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Keith O’Conazole is a 48 year old gentleman who has presented to the Acute Medical Unit with a four day history of feeling generally unwell, with a cough and loose stools. He is on no medication and works as a plumber.

Please take a history and carry out the relevant examination for this gentleman. You will then be asked to present your differential diagnosis and discuss aspects of this gentleman’s case.

You are a 48 year old gentleman called Keith O’Conazole. You have been feeling unwell over the past 4 days, with a cough, headache, temperature and diarrhoea.

PC: Feeling “like the flu” with a cough, headache, diarrhoea, abdominal pain and general muscle aches

HPC: 4 days ago you started to feel a bit “under the weather”. You had a headache which you would describe as a constant achey pain which you would rate as 4/10. It does not get worse on bending down or coughing. It got a little bit better with paracetamol. You have also felt sore and achey all over and much more tired than usual.

Two days ago, you developed a cough which was dry at first but then began bringing up phlegm which was clear to begin with but has started turning green. Last night you coughed up some blood in your phlegm. This has really worried you, and is the main reason you have come in today – you want this checked out! To make matters worse, you have also had diarrhoea and abdominal pain for the past two days. You have been to the toilet six times a day and your stool has been very soft, almost liquid. Going back and forward to the toilet has been unbearable, as you haven’t been able to do anything else at all.

The bowel motions themselves have been a yellow/brown colour and you have not noticed any blood or mucus-y stuff. The pain in your tummy is all over the place and feels like a bad cramp. This also came on around two days ago. It does not move around anywhere and nothing seems to make it better. You would rate this pain as a 6/10. You have not vomited but have felt very nauseous and have not managed to eat anything or drink much more than a few sips of water over the past few days.

You now feel very ill, going hot and cold and having ‘shakes’. You were adamant that you were fine, and that it would come and go, but your wife took your temperature before you came in and said you were feverish. That was the last straw, and together with the blood, this scared you into coming in.

PMH: The GP has mentioned you might have ‘blood pressure’ but you are not really sure and you are not on any treatment. You had your appendix out when you were 19.

SH: You are a smoker and have smoked 20 cigarettes a day since the age of 16. You enjoy a few pints every Friday night down the pub with your mates. On the average Friday you will have six pints of lager, with a kebab on the way home. You live with your wife and two teenage children, age 13 and 16. You’ve worked as a plumber ever since leaving school and you enjoy your job. You have recently started work on the redevelopment of an office building in town. You know you should but sometimes you forget to wear your protective mask. You think that one of your workmates had been complaining of “feeling rough” at the same time you fell ill but you are not sure if any of them have been off sick as you haven’t been at work yourself. You’ve not had any recent travel, except for a week in Spain last July. You have never used any illicit drugs. You have a new puppy, named Oscar, but haven’t had any contact with any other animals. Your daughter wanted a parrot, but your mate had one and tells you it annoyed him because it constantly screeched movie spoilers at him, so he got rid of it. You want none of that nonsense.

DH: Your GP has mentioned you might need some tablets for ‘blood pressure’ but you do not take any currently. You were told you were allergic to horses when you were younger, but you hope that won’t be too relevant today.

FH: Your father, who was a smoker all his life, died of lung cancer aged 65. No other relevant family history.

ICE: At first you thought it was just the flu, but you feel worse than you have ever felt now and the coughing up blood yesterday worried you. You are worried that the blood might mean you have cancer, as your father was coughing up blood before he died and you are also a smoker. You hope that you’re not allergic to the new puppy, because your daughter will ‘go on strike’ if you have to give him away! You would like to know what is wrong with you and get it fixed as you feel worse than you have ever felt.

Please observe the student take a history from this patient. Ideally they should perform a respiratory examination, although a gastrointestinal examination would also be relevant. Their differential diagnosis should sound like the following:

“My differential diagnosis would firstly consist of an infective cause: specifically an atypical pneumonia. I would have a particular suspicion regarding Legionnaire’s disease given this man’s occupation. This could also be a typical pneumonia, however given that this gentleman is under 50 and is presenting with more systemic signs, atypical would be higher on my differential. Furthermore I would want to consider a malignant cause for this gentleman’s presentation, specifically lung cancer. This is an acute presentation and there is no history of weight loss, however haemoptysis, a past medical history of cigarette smoking and a family history of cancer would lead me to want to consider further investigations for malignancy.”

Topics for discussion: • What investigations would you undertake in the acute setting for this gentleman? • What are some other common causes of atypical pneumonia and what risk factors are associated with these? • How would you manage this patient? • What are the public health implications of this disease?