INSTRUCTIONS FOR THE DOCTOR
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.
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
Mother—deceased (dementia, aged 85)
Father—deceased (bowel cancer, aged 79)
Lives with wife
Owns insurance brokerage business
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.
BP 138/85, pulse 80 and regular
Chest clear, good air entry
Heart sounds dual, nil added
Mild peripheral oedema to ankles
Respiratory examination normal
Thyroid examination normal
Abdominal exam difficult due to body habitus, some distension, shifting dullness
Few spider naevi upper chest
You arranged for some initial blood tests and asked Neil to return for a follow-up appointment.
|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) ...|