lung cancer
Doctor Information
Jenson Akerman, age 69
PMH:
Hypertension
Osteoarthritis
Asthma
DH:
Amlodipine 5mg OD
Clenil Modulite 100 micrograms 2 puffs BD
Salbutamol 100 micrograms 2 puffs PRN
No drug allergies
PMH:
Hypertension
Osteoarthritis
Asthma
DH:
Amlodipine 5mg OD
Clenil Modulite 100 micrograms 2 puffs BD
Salbutamol 100 micrograms 2 puffs PRN
No drug allergies
Patient Information
Jenson Akerman age 69
Opening line: I’ve got this cough that I cant get rid off.
History: You have had this cough for about 4 weeks, on and off. Sometimes it is dry but sometimes you get some phlegm up. Your breathing is fine, you do have asthma but it has been pretty stable. Is there any chance you can have a chest X-ray?
If asked only: to be honest, the cough has been there longer than that but you put off coming here. Once or twice you noticed some weird rusty coloured stuff in your phlegm. You can't put your finger on it, but you just don’t feel yourself. You have no appetite anymore. You were always a bit on the chubby side, but now you need a belt to keep your trousers up, and your wife is worried about you. There are no problems at all with your breathing, and no chest pains or fever.
You live with your wife. You have one daughter, Lizzie, who is getting married in January. You used to smoke for many years but stopped about ten years ago. You don’t drink alcohol and you are are a retired pharmacist. You have been putting off coming due to all the organising you're doing for the wedding. Your daughter is very busy - so you and your wife have been helping out. You're really excited about her wedding, as she is your only daughter.
As a side you have noticed a rash on your trunk over the past few weeks, it looks strange - almost fungal, but it's spreading rapidly, and not responding to Daktacort that you bought over the counter.
Ideas: you know something is wrong but you don’t want to say anything to the doctor unless you trust them.
Concerns: the worst thing would be cancer. You promised your daughter you would be at her wedding to walk her down the isle.
Expectations: chest x-ray
You ask the doctor to tell you honesty what he or she thinks. In the back of your mind you have a feeling this is going to turn out to be cancer, and you are frightened. Your wife is not a strong person and she would fall apart. That's why you didn't come earlier, you couldn't bear to find out. But now there are other things - your daughter’s wedding for one, and possibility of grandchildren. Its not a good few months that you want, it is the rest of your life. If the doctor seems reluctant to mention cancer, keep pushing them to tell you what they think. If they discuss it with you as a possibility, you are calm and listen to their advice.
Opening line: I’ve got this cough that I cant get rid off.
History: You have had this cough for about 4 weeks, on and off. Sometimes it is dry but sometimes you get some phlegm up. Your breathing is fine, you do have asthma but it has been pretty stable. Is there any chance you can have a chest X-ray?
If asked only: to be honest, the cough has been there longer than that but you put off coming here. Once or twice you noticed some weird rusty coloured stuff in your phlegm. You can't put your finger on it, but you just don’t feel yourself. You have no appetite anymore. You were always a bit on the chubby side, but now you need a belt to keep your trousers up, and your wife is worried about you. There are no problems at all with your breathing, and no chest pains or fever.
You live with your wife. You have one daughter, Lizzie, who is getting married in January. You used to smoke for many years but stopped about ten years ago. You don’t drink alcohol and you are are a retired pharmacist. You have been putting off coming due to all the organising you're doing for the wedding. Your daughter is very busy - so you and your wife have been helping out. You're really excited about her wedding, as she is your only daughter.
As a side you have noticed a rash on your trunk over the past few weeks, it looks strange - almost fungal, but it's spreading rapidly, and not responding to Daktacort that you bought over the counter.
Ideas: you know something is wrong but you don’t want to say anything to the doctor unless you trust them.
Concerns: the worst thing would be cancer. You promised your daughter you would be at her wedding to walk her down the isle.
Expectations: chest x-ray
You ask the doctor to tell you honesty what he or she thinks. In the back of your mind you have a feeling this is going to turn out to be cancer, and you are frightened. Your wife is not a strong person and she would fall apart. That's why you didn't come earlier, you couldn't bear to find out. But now there are other things - your daughter’s wedding for one, and possibility of grandchildren. Its not a good few months that you want, it is the rest of your life. If the doctor seems reluctant to mention cancer, keep pushing them to tell you what they think. If they discuss it with you as a possibility, you are calm and listen to their advice.
Examination Findings
Pulse 91
Blood Pressure 130/87
General Appearance - pale, loose fitting clothes
Chest has equal breath sounds, no wheeze or crepitations
Sats 96% ra
Rash noted to left side of trunk, appearing like concentric erythematous circles, giving a "wood grain" like appearance.
Blood Pressure 130/87
General Appearance - pale, loose fitting clothes
Chest has equal breath sounds, no wheeze or crepitations
Sats 96% ra
Rash noted to left side of trunk, appearing like concentric erythematous circles, giving a "wood grain" like appearance.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears unsure of how to operate/use instruments Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Explains possibility of lung cancer Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Management approaches reflect an appropriate assessment of risk Refers appropriately & co-ordinates care with other healthcare professionals - ensures 2 week wait referral completed Manages risk effectively, safety netting appropriately Encourages improvement, rehabilitation, and, where appropriate, recovery. Encourages the patient to participate in appropriate health promotion and disease prevention strategies |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate - does not discuss two week wait. Follow-up arrangements are absent or disjointed Fails to take account of related issues or of co-morbidity Unable to enhance patient’s health perceptions and coping strategies |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination, conveys possibility of cancer in an empathetic manner Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Inappropriately influences patient interaction through own views |
Management
Explanation: There are many conditions that can cause a cough. Sometimes it is something simple like an infection or an allergy. But it can also be a sign of something more serious, for example lung cancer. At the moment we don’t know the cause of your symptoms, and we need to investigate quickly to find out. If it does turn out to be something serious we will do everything we can to help.
Suspected cancer is something that could very well come up in a CSA station. The safest method to exclude or confirm cancer is checking red flags. It doesn't take long. Even though the chest examination is normal in this man, he is an ex smoker with possible haemoptysis and weight loss.
This rash in this case is erythema gyratum repens which is a rare paraneoplastic rash associated with many forms of cancer, although more common with lung cancer. For a better idea of what it looks like please click here to see google image search of the condition.
Anyone with symptoms suggestive of cancer should be referred on the two week wait pathway for specialist assessment. You do not have to request a CXR first, and you should not delay the diagnosis. If you had seen someone with respiratory symptoms who has already had a normal CXR, but still has a history suggestive of cancer, you should still refer on this pathway. Any signs of SVC obstruction (puffy face, dilated chest veins, elevated JVP) and the patient should be admitted directly.
Aside from the medical issues, this case is testing your skills at breaking bad news. Yes, nothing is confirmed, but cancer is likely. Don’t be afraid to use the word cancer - often the patient is thinking it anyway, for example ’the symptoms that you have are suggestive of something serious. I can't tell you for certain without a scan, but I am concerned that you may have cancer’.
Explain what will happen so your patient knows what to expect - they will no doubt have a CT chest and an appointment with a specialist. Depending on what they find, they might need a sample of the lung to send to the lab. Usually there is a meeting with the results, that includes doctors from different teams (MDT) who work together to plan the best form of treatment.
Offer your support - they may have lots of questions, give them a chance to come back in and talk about them. Try and be positive if you can - cancer is not a nice diagnosis to get, but there are a lot of different types of treatment available and everyone professional involved will do the best they can.
Suspected cancer is something that could very well come up in a CSA station. The safest method to exclude or confirm cancer is checking red flags. It doesn't take long. Even though the chest examination is normal in this man, he is an ex smoker with possible haemoptysis and weight loss.
This rash in this case is erythema gyratum repens which is a rare paraneoplastic rash associated with many forms of cancer, although more common with lung cancer. For a better idea of what it looks like please click here to see google image search of the condition.
Anyone with symptoms suggestive of cancer should be referred on the two week wait pathway for specialist assessment. You do not have to request a CXR first, and you should not delay the diagnosis. If you had seen someone with respiratory symptoms who has already had a normal CXR, but still has a history suggestive of cancer, you should still refer on this pathway. Any signs of SVC obstruction (puffy face, dilated chest veins, elevated JVP) and the patient should be admitted directly.
Aside from the medical issues, this case is testing your skills at breaking bad news. Yes, nothing is confirmed, but cancer is likely. Don’t be afraid to use the word cancer - often the patient is thinking it anyway, for example ’the symptoms that you have are suggestive of something serious. I can't tell you for certain without a scan, but I am concerned that you may have cancer’.
Explain what will happen so your patient knows what to expect - they will no doubt have a CT chest and an appointment with a specialist. Depending on what they find, they might need a sample of the lung to send to the lab. Usually there is a meeting with the results, that includes doctors from different teams (MDT) who work together to plan the best form of treatment.
Offer your support - they may have lots of questions, give them a chance to come back in and talk about them. Try and be positive if you can - cancer is not a nice diagnosis to get, but there are a lot of different types of treatment available and everyone professional involved will do the best they can.