Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in General Practice. Your next patient is 67-year-old Idris Halidu of African origin, presenting with shortness of breath and cough. Please take a history and perform a relevant examination.
Patient History:
Idris Halidu - a 67-year-old male - office worker.
You really don't want to waste the doctor's time, so will keep this short and sweet. Your daughter was worried because your breathlessness hasn't gone even after all these years. In fact, it's getting worse, but you're really not the type to complain and go to the doctors. You've seen a lot in life, travelled to many places, and worked many jobs, so you have learnt that the secret to happiness is to keep moving forward and that "insouciance is bliss".
The shortness of breath started several years ago (maybe about 4/5 years) and initially only when working hard. Now you've noticed even when sitting down, it's present. You're not breathless when lying flat; you sleep with one pillow and don't wake up feeling breathless.
And the cough. Oh, the cough. Endless coughing. No sputum or blood, and nothing makes it better, not even your favourite Hibiscus tea.
You've no chest pain, palpitations, syncope, or ankle swelling. No fever or recent weight loss, though you're not the strong, well-built man you used to be 5 years ago. You're looking more like a thin old codger!
Ideas, Concerns, Expectations:
You think this is life's retribution for all those years of smoking. You're not concerned about much. If you're probed, you are concerned that the symptoms are getting worse and that this might mean cancer. You're content if the doctor says they can't do anything, but you just wish you don't lose more independence at home by having to rely so much on your daughter.
Past Medical History:
Hypercholesterolaemia, TB, rheumatoid arthritis, MI 2018. Skin cancer. Irregular heartbeat.
Drug History:
Methotrexate 7.5mg weekly
Atorvastatin 80mg
Aspirin 75mg
Verapamil 40mg three times daily.
Allergic to trimethoprim (used to have recurrent urinary infections as a young child, so was on long-term nitrofurantoin).
Family History:
Your mother died of lung cancer at 70yrs though she never smoked.
Social History:
You live at home alone, so you have become increasingly reliant on your daughter for shopping and cooking when she visits each day, which really saddens you.
You smoke 10 cigarettes a day from when you were 17 years old (25 pack years).
You've retired but have worked many jobs: you first worked at a zoo from where you developed your lifelong passion for pigeon keeping. Back home in Nigeria, you worked in construction, demolition, ceramics and sandblasting, and it was there that you contracted TB. When you moved to the UK, you had to move to office work because of your rheumatoid.
Examination Findings:
Irregularly irregular pulse
Respiratory rate 20
Finger clubbing
Occasional dry cough
Equal chest expansion
Bilateral fine crackles on inspiration.
Differentials:
Interstitial lung disease
Idiopathic pulmonary fibrosis
Pneumoconiosis = asbestosis, silicosis
Hypersensitivity pneumonitis e.g. bird fanciers' lung
Drug-induced e.g. methotrexate, nitrofurantoin.
Rheumatoid arthritis
Sarcoidosis
Tuberculosis
COPD
Lung cancer
Investigations:
Bedside:
Vital signs (exertional desaturations may be an indication for ambulatory saturations)
ECG (previous MI, ventricular strain, cor pulmonale)
Bloods:
FBC = (infection, anaemia)
U&E & LFT = (before meds)
ESR/CRP
BNP = (<100 makes the diagnosis of heart failure unlikely as per NICE guidance; hence has good -ve predictive value)
ABG = (respiratory failure)
Auto-antibody screen e.g. RF, ANA, CK = (to rule out connective tissue disease as a cause)
ACE = (if suspect sarcoidosis, but low sensitivity)
Imaging & Special Tests:
CXR = (basal reticulonodular shadowing in IPF, progressive massive fibrosis affecting the upper lobes in silicosis/coal-workers, linear fibrosis in asbestosis, bilateral hilar lymphadenopathy in sarcoidosis & TB)
Pulmonary function tests & Spirometry = (will show a restrictive picture in ILD)
High-resolution CT = (diagnostic for ILD. Honey-combing in IPF. Ground-glass shadowing in hypersensitivity pneumonitis. Beading along fissures in sarcoidosis.)
Bronchoalveolar lavage
Lung biopsy
To rule out secondary pulmonary fibrosis, conditions to consider: alpha-1antitripsin deficiency, rheumatoid arthritis, systemic lupus erythematosus (SLE), systemic sclerosis
Management (ILD):