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Perry Arrest is a 68 year old man who has presented to GP complaining of fatigue and left leg pain. This is a problem he has been having for 2 months and the pain has become so severe that he has quit his bi-weekly jogging club. He has been otherwise healthy in life, other than a series of chest infections over Christmas. He would to know what is causing his pain.

Please take a history from Perry and undertake the most relevant examination.

You are Perry Arrest, a 68 year old man who loves to keep fit. You used to be a long distance runner in the good old days, and are proud that you have continued running for so long. However, for the last few months you haven’t been able to run as much as before, due to pain in your leg.

HPC: The pain has come on gradually, and is getting worse and worse. It started two months ago, and is around your left hip. It sometimes moves to your left thigh. It’s worse when you exercise, which has really annoyed you, as you’ve had to stop going to the running club you lead. This is very disappointing, as you had just taken on a lot of new young runners, and feel like you are letting the team down. There’s nothing that makes the pain better, apart from stopping exercising. You also sometimes get the pain in your ribs, which is really unusual. You generally feel a lot more rubbish, too. Running would always give you a ‘get up and go’ motivation, but now you feel flat and tired all the time. You sleep for 9 hours a night and don’t feel very refreshed. You even have naps… you always said naps are for losers! The only other odd thing you have noticed is that you have some pain when you go to pass water. Your urine looks a little dark too. You think it might be because you’re not drinking enough water. You don’t have a cough, but you do have some shortness of breath. This comes on when you are running, so you haven’t noticed it all that much recently. You did have some shortness of breath before Christmas, when you had to go into hospital for chest infections. They were a bit unpleasant, and you coughed up some blood at one point. It was frustrating: as soon as you were able to shake off one infection, another one came along. However you have managed to win that battle a few months ago, so things are looking up!

ICE: You thought that you might have pulled a muscle in your leg when this all started, but this has gone on for a while without getting better, so you’re not sure anymore. The last time you went to the GP about this, he asked you if you were depressed. You told him that the very idea was nonsense! Your mood has been fine, aside from being cranky that you can’t run. You’d like to find a diagnosis for all of this and a quick and simple treatment, ideally, so you can get back to your routine. No time to be wasted!

PMH: You have broken your wrist in the past, and your right knee isn’t quite what it used to be: you think it might be a touch of arthritis. Otherwise, you’ve always been quite well, apart from the chest infections over Christmas. You don’t take any over the counter medications and don’t have any allergies.

SH: You live with your wife, Paula. She has never been interested in running, despite your best efforts! She is quite worried about you, however, and has made you come along today. Your two kids are now grown up and working as accountants in the city. You have never smoked and don’t drink alcohol.

FH: Your dad died of lung cancer. He smoked for years and you never ever could have smoked because of this. It still makes you sad thinking about it.

The student should demonstrate a clear history of impact this pain is having on this patient’s life. A good systems inquiry should identify most of the salient points in this history, and addressing the ideas, concerns and expectations of the patient should make an ideal history. A musculoskeletal exam would be appropriate, or a respiratory examination could also be acceptable, depending on the student’s diagnosis. The student’s differential diagnosis should sound something like:

My differential diagnosis would include a haematological cause, more specifically multiple myeloma. This is because this patient has presented with fatigue, bone pain and urinary symptoms which could indicate renal failure. However, it would be important to rule out other forms of malignancy, especially lung cancer. This could have spread to this patient’s bones, leading to bone pain. This is particularly relevant given the patient’s family history of lung cancer. Other diagnoses to consider would be renal cell carcinoma or SLE.

Example for discussion may include:

  • How would you investigate this patient in the acute setting?
  • How would you manage this patient acutely?
  • How does Multiple Myeloma present?
  • What influences the decisions regarding the treatment of multiple myeloma?
  • Who could be involved in the care of a patient with malignancy?