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You are a junior doctor on a medical admissions unit. 83-year-old Mr Al Fentanil has been brought in with his daughter. She tells you he has metastatic lung cancer and is not currently receiving any curative treatment. He was due to see his oncologist on Monday but has become much more unwell over the past two days, so she called an ambulance.

Please a detailed history from Mr Fentanil and perform the appropriate examination. You will then be asked to discuss your management plan with the examiner.

You are Al, a quite private man who is very close to his daughter and usually very calm and pragmatic, but feeling quite anxious about your breathing difficulties. You didn’t want to come to hospital and make a fuss, but did it because your daughter was so keen for you to be seen.

HPC: You have significant dull pain in your right lower ribs, which you have not tried any medicine for. It seems to have gotten a lot worse over the past couple of weeks and is now a constant 8/10. It doesn’t spread anywhere and nothing makes it better, but breathing, coughing and moving are especially painful. You are struggling to get your breath at all (bringing up lots of blood-streaked sputum) and this is making you very anxious. On direct questioning, admit that you haven’t told your daughter but you haven’t managed to sleep much because of the breathlessness and cannot keep food down (for the past week).

ICE: You think this is the cancer spreading in your lungs and that you may need an operation which you are not keen for. Your main problems are breathlessness, nausea and vomiting and pain. You would like to just have these treated and be allowed to go home, and do not want much medical intervention. On direct questioning, you admit that you know you are dying, and would like to be at home with your daughter.

PMH: You found out you had lung cancer a few weeks ago after your GP sent you for a chest X-Ray for a cold which rumbled on for some time. By the time of diagnosis, you had lost around 2 stone across 6 months. Because of your age and frailty, you were not deemed suitable for chemo or radiotherapy. Apart from this, you also have high blood pressure, type 2 diabetes, osteoarthritis in both knees and a left cataract.

SH: You smoked 12 cigarettes a day from being 14 and gave up at 62 when your grandson was born. You are a retired welder and have worked in various shipyards and factories in the North East. Never been much of a drinker. You live alone since your wife died 8 years ago from breast cancer, and you only have one daughter, who lives just around the corner and helps with shopping and housework. You have no formal carers. You potter about the house with a stick but mostly just sit in your chair, where you sleep.

FH: Your father and brother (also both worked in the shipyards) both died of lung cancer in their 60s. You aren’t aware of any other family history.

DH: You have no known allergies. You take a lot of tablets which come in a box from the pharmacy- you think there’s something for blood pressure and something for your sugars. You haven’t needed any pain killers.

This is a challenging case which could be approached in a number of different ways. Most importantly, the ideas, concerns and expectations of the patient should be elicited, and the patient should be treated (as all patients!) with appropriate empathy.

The student may take a symptom-based history, assessing pain, breathlessness, agitation, nausea and vomiting and secretions. They may carry out a chest exam.

A differential diagnosis for this particular episode may include a respiratory cause, specifically pleural effusion, pneumonia or a PE.

During discussion with the examiner, the possible treatment options (chest drain, antibiotics) should be discussed, with the option of no treatment also being acknowledged.

Topics for discussion could include: anticipatory medicines at the end of life, discussing DNACPR/ADRT/ceiling of care, treatment of pneumonia, choice of pain relief, oncological emergencies.