Patient Details
|
Name |
Mark Green |
|
Age |
61 |
|
Sex |
M |
|
Medications |
Salbutamol 2-4 puffs PRN Rivaroxaban 20mg PO daily Atenolol 50mg PO daily |
|
HPC |
Patient has had increasing cough for the last four months. The cough is not productive, but persistent and distressing to the patient. He has also noticed that he is getting increasingly short of breath on his five-kilometre morning walks with his dog. He has also been quite frustrated by a constant right shoulder pain. He has not been able to relieve this with anything. On the same arm he has noticed some hand weakness. His family has also commented that his right eye looks a little droopier than normal. He has no haemoptysis or chest pain. He has not noticed any significant weight loss, abdominal pain, bone pain or headache On examination with the GP, they noticed digital clubbing and small muscle wasting on the right hand. The right eye demonstrated ptosis and miosis and enophthalmos. There also appeared to be decreased sweating on the right side of the patient’s face. There were no changes on auscultation. The GP did however decide to investigate further with a CXR initially. |
|
PSxHx |
Appendectomy – no post-op complications |
|
PMHx |
Mild COPD FEV1 76% predicted Atrial fibrillation |
|
Allergies |
NKDA |
|
FHx |
Mother and father both died of influenza in the same season in their 90s. The patient’s brother died from mesothelioma due to occupational asbestos exposure. No other significant family history. |
|
SHx |
Patient lives alone since his wife died three years ago. He has a border collie which he walks five kilometres every morning. His three children and their families all live locally. The patient is a smoker; he has smoked a pack a day since he was 15 (46 pack year history). He drinks wine only on social occasions. He is a retired surveyor. |