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You are the FY1 on the acute medical unit. Lynn Foama is a 30 year old lady who has presented to the unit with shortness of breath.

Please take a history from Lynn and perform the appropriate examination. Please focus on Lynn’s history of presenting complaint. You will then be asked to discuss the case with the examiner.

You are Lynn Foama, a 30 year old lady who feels pretty rough. You work in a office job that you hate, and feeling so dreadful lately is just making daily life such a chore. Despite this, you are very chatty and keen to discuss things which may not even be slightly relevant during this history.

HPC: This all began around two months ago, when you noticed that you were becoming more short of breath. You used to be quite fit, running the occasional half marathon and playing in your volleyball team, however things have tailed off in the past year as your work commitments have got more intense. Originally you put the shortness of breath down to being unfit, but it has just got worse and worse. You get breathless now going up the stairs at home!

Thankfully, you’re not breathless when you’re sitting or lying down. You have had a cough alongside this, but haven’t brought anything up with it. You spoke to your friend, who is a pharmacist, and they reckoned it was viral, so you haven’t bothered too much with it. You haven’t coughed up any blood or anything scary like that. Not even anything green! The cough seems pretty dry actually, you’ve had to keep going forward and back to the water-cooler at the office. This is getting you in trouble with your manager as he thinks you are trying to avoid work!

You’ve been feeling pretty tired alongside all of this. You suspect that this is likely due to your job. The job is in a call centre in a town which is one hour’s drive away, so the commute is becoming overwhelming. You hate the job itself, and have considered quitting due to all of this. You are always waking up early in the morning feeling drained. Sometimes you wake up in the middle of the night, drenched in sweat.

You saw your mum at the weekend and she was commenting that you looked really thin: but not in a good way. She reckoned that your face was quite thin, which was strange because you haven’t done any exercise lately. She proceeded to treat you to a seven-course dinner. You made a note to have a thin face more often!

In terms of other problems, you haven’t noticed that much. You have quite a few bruises on your legs. This used to be really common when you played volleyball, but you haven’t done any contact sport or fallen over in a while, so you’re not sure how you managed to pick those up. You haven’t had any chest pain, tummy pain or joint pain. Your bowels and waterworks are absolutely fine – though you’re weeing more because you’re drinking so much water!

ICE: You’re not quite sure what is going on – perhaps you have picked up a bug which you haven’t managed to shake off. You’re a bit worried though: being breathless going up the stairs is something your gran experiences, it shouldn’t be happening to you as a thirty year old! You hope that you can get some scans to get the ‘all clear’.

SH: You live by yourself in a maisonette flat. You have started to struggle with the stairs after work, becoming breathless. Your ex partner used to live with you, but you recently broke up. You were really frustrated by his lack of understanding of how you were feeling, and how generally unhelpful he was. He got really annoyed waking up in the night to find you covered in sweat, and was cross when he had to wash the sheets over and over again. An argument about this was the last straw, and you dumped him. You’re much better off without him!

You don’t smoke and you don’t really drink alcohol any more – you used to binge at the weekends but not so much anymore. You haven’t been abroad anywhere in a few years – you can’t afford it! However you are saving up to go to Russia: you’re fascinated by Russian history and would love to visit the Kremlin. You’ve had all your vaccinations and haven’t been around anyone who is unwell.

PMH: You have coeliac disease, so your diet is strictly gluten-free. Consequently you haven’t been bothered by symptoms with that since you were around 17 or 18, when you had a lot of bloating and weight loss. You don’t take any tablets and aren’t allergic to anything.

FH: Your gran has emphysema and has recently been put on oxygen at home. You’ve had to try to convince her to stop smoking, but occasionally catch her smoking whilst leaning out the window. You keep telling her that she might blow her house up if she keeps going, but she won’t stop!

The student should take a focused history of presenting complaint from Lynn. This history has the potential to be challenging due to the vague nature of the symptoms and Lynn’s tendency to discuss things in great depth. However, a competent history will include screening for ‘red flag’ symptoms for malignancy and elicit her concerns in an effective way. Most students would perform a respiratory examination in this case, due to the symptoms described. However, other examinations may be justified depending on the history.

A quality differential diagnosis would sound something like:

“My primary differential would be a multi-system cause: more specifically sarcoidosis. This is because of the shortness of breath, dry cough, malaise and night sweats in a patient who is relatively young. This is accompanied by weight loss, which is also a symptom of sarcoidosis. However the red flag symptoms here would make me concerned about my second differential: a malignant cause. Specifically lymphoma given the night sweats, or lung cancer given the shortness of breath. Finally, an infective cause should be considered: tuberculosis. This also presents with the aforementioned symptoms, however this is less likely due to lack of risk factors in the history.”

Possible questions for discussion may include: - How would you investigate this patient in the acute setting? - What are the findings on chest X ray for sarcoidosis? - What investigation is diagnostic for sarcoidosis? - How is sarcoidosis managed? - Talk to me about the systemic symptoms associated with sarcoidosis. - TB would be a reasonable differential in this case. How is TB diagnosed?