CASE 98: CHANGE IN CHARACTER
History
A 66-year-old man has been persuaded by his wife to go to his general practitioner (GP).
She is worried that he has changed. Over the last 4 weeks he has become lethargic and
rather vague. He has a 12-year history of chronic cough and sputum production, but she
thinks that these symptoms may have increased a little over the last 8 weeks. He has
smoked 20 cigarettes daily for the last 50 years and he drinks around 14 units of alcohol
per week. Two years ago he became depressed and was treated with an antidepressant for
6 months with good effect. She cannot remember the name of the medication. He had
worked all his life as a postman until retirement 6 years ago.
Examination
He is a little vague in his answers to questions. There are no abnormalities to find in the
cardiovascular, respiratory or abdominal systems. There is no lymphadenopathy. On neuro-
logicalexamination he seems to have mild generalized muscle weakness. Reflexes, tone
and sensation are all normal. His peak flow and spirometry are within normal limits.
NormalHaemoglobin 14.8 g/dL 13.0–17.0 g/dL
Mean corpuscular volume (MCV) 86 fL 80–99 fL
White cell count 6.9% 109 /L 4.0–11.0% 109 /L
Platelets 297 % 109 /L 150–400% 109 /L
Sodium 119 mmol/L 135–150 mmol/L
Potassium 3.5 mmol/L 3.4–5.0 mmol/L
Urea 3.1 mmol/L 2.5–7.5 mmol/L
Creatinine 63 &mol/L 70–120&mol/LHis chest X-ray shown in Fig. 98.1.INVESTIGATIONS
Figure 98.1Chest X-ray.Questions
- How do you interpret these findings?
- What would be the appropriate management?