Fred Alberta

Age: 42 years old male

Full Case

Station List
Doctor
Patient
Examiner

Patient’s Data​

Patient’s name:  Fred Alberta

Age: 42-year-old male

Past medical history

  • Nil

Drug and Allergy History 

  • Nil 

Recent notes/consultation

Seen by Michael Barns (Nurse Practitioner) 5 weeks ago

Presenting Complaint: Persistent dry cough lasting 3 weeks

Examination findings: Chest is clear on auscultation

Oxygen saturation: 98% on room air

Respiratory rate: 18 breaths per minute

Blood pressure: 145/90 mmHg

Impression: likely chest infection

Plan: PO amoxicillin 500mg TDS for 5 days. Safety netting and worsening advice given.

Patient booked appointment to discuss ongoing concerns

Patient's Story (Role player’s brief)

Patient’s Story 

Opening Statement: “Doctor, I’ve had this cough for a while now — it’s been going on for about 8 weeks and just doesn’t seem to be getting better. I thought the antibiotics would help, but it’s still there and really bothering me.

IF ASKED TO EXPLAIN FURTHER

The cough is dry, occurs throughout the day, but seems worse at night and sometimes after eating. You do not experience shortness of breath, chest pain, fever, or palpitations

ONLY SAY THE FOLLOWING IF ASKED:

You occasionally notice an unpleasant sour taste in your mouth when lying down at night, and you sometimes experience heartburn, though you didn’t think it was significant.

You feel tired most of the time, but you attribute this to stress from your new managerial role at a pharmaceutical company.

Social History: You have a history of smoking—20 cigarettes a day for 15 years—but you quit 3 years ago. You live with your wife and one child. You work as a manager in a pharmceutical company. 

No family history of any cancer or disease

Idea: You believe this may be a stubborn chest infection that hasn’t cleared up.

Concern: The ongoing cough is both distressing and embarrassing for you.

Expectation: You’re hoping the doctor will prescribe another course of antibiotics.

Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.

Marking Scheme

Data Gathering and Diagnosis

  • Ask about the onset and duration of the cough
  • Ask if the cough is productive or dry as this can distinguish between infective causes vs. non-infective such as reflux or postnasal drip
  • Ask if there is any haemoptysis (coughing up blood)- Red flag for lung malignancy, TB, or severe infection
  • Ask if there is any wheeze or noisy breathing (To assess for asthma, COPD, or other reactive airway diseases)
  • Ask about associated shortness of breath (SOB), chest pain, or palpitations to assess for cardiac or pulmonary involvement
  • Ask if cough worsens at night or after meals (Suggestive of gastroesophageal reflux disease but note that asthma type of cough can be worse at night)
  • Ask about reflux symptoms — heartburn/ epigastric pain, feeling full or bloated, vomiting or nauseous and sour taste in the mouth (Note that sour taste in the mouth can be a symptom of both acid reflux and post-nasal drip) 
  • Ask about flu-like symptoms, nasal congestion, throat clearing or feeling of mucus or phlegm dripping down the back of the throat (postnasal drip)
  • Ask about voice changes or hoarseness (Laryngopharyngeal reflux, malignancy, or chronic irritation)
  • Ask about red flag symptoms — weight loss, night sweats, fatigue, or loss of appetite (To screen for underlying malignancy or systemic illness)
  • Ask about past smoking history — current and previous use
  • Ask about their job and whether they may be exposed to things like dust, fumes, or chemicals at work to rule out occupational lung disease 
  • Ask about any history of allergies or atopic conditions (To explore possibility of asthma or allergic rhinitis)
  • Ask about over-the-counter medications or recent use or initiation of prescribed medications like ACE inhibitors (ACE inhibitors can cause persistent dry cough)
  • Ask about family history of atopy, asthma or lung cancer 
  • Make a working diagnosis of chronic cough likely triggered by acid reflux, but explain the need to rule out any serious underlying causes, such as cancer.

Example of explanation to patient​

Fred, thank you for taking the time to talk me through everything you’ve been experiencing I completely understand why you might think this is still an infection, especially since you’ve had a lingering cough and it’s understandably frustrating. But based on what you’ve told me and the fact that you’ve already had a course of antibiotics, it’s unlikely that this is due to an ongoing infection.

Infections that need antibiotics usually come with other symptoms like fever, feeling generally unwell, chest pain when breathing, or coughing up discoloured mucus. In your case, you’re not experiencing any of those, and your chest was clear when examined previously. This makes an infection much less likely right now.

Instead, it sounds like your cough might be linked to something we call acid reflux. That’s when acid from the stomach travels upwards and irritates the back of the throat. You mentioned having heartburn and a sour taste in your mouth, especially when lying down, and that your cough gets worse after eating — all of this fits with reflux being a possible cause.

However, because your cough has been going on for several weeks, and you also mentioned feeling tired all the time, along with your history of smoking, I think it would be sensible to arrange a chest X-ray and some blood test, including one that looks at your blood count

This is just to make sure we’re not missing anything more serious. I don’t want to alarm you, it’s very likely nothing worrying, but we do this as a routine step to be thorough and rule out anything like cancer. Does that all make sense?

In addition, would it be alright if I asked you to come in today so I can see you in person? I’d like to listen to your chest, check your tummy, and have a look at your throat to get a clearer picture. 

In terms of treatment, I’d like to start you on a medication called omeprazole. It’s taken once a day and works by reducing the amount of acid your stomach makes. We’ll try it for four weeks and see how you respond. Alongside this, there are some helpful lifestyle changes that can make a real difference,  such as avoiding spicy foods and coffee, and trying not to eat too close to bedtime, ideally leaving 3 to 4 hours between your last meal and when you lie down.

Finally, you mentioned stress — which is understandable, especially with your new work role. Stress can sometimes make physical symptoms worse too. Some people find mindfulness techniques or apps like Headspace helpful for coping. Yoga or simple breathing exercises can also help you unwind.”

And just so you know — if anything changes or gets worse, like if you develop chest pain, start coughing up blood, lose weight without trying, or feel breathless, I’d want you to get in touch urgently. But for now, let’s get started with this plan and check back in after a few weeks.

Management

Management

  • Offer a face-to-face appointment to examine his chest, abdomen, and throat in more detail 
  • Arrange a chest X-ray within 2 weeks, given the ongoing cough, fatigue and history of smoking
  • Offer blood tests, including a full blood count (FBC), to look for signs of inflammation, such as raised eosinophils, which may indicate asthma or other clues like elevated platelet levels, which can be associated with lung cancer
  • Start a 4-week trial of omeprazole 20mg once daily, as the symptoms suggest acid reflux may be contributing to the cough
  • Advise avoiding known reflux triggers such as spicy foods, coffee, and large meals
  • Suggest not eating within 3–4 hours before going to bed to help reduce night-time reflux
  • Recommend stress management strategies such as using the Headspace app, practising mindfulness, or trying yoga
  • Mention that his blood pressure reading from the last visit was slightly raised — advise booking a follow-up to monitor this properly (and recheck at F2F visit)
  • Provide safety netting advice: if he develops any new or worsening symptoms like shortness of breath, coughing up blood, unexplained weight loss, chest pain, or palpitations, he should seek medical attention promptly.

Learning point from this station: ​

Cough can be classified based on its duration: acute if it lasts less than 3 weeks, sub-acute if it lasts between 3 to 8 weeks, and chronic if it persists for more than 8 weeks. 

This case reinforces the importance of a thorough and structured approach to assessing chronic cough in primary care. Cough persisting for more than 8 weeks is considered chronic and may have a wide differential diagnosis, ranging from benign causes like reflux or post-nasal drip, to more serious pathologies like lung cancer or interstitial lung disease. In this case, although gastro-oesophageal reflux (GORD) is the likely cause given the presence of heartburn and nocturnal symptoms, the patient’s smoking history and unexplained fatigue necessitate a cautious approach.

A chest X-ray should be organised given the presence of a persistent cough, unexplained fatigue, and a history of smoking. Although the patient attributes his tiredness to work-related stress, this symptom should not be dismissed, as it could potentially represent a red flag. Taking a safe and thorough approach to managing uncertainty is essential to avoid missing serious underlying causes such as lung cancer.

Blood tests including full blood count (FBC) can help detect clues such as thrombocytosis, which may be associated with malignancy, or raised eosinophils, which could point toward eosinophilic bronchitis or asthma.

Upper airway cough syndrome (post-nasal drip) is a common cause of chronic cough. Management involves prescribing an antihistamine (e.g., chlorphenamine) and short-term use of a decongestant (e.g., pseudoephedrine), usually for no more than 5 to 7 days, to avoid rebound congestion known as rhinitis medicamentosa. Nasal irrigation with a saline solution can also be considered to help clear mucus and reduce irritation.  Patients should also avoid environmental or allergic triggers. Symptoms often improve within 1–2 weeks, but full resolution may take several weeks to months.

  • If sinusitis is suspected, typically presenting with nasal blockage/obstruction/congestion or nasal discharge, facial pain/pressure, and/or a reduced or lost sense of smell — management may include intranasal corticosteroids (e.g., mometasone) or antibiotics.
  • If rhinitis is present, characterised by sneezing, nasal itching, runny nose (rhinorrhoea), and congestion — treatment options include intranasal corticosteroids, intranasal antihistamines (e.g., azelastine), or intranasal sodium cromoglicate.

According to NICE guidelines for suspected lung cancer:

A suspected cancer pathway referral (for an appointment within 2 weeks) should be made if:

  • A person has chest X-ray findings suggestive of lung cancer, or
  • Is aged 40 or over and presents with unexplained haemoptysis.

An urgent chest X-ray (to be done within 2 weeks) should be offered to people aged 40 or over who have ever smoked and present with one or more of the following unexplained symptoms, or to those who have never smoked but present with two or more:

  • Cough
  • Fatigue
  • Shortness of breath
  • Chest pain
  • Weight loss
  • Appetite loss

NOTE: “Unexplained” means the symptom or sign has not been attributed to a clear diagnosis following initial assessment in primary care.

A chest X-ray should also be considered urgently (within 2 weeks) in anyone aged 40 and over with any of the following:

  • Persistent or recurrent chest infections
  • Finger clubbing
  • Supraclavicular or persistent cervical lymphadenopathy
  • Chest signs that are concerning for malignancy
  • Thrombocytosis (raised platelet count)
Further reading