Station 74

Michael O’Donoghue

Age: 50 year old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis

  • Ask about the onset of cough
  • Ask if the cough is productive; if so, ask about the colour of the sputum and whether there is any haemoptysis 
  • Ask about associated wheeze, fever, shortness of breath, chest pain, and palpitations (to assess for possible chest infection, pneumonia, or pulmonary embolism) 
  • Ask about contact with anyone experiencing a similar cough or any recent travel outside the UK to assess the risk of tuberculosis
  • Ask if there are any flu-like symptoms/postnasal drip—blocked nose, runny nose, feeling of mucus draining at back of throat
  • Ask about reflux symptoms—heartburn, sour taste in mouth
  • Ask about hoarse voice
  • Ask if there are any precipitating factors (to identify potential triggers such as allergens, irritants, or exertion that may help clarify the underlying cause of the cough) 
  • Ask about red flag cancer symptoms—weight loss, night sweats, loss of appetite, fatigue
  • Ask about smoking history
  • Ask if patient has any medical problems that we are not aware of
  • Give a diagnosis of potential diagnosis of Lung cancer. 

Example of explanation to patient​

Michael, based on what you’ve told me, particularly the persistent cough, the yellow phlegm, the tiredness, weight loss and the fact that you’ve noticed some blood in your sputum, I’m concerned that this may be more than just a simple chest infection.

When we also take into account your long-term smoking history, I’m worried about something more serious. By serious, I mean the possibility of lung cancer.

Now, I’m not saying this is cancer, but it is something we need to rule out urgently. That’s why, ideally, I would want to see you face-to-face to examine your chest properly and check your vital signs like your temperature, oxygen levels, and heart rate.

However, I understand that you’re travelling out of the area today and don’t know yet where you will be going. What I would like to do is arrange a follow-up call in two days’ time, just to check where you’ve moved to. As soon as we know your new location, I will make an urgent referral, called a two-week wait referral, to a chest specialist so they can assess you quickly. Please make sure you register with a new GP immediately you get to the new area. I will also make sure your new GP is informed and that your records are transferred electronically, so nothing gets lost along the way and they can help coordinate your care.

If you don’t hear from a specialist within two weeks, please call either us or your new GP to follow up.

Now, you mentioned you were hoping for antibiotics. I completely understand that, but based on your symptoms, there’s no strong evidence of a bacterial infection at the moment. Antibiotics wouldn’t help in this situation and using them unnecessarily can cause side effects like diarrhoea or nausea, and may lead to antibiotic resistance, meaning they may not work when you do really need them. So, it’s best to avoid them for now, unless things change.

Does everything I’ve said so far make sense? Is that okay with you?

If your symptoms get worse in the meantime, so if the amount of blood in your sputum increases, you feel more short of breath, develop chest pain, difficulty breathing, or new symptoms like a persistent fever, please don’t wait. Seek urgent medical advise

Management

Management

  • Offer a face-to-face assessment to examine the patient in person
  • If the patient declines, explain your concern about possible lung cancer and outline the following options:

If the patient is aware of the location he is moving to:

  • Advise him to register with a GP in the new area without delay
  • Offer to directly make a 2-week wait (2WW) referral to a respiratory specialist in his new area while simultaneously transferring his medical records electronically to his new GP. 
  • Advise that you will inform his new GP that the referral has already been made to ensure they are aware and can follow up accordingly.   

If the patient is uncertain about where he will be moving to:

  • Offer a follow-up telephone call in 2–3 days to check his new whereabouts
  • Emphasise the importance of registering with a GP as soon as he settles in a new area
  • Once the new location is known, arrange a direct two-week wait (2WW) referral to a respiratory specialist in the new area.
  • Inform his new GP about the referral so they can follow up appropriately and arrange for his medical records to be transferred electronically. 

Note: A two-week wait (2WW) referral can be made to any hospital within the UK, regardless of the patient’s current location. For instance, if he is relocating from Manchester to London, a 2WW referral can be sent directly to a respiratory specialist in London to ensure timely assessment. Medical records in the UK are transferred electronically, not by paper or hand delivery.

  • Stress that the referral should be treated as urgent given the concerning nature of his symptoms
  • Do not prescribe antibiotics, as they are not clinically indicated in this case
  • Offer advice and support on smoking cessation
  • Provide clear safety netting: advise the patient to seek urgent medical attention via 111 or A&E if he notices an increase in the amount of blood in his sputum, develops worsening shortness of breath, chest pain, difficulty breathing, or experiences new symptoms such as persistent fever or significant weight changes
  • Arrange a follow-up telephone call in 2–3 days to confirm that he has registered with a local GP and to assist with the referral process if needed

Learning point from this station: ​

This case illustrates the challenge of managing clinical uncertainty when red flag symptoms overlap with multiple serious conditions. In a patient presenting with a persistent productive cough, haemoptysis, weight loss, and fatigue, tuberculosis (TB) must be considered as a differential diagnosis. However, in the absence of risk factors such as recent travel to high-prevalence areas, immunosuppression,  known TB exposure (contact with persons with similar cough), or systemic symptoms like prolonged night sweats or persistent high fever,  TB becomes less likely in comparison to lung cancer, especially in the context of a 30-year smoking history.

Antibiotic Prescribing in Chest Infections/Cough

Lower respiratory tract infections (LRTIs) are generally classified into two main types: bronchitis (affecting the airways) or pneumonia (affecting the lung alveoli)

  • Pneumonia is suspected when a person has at least one respiratory symptom (such as breathlessness, sputum, wheeze, or pleuritic chest pain) along with at least one systemic feature (such as fever or muscle aches). Pneumonia is usually caused by bacteria, so antibiotics are needed.
  • Bronchitis is suggested by a cough (with or without sputum) and may also involve breathlessness, wheeze, or general fatigue. It is usually viral, so antibiotics are not needed.

Antibiotic Prescribing in Acute Bronchitis

  • Antibiotics are not needed for otherwise healthy individuals who are not at high risk of complications. People at high risk of complications include; Those with pre-existing lung conditions (e.g., COPD, asthma, bronchiectasis, cystic fibrosis), Chronic health conditions (e.g., heart disease, diabetes, immunosuppression, significant neurological disorders), Older adults with frailty or people with multiple comorbidities.
  • Bronchitis is usually self-limiting (the cough usually lasts about three to four weeks) and improves on its own, so antibiotics are rarely required. 
  • Studies and expert guidelines from NICE confirm that most cases of acute bronchitis are viral, and antibiotics have limited effectiveness in treating them.
  • Unnecessary antibiotic use can lead to antibiotic resistance, increased healthcare costs, and potential side effects.

Antibiotics in acute bronchitis can be considered for the following people 

1-For Age over 65 with two or more of the following, or age over 80 with one or more of the following: 

  • Hospital admission in the past year 
  • Type 1 or Type 2 diabetes 
  • History of congestive heart failure 
  • Current use of oral corticosteroids

2- People at high risk of complications include; Those with pre-existing lung conditions (e.g., COPD, asthma, bronchiectasis, cystic fibrosis), Chronic health conditions (e.g., heart disease, diabetes, immunosuppression, significant neurological disorders)

Further reading