Barry Plex
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You are the F2 on your GP placement. You have been asked to see a 79 year old man called Barry about his recent blood tests. These have shown an Hb of 76 with a low MCV, and were taken to investigate the patient’s fatigue. The last sets of bloods on the system were taken over a year ago, at which time the Hb was normal, at 142. Please take a focussed history of the patient’s presenting complaint and perform a relevant examination.
You are Barry Plex, a 79 year old man who has been asked to see the GP about some blood test results. You were told over the phone that your blood count was very low. You don’t really know what this means. HPC: Over the past few months you have been feeling increasingly tired and like you have no energy. You have been finding it harder to get around as you keep getting out of puff. You used to be able to walk to the end of the road to buy the paper and your usual pack of cigarettes, but now you have to stop 2 or 3 times each way to catch your breath. When it gets bad you also get tightness in your chest, but that settles after 5 minutes of rest. You think you’ve lost a few stone over the past month without meaning to, although you haven’t weighed yourself, and you’ve noticed that your appetite hasn’t been very good. You mostly now snack throughout the day on crisps and pork scratchings as you just don’t have the energy to cook anymore. You had a bit of indigestion as well, which you notice at night when you lie flat. You think this is probably because you’re just eating rubbish at the moment. You haven’t had a cough or fevers recently. There’s been no change to your bowels, and you haven’t noticed any blood from anywhere it shouldn’t be coming. PMH: You’ve got a tight aortic valve, high blood pressure and high cholesterol. Medications: You take Simvastatin 40mg at night, Lisinopril 20mg, Aspirin 75mg and Furosemide 40mg in the mornings. SH: You live on your own with your Border Collie Jessie ever since your wife left you for her yoga instructor 11 years ago. You smoke a pack a day, and drink 2 measures of whiskey a night, apart from Fridays when you go down to the local and have 4 or 5 pints of stout. You worked as an aircraft engineer until you retired, and there was plenty of exposure to asbestos. ICE: You think it’s probably your heart getting worse that is causing all of this, and hope they can do something like a bypass to fix it. You’re worried that without this you might lose your independence, which you’re very scared of.
This potentially a challenging scenario as there are multiple lines of questioning to explore. A good candidate will establish whether the patient has any symptoms of anaemia, and whether there any red flag features for respiratory or GI malignancy, or obvious sources of bleeding. Candidates could perform a respiratory, cardiac or abdominal examination. The positive findings are conjunctival pallor, an ejection systolic murmur radiating to the carotids, mild bilateral pedal oedema, mild epigastric tenderness (although the abdomen is soft without signs of peritonism). There are a wide variety of potential differentials here, but students should identify that this is symptomatic iron deficiency anaemia and raise the possibility of a GI cancer given the unintentional weight loss and GI symptoms. Questions you may wish to ask could include: • What symptoms of anaemia are present in this case? • What are the different types of anaemia and how can you differentiate them on blood tests? • What are the causes of iron deficiency anaemia? • How should this man’s anaemia be investigated further?
