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 GP. Your next patient is 65-year-old Sandra Cook, a retired primary school teacher presenting with a cough. Please take a history and perform a relevant examination.
Patient History:
(You should speak with a hoarse voice)
Sandra Cook - a 65-year-old female - retired primary school teacher.
Well, you didn’t expect to be coming here! You have been having a cough for the last 6-8 months, and it just has NOT gone away! No cough syrup or herbal tea seems to have the slightest effect. The cough has even started to wake you up at night. On specific questioning, you remember you coughed up a few spots of blood twice recently.
You’ve also noticed a new hoarse voice over the past two weeks. You also noticed unexplained weight loss and night sweats.
You don't feel particularly short of breath, but you've been feeling more run down recently.
No chest pain, wheeze, ankle swelling, palpitations, or syncope. No reflux. No fever or rashes. Score 0 in Well's Score for PE except for haemoptosis.
Ideas, Concerns, Expectations:
You are not sure what it is, but the girls at your tea club mentioned that having a clot in the lungs can be dangerous. Your main concern is the tiredness, it's stopping you from leaving the house often. You just want antibiotics, and you'll be on your jolly way.
Past Medical History:
"Mini-stroke" in 2018. Osteoarthritis. Hypertension. Type 2 diabetes mellitus.
Drug History:
Ibuprofen 400mg PRN
Clopidogrel 75mg
Atorvastatin 80mg
Ramipril 2.5mg OD
Metformin 500mg TDS
No known drug allergies
Family History:
Nil.
Social History:
You live at home with your dog, Patty.
You have smoked 20 cigarettes since the age of 18, but you drink very rarely.
You're now retired but previously worked as a primary school teacher in Cornwall.
Examination Findings:
Respiratory rate 18
Hoarse voice
Finger clubbing
Ptosis & miosis of the right eye
Distended neck and chest veins
No signs on auscultation
Differentials:
Lung Cancer/ malignancy needs to be ruled out
COVID-19
Tuberculosis
Interstitial lung disease
Adverse effects of ACE inhibitor
GORD
Investigations:
Bedside
Vital signs
ECG
Sputum analysis
Bloods:
FBC = (infection, anaemia)
U&E = (baseline, before CT with contrast)
LFT = (baseline before meds, metastases)
CRP/ESR
Bone profile = (hypercalcaemia)
D-Dimer
Imaging/Special Tests:
Initial imaging = CXR
Staging = CT TAP, PET-CT
Other = bronchoscopy with lavage, EBUS, transthoracic CT/US-guided needle biopsy
Consider CTPA if suspecting PE
Management of lung cancer depends on the type, staging and functional status of the patient: