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You are a Foundation doctor working in GP. Mr Sota Lol is a 57-year-old man, presenting to your surgery with persistent heartburn.

Please take a history from Frank and undertake an appropriate examination. You will then be asked to discuss the case with the examiner.

You are Sota Lol, a 61 year old gentleman who has decided to get his heartburn finally sorted out. It’s probably just another ulcer: all you need is a prescription and you’ll be on your way as you don’t really want to bother the doctor. You have lived in the UK for 20 years, and are originally from Japan.

HPC: You’ve been having some awful heartburn since coming back off holiday a few weeks ago. It’s getting quite embarrassing the amount you’ve been burping. You’re not sure how much you’ve been burping: just that it’s a lot – enough to make people around you notice! You’ve not been sick but have felt a bit nauseous of late, probably from the acid. You haven’t noticed any changes when going to the toilet: you had an anal fissure a few years back, which was agony. Since then you always check for blood and things. Nothing like that in your stools lately!

Your appetite is OK but you think you might be getting full quicker than you used to. You don’t mind that too much, if it means that your weight stops yo-yo-ing! When you were younger your weight seemed to be a constant in space and time – you’d never put on weight, no matter what rubbish you ate! Your mum used to say: “son, you’ve got the metabolism of a blast furnace!” Unfortunately that blast furnace slowed down a few years ago, and you’ve piled on the pounds a little, until about 6 months ago. No more cake for Sota! Then you began to lose weight again – about 2 stone since. Your body can’t decide what it’s doing. Your diet is, as ever, really bad. You can’t help eating take aways and fatty foods!

You’ve been having some pain around your stomach, on the left side. It was an aching pain, which was there most of the time. You haven’t really tried taking anything for it: you’ve dealt with worse pain before – you broke your leg when you were young – that was agony. You think that the pain is worse when eating, but you’re not entirely sure. It doesn’t spread anywhere, and you reckon that it is a 3/10 in terms of severity. So, a nuisance really. Otherwise, you feel fairly well. You haven’t had any shortness of breath, your water works are OK and you are a bit more run down than usual. You have put that down to age.

PMH: You have had a few ulcers in the past, which clear up for a while with the medications. The doctor said a year or so ago that you had an infection in your stomach – you had some loose stools at the time. However the loose stools stopped, so you didn’t bother taking the antibiotics the GP gave. Problem solved! You’re a type 2 diabetic but not the best with diet control. You’re not taking any medication for it you but think might be if you keep misbehaving! Otherwise, you are fine.

DH: You tried taking some fruity antacids, which are nice enough by themselves, but they’re not doing the trick: neither is the Gaviscon. You’ve taken some PPI things in the past which helped but you can’t remember the name. You have a funny reaction to penicillin which give you some tummy troubles and a rash.

FH: Your father and quite of lot of uncles have had stomach cancer but “that’s pretty common back home”. Your mother is relatively well, but living in a residential home at the moment as she’s a bit frail.

SH: You live with your wife, and you work as an engineer for a large company. You have two kids: one son who’s had his first child and a daughter who’s going off to university soon. You smoked until about a year and a half ago – prior to this you smoked 10 cigarettes per day for about 15 years. You have a whiskey at night to help get to sleep, and maybe a couple of pints at the company karaoke night “but not much else”. You think that anyone in their right mind would have had much more to drink at that party – it was dreadful.

ICE: You think you’ve just given yourself another ulcer from the stress of seeing your family in Japan and having to drag your granddaughter on a long transatlantic flight. You’re concerned that the ulcers are not going to get better and that they’re going to ruin your appetite and ability to appreciate food. You’re expecting the pills to make it go away.

Observe the student taking a focused history of presenting complaint regarding this patient’s symptoms. A quality candidate will assess for key risk factors for malignancy in the history and identify any red flags.

A good differential diagnosis would sound something like:

“My primary differential diagnosis for this gentleman would be a gastrointestinal cause: more specifically gastric carcinoma. This is because of red flags for malignancy, including recent weight loss, in addition to multiple risk factors for gastric cancer, such as poor diet, age, family history, Japanese background and smoking history. Alternatively it would be important to consider recurrence of gastric ulceration in this gentleman with a background of gastric ulcers. From the history it also sounds like he may have had a helicobacter pylori infection in the past: this would also increase the risk of malignancy.”

Possible questions for discussion may include:

  • Tell me about some risk factors for gastric cancer.
  • How would you investigate this gentleman?
  • What would indicate a referral for investigations and how long would the patient have to wait to be seen in these investigations?
  • How is gastric cancer managed?
  • What is the management regime for Helicobacter pylori eradication?