Gen Med Station 10

Setting:

You are a Foundation Year doctor working in a GP practice. This patient has presented with a cough.

Julie Mathews

Tasks:

1. Take a history from the patient.

2. Discuss your management plan with the patient

3. Answer any questions the patient may have.

Briefing

Diagnosis: SCC lung cancer, presenting as a new cough
You are Julie Mathews. (age: 79)
You have presented to the GP surgery with a new cough that you have had for the last 2 months.

Appearance and Behaviour

You are a well kept 79 year old lady. You should not appear particularly concerned about it, if anything it's more of a daily annoyance than anything else. .

Opening statement

I’ve had this cough for the last month or two and it just hasn’t gone so I thought I’d come and see if you could give me a tablet or inhaler or something to get rid of it.

Information to Give Freely

It’s a cough but I’m not bringing anything up with it but I can’t seem to get rid of it.

Presenting Complaint

Site – Dry cough
Onset – 8 weeks ago
Character - dry, not bringing up sputum or blood.
Associated symptoms - ONLY IF DIRECTLY ASKED

You’ve lost some weight unintentionally (trousers are baggy)

You’re having to sleep with towels on the sheets as you have been getting very sweaty at night.

You’ve also been feeling tired, you think its due to feeling hot overnight.

Timing – you are coughing more as the weeks go on
Exacerbating/relieving- nil
Severity – it is rather annoying and I can’t seem to stop coughing which is very annoying

Past Medical History

Previous similar episodes - nil
Other medical conditions - Type 2 diabetes, Macular degeneration right eye, hypertension
Previous surgeries - Right mastectomy for breast cancer 10 years ago

Drug History

Prescribed - Amlodipine 5mg, paracetamol 1 gram
Over the counter - nil
Allergies - penicillin (rash)

Family History

Your brother has hypertension

Social History

Smoking history - ex-smoker quit 6 months ago. Smoked 20 a day for 50 years
Alcohol - about 4 glasses of wine a week
Home - Lives alone in a bungalow. Husband died last year
Mobility - independent
ADLs - no issues

Systems Review

General/red flags - night sweats, weightloss, fatigue
Neuro - nil
ENT - nil
Resp - dry cough, nil chest pain, nil SOB
Cardio - nil
GI - loss of appetite
GU - nil
Joints - nil

Ideas / Concerns / Expectation

Ideas- Have I got a chest infection
Concerns- If it’s an infection is it getting worse
Expectations- can you give me an antibiotic or something?

Discussion / Questions

The student should explain empathetically that he is concerned about some of your symptoms and that they think further investigation is needed. They should mention that they are concerned about the possibility of lung cancer (given red flags, smoking history and previous breast cancer). If they don’t say why they are concerned then please ask if they are concerned.

They should explain they want to refer you on a 2week wait pathway for a chest X-ray and referral to the respiratory team. They will also ask for blood tests- ask what these will be.

If anything is unclear please ask for more details.

Become upset when the student tells you that they think you may have cancer- if they are empathetic then express that you appreciate it.