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You are an FY1 working in a GP surgery. Your next patient is Matt Formin, a 66 year old gentleman who has come in for a routine appointment because he has been feeling breathless. His current medications are: Amlodipine OD, Salbutamol PRN, Seretide 500 Accuhaler (fluticasone with salmeterol) Please take a thorough history from this man and perform the appropriate examination. You will then be asked to discuss the case with the examiner.

You are Matt Formin, a 68 year old happily retired plumber. You live with your wife and three dogs, Pippin, Daisy and Oscar- you like to joke that the dogs were a replacement for your children when they moved out a few years ago! HPC: You have come in because you have been getting more breathless recently. Your wife was the first to notice that you kept stopping to catch your breath when you were walking the dogs. You have COPD, so you thought that it was that, but your inhalers haven’t made any difference, and it’s been getting worse and worse over the past three months. You’ve got to the point where you can’t get around the supermarket or go upstairs without having to take breaks, which is making your wife worried. Over this time you’ve also been getting pain in your right side and back around your ribs. It is constant and isn’t affected by anything that you do. It is dull and aching and seems to be getting worse. You tried taking paracetamol and ibuprofen, but they don’t help and it is affecting your sleep. You have been feeling ‘knackered’ for the past few weeks, and you’ve lost a stone in weight since all this started. In the past week you’ve been waking up to find the bedsheets soaked with sweat. Your wife is annoyed because she has to keep changing the sheets, but you can’t control it! You have a cough, which has been worse this week. You bring up a little white phlegm with it, but never any blood. You haven’t noticed a wheeze or any other problems. ICE: You wonder if you might have picked up a chest infection. You are hoping that you can get some antibiotics and be on your way. You don’t like to dwell on it, but one of your old work mates had a similar thing a couple of years ago and it turned out to be lung cancer. You think it’s unlikely, but it’s part of why you really thought you should come to the doctors. PMH: You have high blood pressure, and you found out that you had COPD three years ago when you got a nasty chest infection. You have a couple of inhalers for this and have been fine since. DH: amlodipine, salbutamol, Seretide inhaler. No known allergies. FH: Your dad died of a stroke in his late 60s. Your mum died of breast cancer a few years after. Your younger brothers are both fit and healthy. SH: You live in a terraced house with your wife and dogs. You are finding the stairs increasingly difficult to climb. Your house in on a hill, and you’re fine going down, but getting back up is a struggle. You smoke 10 cigarettes a day, which you’ve done since you began working in the shipyards at 16. You worked in there for 5 years, and then as a plumber until you retired 2 years ago. You were exposed to asbestos a lot in the shipyards and on building sites over the years. You never had any protective gear for this. You have two children, a son and a daughter, who are both in their twenties and moved out a few years ago. You drink 8-10 pints a week, mainly at the weekends.

Please observe the student taking a history from this patient. Ideally, they should perform a respiratory examination. You should ask them to present their findings to you, with a list of possible differentials. An ideal list of differentials would look something like: “My primary differential diagnosis would be a malignancy, specifically, malignant mesothelioma, due to the significant exposure to asbestos and chest pain. I would also consider non-small cell or small cell lung cancer, due to the dyspnoea, weight loss and night sweats. Other differentials would include tuberculosis, or cancer elsewhere that has metastasised to the lungs, however this is less likely given the lack of other symptoms and presence of chest pain.” Topics for discussion may include: - What would you expect to find upon examination? - How can you classify pleural effusions? - What investigations would you perform to confirm your diagnosis and what would you expect to find? - What are the other manifestations of asbestos exposure? - How quickly does mesothelioma progress? - What are the implications of confirmation of a mesothelioma diagnosis?

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