), but has no signs of depression or anxiety.

You ascertained that Neil is not particularly bothered by his swollen ankles, but that he thought this was a sign that it was time to come to get things checked up.

You collected the below information:

  • Past medical history

  • Bilateral inguinal hernia repairs aged 45

  • Medications

  • Nil

  • Allergies

  • Nil known

  • Family history

  • Mother—deceased (dementia, aged 85)

  • Father—deceased (bowel cancer, aged 79)

  • Social history

  • Lives with wife

  • Owns insurance brokerage business

  • Preventative health

  • Non-smoker

  • Alcohol—four to six full-strength beers most nights

  • Nutrition—typical daily intake consists of three slices of toast with jam plus a glass of orange juice for breakfast, a pie and a can of coke for lunch, half a packet of biscuits and cheese with a few beers after work, meat/potatoes/beans/carrots for dinner and a large bowl of ice-cream while watching TV at night

  • Physical activity—mows the lawn fortnightly, sedentary job

  • Bowel cancer screening—non-participant.

Examination

BP 138/85, pulse 80 and regular

Weight 132 kg

Height 177 cm

BMI 42.1

Chest clear, good air entry

Heart sounds dual, nil added

JVP not elevated

Mild peripheral oedema to ankles

Respiratory examination normal

Thyroid examination normal

No lymphadenopathy

Abdominal exam difficult due to body habitus, some distension, shifting dullness

Few spider naevi upper chest

Palmar erythema noted

You arranged for some initial blood tests and asked Neil to return for a follow-up appointment.

Initial investigations

Full blood count

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Haemoglobin 142 (130–170) g/L
MCV 98 (82–99) fL
Platelets* 132 (150–400) × 109/L
White cells 10.3 (4.0–11) × 109/L
Neutrophils 70% 7.2 (1.8–7.5) × 109/L
Lymphocytes 22% 2.27 (1.0–4.0) × 109/L
Monocytes 6% 0.41 (0.1–1.2) × ...

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