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Lung Cancer

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 doctor working in family medicine. 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:

  1. Lung Cancer/ malignancy needs to be ruled out

  2. COVID-19

  3. Tuberculosis

  4. Interstitial lung disease

  5. Adverse effects of ACE inhibitor

  6. 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:

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