Ted Stockings
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Ted Stockings is a 66 year old man who has presented to the GP practice about his cough. You are the F1 doctor asked to come and see him. You can see from the medical records that Ted has hypertension, depression and hypothyroidism, and takes tablets for all of these. Please take a history of Ted’s presenting complaint, ensuring that you explore any associated symptoms and concerns he may have. Following this, please perform the appropriate examination.
You are Ted, a 66 year old man who has had a cough for the past five months. It is keeping your wife up and she has asked you to come in to get some tablets for it. You don’t see the problem though - it’s only a little cough…
HPC: The cough has been ongoing for the last five months and there is no pattern in the day for when it seems better or worse. Over the course of the day you only cough up about a teaspoon or two of white phlegm. If asked, you admit there has often been blood mixed in it too. You have had no chest pain and no recent illnesses/fevers. Over the past two years you think you’ve been more short of breath. You’ve only noticed this as you used to walk to the local pub and back every Sunday for the pub quiz - around half a mile each way - with ease (even when you were carrying a heavy envelope of cash from your winnings!) In the past half a year, you have had to stop every 500 yards for a minute before carrying on. If asked, you’ll admit you have lost one and a half stone in the past five months. You are ecstatic about this as your wife is always badgering you to eat more healthily, and with this recent weight loss she’ll never realise you go to the local chippy every Tuesday with your friends.
ICE: The cough does not bother you, although it is worrying you as some people in the other pub quiz teams have accused you of trying to distract them with all the noise! You reckon it’s a nasty infection that will soon clear with a course of antibiotics.
PMH: You have suffered from low mood in the past but feel fine since starting citalopram two years ago. The blood pressure is not a bother and you don’t mind taking tablets for that – you can’t remember what they’re called but one begins with “R” and the other begins with “N”. Your thyroid disease is apparently only mild, and you take a tablet for that every morning.
SH: You recently started volunteering at a Boy Scout’s club and consider this as your current job. If asked, you used to work as a roofer and general handyman – you have probably had exposure to asbestos as “everyone probably has.” You were last abroad on your silver wedding anniversary trip to Tobago with your wife two years ago. You have been a heavy smoker since the age of 16 and estimate smoking about 40 a day. You don’t see the point in quitting now. You enjoy around five pints of cider a week.
FH: Your father died of stomach cancer and your mother died of dementia. You know they both had hypertension but are unaware of any other family history.
The student should elicit all points of the history, including the red flags of haemoptysis and weight loss, as well as the patient’s ideas, concerns and expectations. They should then perform a full Respiratory examination. Their main differential diagnosis should be lung cancer. Other causes of haemoptysis include TB and pneumonia. Examples for discussion may include: -This patient may have clubbing on examination. What are the respiratory causes of finger clubbing? -What tests would you do for this gentleman? -What types of lung cancer are there? -What are the oncological emergencies associated with lung cancer? -How is lung cancer managed? Which other healthcare professionals would be involved?
