Who you are:
You are an F2 in GP clinic.Who the patient is:
Mr. Smith Rickson, aged 55, presents to the clinic with cough for 7 monthsWhat you should do:
Please talk to the patient, discuss your initial plan of management with her and address her concerns.
Patient Story:
- A 55 year old has come to the hospital with complain of cough for 7 months.
- Cough - productive, weight loss since 2months, didn’t measure it.
- Loss of appetite present.
- Smoke 40/day for 20y.
- works as carpenter.
- His son sometimes has cough. But nothing became serious.
- Otherwise he is fit and well, no past medical history, no allergies.
- Lives with wife, stable partner.
Concern: Is it cancer? My colleague had cancer.
Examination: Observations temperature 38, RR 22, HR 108, Chest - normal
Data Gathering
- Greet and confirm identity.
- Explore cough ODIPARA
- D.D FLAWS, Anything else? Leg swelling? Leg pain? Rash and wheezes?
- P2
- P3 DESA (smoking in details) , IV drug abuse, Sexual history
- MAFTOSA (blood thinner) (Travel) + Contact
- Verbalize examination.
Diagnosis
- Explain Provisional diagnosis
- I am a bit concerned as you told me that you are having (S/S) and you worked as carpenter Best case: infection and unfortunately worst case scenario cancer of lung covering.
- To find out the cause and confirm: Further Investigations: Routine bloods (FBC, CBC, RBS, inflammatory markers, ABG) + CXR + sputum culture
- Urgent referral to the Specialist where they will do further tests like CT scan on the chest,
- abdomen and pelvis + Bronchoscopy which is a special camera test to look into the lungs
- and take some samples for testing
- senior
- Safety netting: fever, drowsiness
- Follow up after been seen by specialist
- Senior
- Safety netting: worsening of the s/s or blood in the sputum, or if specialist doesn’t call you withing 2 weeks.