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Please take a history concentrating on his presenting complaint and perform an appropriate examination on this patient. This is a 59 year old male who is presenting to his GP as he has been increasingly short of breath over the last year. He’s finding this quite concerning. Please find out why. DH methotrexate, sulfasalazine, hydroxychloroquine Paracetamols SH Works in a scrap yard and in a pub

You are a 59 year old male called Paul Munnery You are presenting with shortness of breath that has been getting worse and worse over the last year. You didn’t even notice it initially but now it’s really getting in the way.

PC: ‘I just can’t catch my breath doctor’

HPC: It’s been getting worse over the last year. You never used to have any problems at work but now you just find yourself gasping after walking around for 20 mins. You have never been one for exercise but you have never struggled at work. You have a cough quite a lot at the moment, it started about a year ago, probably before the shortness of breath when you think about it, sometimes you bring up ‘green gunk’ but most of the time you are just bringing up this clear stuff. The cough comes and goes but has been getting more persistent recently. There has not been any blood, it’s just pretty annoying. Your wife thinks it’s disgusting. Your wife also said you seem to be quite noisy sometimes when she breaths, she finds that annoying as well! You have lost a little weight recently, but that can only be a good thing! You have no chest pain or any other symptoms, ‘it’s just this blooming cough and the shortness of breath!’ It’s so annoying.

ICE : The shortness of breath is really really annoying now, you feel like you have tried everything to make it better but nothing seems to be helping. It’s getting in the way at work where you have quite a manual job and sometimes you have to spend hours walking round looking for parts. You can’t manage this at the moment and are worried about how much longer your boss will out up with it. If the doctor seems nice please tell them you are also worried about lung cancer. You have smoked for a long time and haven’t really looked after yourself. You know that you shouldn’t have smoked but it’s just part of you so you just do smoke. You expect to be told you have lung cancer today and this is really scary for you. But the doctor is the first person you have told of this worry, you didn’t want to tell anyone else as your brother was recently diagnosed with lung cancer

PMH: You have had rheumatoid arthritis for the last 10 years and have been on the same drugs for the last 6, they seem to have it under good control.

DH: No known drug allergies methotrexate, sulfasalazine, hydroxychloroquine Paracetamols

FH: Brother recently diagnosed with lung cancer

SH: You live with your wife in a house with 2 sets of stairs, which you currently manage You work in a scrap yard, which you love You chain smoke, probably about 40 a day, but sometimes more and sometimes less, and you have done for the past 35 years. Drink a couple of pints of beer on a weekend socially You and your wife manage at home with no help, you are only 59! You have 4 children, 3 boys and a girl. All grown up but live locally and you see them all often.

Please observe the student taking the history and performing the examination. Ideally the student should preform a respiratory examination Ask the student to summarise their findings, and then ask for their differentials. Topics for discussion: - How would you initially investigate this patient - How do you diagnose COPD - How do you manage COPD long term - How would you manage an acute exacerbation - How would you tell COPD from pulmonary fibrosis - What risk factors does this gentleman have for respiratory problems - How do you manage pulmonary fibrosis - How would you investigate for lung cancer specifically