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INSTRUCTIONS FOR THE DOCTOR

This is a long case.

Please take a history and conduct an appropriate clinical examination. Discuss with the patient the most likely diagnosis, your differential diagnoses and negotiate a plan for management.

Scenario

Nicholas Morris is 63 years old and has booked in to see you this morning. The last entry in the notes was five years ago when he attended after a dog bite.

The following information is on his summary sheet:

  • Past medical history

  • Dog bite

  • Medication

  • Nil

  • Allergies

  • Nil

  • Immunisations

  • Nil recorded

  • Social history

  • Maths teacher

  • Single

  • Smokes 30 cigarettes per day.

INSTRUCTIONS FOR THE PATIENT, NICHOLAS MORRIS

You are a 63-year-old maths teacher and a lifelong smoker. You enjoy smoking and get quite offended when people suggest that you should give up. Even the pupils at school keep telling you to stop when they see you smoking around town at the weekends. You only go to the doctor when you really have to.

In the last few months you have become increasingly short of breath. You take your dog for walks in the morning and this is getting more difficult. You have begun to arrive earlier to school so that you can get a parking space near the staffroom.

When asked by the GP you will reveal that you have had a productive cough in the mornings for the last few years. You have never coughed up blood. Colds ‘always go to your chest’ and when this happens you get a wheeze.

You have been saving up to visit your relatives overseas and are due to fly soon. You have made the appointment to discuss your breathlessness with the GP and want to know if there is any medication that will fix the problem.

Clinical examination findings

Height 1.72 m

Weight 75 kg

BMI 25.3 kg/m2

Tobacco stains on the fingers

No respiratory distress, respiratory rate 16 breaths per minute

Chest shape and expansion normal

Percussion normal

Auscultation reveals scattered wheezes

PEFR 320 L/min, predicted 620 L/min

ECG shows normal sinus rhythm.

The following information is on your medical record:

  • Past medical history

  • Dog bite

  • Medication

  • Nil

  • Allergies

  • Nil

  • Immunisations

  • Nil recorded

  • Social history

  • Maths teacher

  • Single

  • Smokes 30 cigarettes per day.

INFORMATION FOR THE FACILITATOR

If requested, please hand these spirometry results to the doctor:

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Actual: FEV1 2.0L FVC 3.3L Ratio FEV1/FVC 60.6%
Predicted: FEV1 3.2L FVC 4.3L Ratio FEV1/FVC 75.1%
After salbutamol: FEV1 ...

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