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You are an FY1 on your Acute Medical Unit rotation. A 25 year old man has presented with a history of cough and general malaise.

Please take a history from the patient, considering his risk factors for his condition. You will then be asked to perform a focused examination of a relevant system, before participating in a discussion about the case.

You are a 25 year old man. You have come to A&E as you have had a bad cough that wouldn’t shift, and you have been feeling generally rubbish. You previously visited your GP with this issue, but it hasn’t got any better and so you have come to hospital to try to get yourself sorted.

HPC – Your cough is dry, and has been getting worse over the course of around a month. You have not brought up any phlegm or blood. You are becoming more and more short of breath, and walking short distances is becoming difficult – you had to get a taxi to the hospital. You have also had a sore throat that has been going on for a while – although you think that’s because you talk too much. You have had no chest pain.

You have noticed yourself becoming increasingly fatigued, and you’ve lost about half a stone in the last couple of months. You were initially pleased with this, as you had been trying to lose weight, but it’s a bit confusing – you haven’t been to the gym in months and had pretty much given up on the whole weight loss thing. You have felt feverish, generally very run down and unwell in yourself. Over the last couple of weeks you’ve woken up in the middle of the night drenched in sweats. That’s what really scared you.

PMH – You suffer from ongoing genital herpes outbreaks, having experienced them more frequently recently. You had a bit of a fluey illness and rash last autumn.

DH – The GP prescribed some amoxicillin last week but your symptoms have not improved. You finished the course.

FH – Mum has osteoarthritis, no other family history.

SH – You have never smoked and you drink socially. You’ve never used IV drugs. You live with two housemates in a flat, and no one else at home has been unwell. You do not have any pets, and have had no contact with animals recently apart from a friend’s new puppy. You work in IT at an office in the city centre, but you’ve had to take time off recently due to your illness. You went to Spain last summer for a week, but no other travel history.

In terms of sexual history, you have had unprotected anal sex with four new partners since your last sexual health screen last year, which was negative. All partners said that they were negative for the bug, but you do keep meaning to go and get another test soon.

ICE – You initially thought it was just one of those illnesses that has been going around, but everyone else has seemed to get better much more quickly, and hasn’t had it as bad as you. You also have a little niggle in the back of your mind about your sexual history, and worry that you could maybe have caught HIV, although you doubt it.

The student should take a focused history on the presenting complaint. They should also ask relevant questions to identify the cause of the symptoms and important risk factors.

Differential diagnosis should include pneumonia, although the length of symptoms and weight loss, together with PMH and sexual history should guide towards an abnormal organism, caused by possible HIV infection.

Some questions for discussion should include – How would you investigate this patient acutely? - What findings would you expect on examination? - What organism is causing this pneumonia? - What could be the relevance of this patient’s previous rash and flu-like illness?
- What could be the relevance of this patient’s sore throat? How would you proceed with management?