Case authors: Laurence Biro

Date of original case: October 26, 2015

Name of patient:  Gerald White

Learner’s level of expertise:  Year 1-4

What kind of case is this? (History or history + physical examination)

Anticipated length of case in minutes: 10 minutes history for first years, 10 minute history + physical for upper years

Patient’s problem(s):  Coughing up blood

Most like diagnosis:  Lung cancer

Differential diagnosis: Lung cancer, tuberculosis, community acquired pneumonia, pulmonary embolism, hematemesis, epistaxis

Examination room set-up: Two chairs

Instructions for actor

Current problem(s): Coughing up blood

Age: 68

Setting: Family physician’s office

Proximal biomedical perspective

You are normally a fit individual.  You have been retired as general laborer for the last five years and have been very active and healthy since going on daily walks and swimming about twice per week with your wife.  About a month and half or you developed this nagging cough.  You thought it would go away but it has progressively worsened.  Initially it was a morning cough that would last about thirty minutes but now it can go on for most of the day.  Besides the cough you generally have been feeling weaker than usual.  The amount of sleep you require has increased from seven to nine hours and a few weeks ago you have found that you needed to take thirty minute naps in the afternoon.  Still, even with that you are feeling sluggish.  The last time you swam was 4 weeks ago and it has been a struggle to go on your daily walks with your wife.  She says you are not the same person you usually are.  Besides your overall energy level, your appetite is also down.  Your clothes are feeling looser and you think you are down two belt notches.  You have started sweating and feeling chilled at night.  It was so bad two nights ago you need to change the sheets on the bed.

More alarming has been the blood. A week ago you coughed up about a teaspoon of blood in the morning and have continued to do so about every other morning since then.  You have been able to hide this from your wife up till now.  However, this morning you coughed about half a cup of clots and she yelled at you for hiding this from her and made the appointment to come in today.

You have not experience any shortness of breath, chest pains, vomiting or diarrhea.  Food has made you mildly nauseated over the last two weeks leading to decreased appetite and occasional missing meals.  You have never done any traveling outside of Ontario.  There have been no trips to Northern Ontario or the developing world.  You have never encountered anyone with similar symptoms.  No one is sick at home.  You do not have any calf pain or chest pain.  You have never had pneumonia or blood clot.  No one in your family has ever had a blood clot.  You have not had any nose bleeds nor have you vomited up blood.

Distal biomedical perspective

Past Medical History

• High blood pressure x 10 years
• No hx of blood clots, pneumonia
• No hospitalizations besides appendectomy 50 years ago

Medications

• Hydrochlorothiazide 25mg po daily (for blood pressure)
• Ramipril 5mg po daily (for blood pressure)

Medical Family History

• Mother died of stroke age 70
• Father died of a myocardial infarction at age 65
• Younger brother is being followed for prostate cancer but is not receiving any treatment

Smoking / rec drugs

• never

EtOH

• 2-4 beer / week x 40 years

Proximal context

• Relationship status: married to wife x 45 years
• Sexual orientation: heterosexual
• Children: two, one is married with children, one is single, they are healthy, live outside of town for work
• Partner’s occupation – wife has always been at home raising children, she was very active in the volunteer community, lead the parent teachers association at their children’s school for several years
• Where do you live – apartment building in suburban Toronto
• Transportation – owns and drives a car
• Social background – middle class
• Support network – mostly wife, has a good circle of friends

Occupation, financial support

You have worked as laborer at a wide variety of factories in Toronto and Montreal.  Your jobs have typically been low skilled.  For a period of time you were driving a forklift truck.  Of note there was a five-year period of time about thirty years ago you worked in an asbestos warehouse.  You were responsible for moving boxes of asbestos around.  No one ever wore any personal protective equipment and you were and are still not aware of that is an issue.

Patient’s perspective

• Ideas and thoughts
  • What did you think have caused your problems?
    • You are not sure why you are coughing up blood.  You are aware this can be a sign of lung cancer but that doesn’t make any sense to you as you don’t smoke.
    • You have no awareness that there is an association between asbestos and lung cancer
  • What have they told you so far?
    • Your wife told you this is dangerous and made you feel very guilty for not saying anything
• Concerns
  • What are you concerned about?
    • You are concerned about lung cancer
  • Have you any underlying fears?
    • Worried about dying and leaving your wife alone
• Expectations
  • What are you hoping for?
    • You are hoping this is just a virus and you need some antibiotics and it will go away
• Feelings
  • How are you feeling about it all?
    • You are feeling frightened and worried

How to present the symptom(s) or problem(s)

How to start the consultation:

• Opening line of the interview:
  • “My wife told me to come in this morning when she noticed I was coughing up blood”

• What to divulge to screening questions (e.g. ‘So abdominal pain and fever — anything else?’)
  • Sweating at night
  • Low energy
  • Not hungry

How to respond to specific types of questions or approaches: what to divulge spontaneously and what not to

• What to divulge only to closed questions
  • Only reveal the asbestos if the asked explicitly about work place exposures or exposure to asbestos
• How to respond to emotional subjects and questions
  • Look away, freely state your fears of something dangerous, fear of leaving your wife alone if she dies
• Verbal statements to be made at some point:
  • “Doctor is this dangerous? Am I going to die?”
  • If asbestos is brought then ask “was the asbestos dangerous? Should I be worried about it?”

Post Encounter Probe

• What your differential diagnosis?
• What is your most likely diagnosis and why?
• What tests would you order?