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Basil Arinfarct is a 65 year old gentleman who has presented to the Acute Medical Unit with febrile illness for over five weeks.

Please take a history from Basil and undertake the appropriate examination. You will then be asked to discuss the case with the examiner.

You are Basil Arinfarct, a 65 year old retired postman. You have been feeling really rough for about six weeks now, and have been sent to the hospital by your GP.

HPC: This all started six weeks ago, when you began to feel rubbish: tired all the time and then feeling hot and cold. At around the same time you picked up this cough. You went to the GP with it after a couple of weeks. At first the GP told you it was a virus, and would go away. However, it didn’t go away at all. You started bringing up white stuff with the cough, and the tiredness got worse. This really confused you, because you haven’t really been doing anything too strenuous since you retired.

You take ages to get up in the morning, and have started taking long naps in the afternoon. In the evening and during the night you sometimes feel really hot and sweaty – once your girlfriend had to get up and sleep in a different bed because you absolutely drenched the sheets!

You have been a little more breathless when getting about, but you put this down to the cold the doctor said you have. You’re not breathless normally when you’re just sat down. You haven’t coughed up any blood and haven’t had any chest pain, or anything scary like that.

Your girlfriend has commented lately that you have lost a bit of weight. You think that this is because you used to have a pastie or two after your morning post round, but now you can’t be bothered to leave the house, so haven’t had as much rubbish food. Come to think of it, you haven’t been eating too much at all lately: you just pick at your food. You haven’t been around anyone who is unwell, so you’re not sure where you picked this up from. Your waterworks have been absolutely fine, whilst you have been a little bit constipated lately. You haven’t had any falls, and don’t remember being confused at any point.

ICE: You’re worried by the reaction of your GP when you went to see him last. He said he wanted you to come straight in for some tests because of these temperatures, and because you have big swollen glands in your neck. You hadn’t noticed that yourself! You hope it’s not a bad infection.

PMH: You’ve been generally healthy all your life: you retired a little early because your knees had a bit of arthritis in them, and your eyesight isn’t what it once was. Otherwise, you have always been reasonably healthy! You don’t take any regular tablets. You’ve never had any vaccinations in the past. Your aunt, who brought you up when you were young, never believed in them, so neither do you.

SH: You live in a terraced house, and your girlfriend comes to stay at the weekends, since she lives and works far away. You enjoy having her company as you don’t have many friends: you’ve become much more of a reclusive person lately. Whilst initially you put that down to enjoying the peace and quiet of retirement, now you just feel a little bit too tired to get about as much. You can’t be bothered.

You smoked for about twenty years – smoking a pipe – but gave up about five years ago. You have a couple of glasses of brandy on an evening, but no more than that. You find it helps you sleep now. You haven’t been around anyone unwell, and haven’t eaten anything concerning. You haven’t been abroad in years – who has the time? – and have had the same partner for the past 2 years.

FH: You didn’t know your parents, unfortunately they passed away when you were very young, in a train accident. You grew up with your aunt, who died about ten years ago of bowel cancer.

The student should take a focused history of the patient with unexplained febrile illness. This should include red flags for malignancy and risk factors for infection. An appropriate examination would be a respiratory examination, however abdominal examination may be justified. If lymph nodes are palpated, the student should be informed that there are enlarged supraclavicular and submandibular lymph nodes.

A reasonable differential diagnosis could include:

My differential diagnosis would be a haematological cause: more specifically a lymphoma. This could then be further categorised upon investigation. My reasoning behind this would be a history of night sweats, weight loss and generalised febrile illness for over five weeks. An alternative diagnosis would be an infective cause: more specifically infectious mononucleosis or tuberculosis. These share the symptoms I have just mentioned. However, there are no clear risk factors for infection in this individual, though he has not received the BCG vaccination. Finally, it would be important to rule out lung cancer in this gentleman, due to the weight loss, cough and extensive smoking history.

Questions for discussion may include: - How would you investigate this gentleman in the acute setting? - How is lymphoma managed? - What types of lymphoma do you know about? - What are the complications of infectious mononucleosis? - What risk factors do you know for TB? - How is TB managed? - What complications are associated with TB treatment? - Who would be involved with this patient’s care?