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Snapshot diagnosis - why is this fit 50 year old suddenly tired?

He’s a 50-year-old, 15-a-day smoker but had been very fit – so why has he recently lost weight, started coughing and feeling ‘knackered’? Dr Mike Wyndham describes another case

He's a 50-year-old, 15-a-day smoker but had been very fit – so why has he recently lost weight, started coughing and feeling ‘knackered'? Dr Mike Wyndham describes another case

The patient

Jack had worked as a builder all his life and had always felt pretty fit. His body didn't look like that of a 50-year-old, and that was despite ‘eating like a horse'. Lifting a hod of bricks was a ‘stroll in the park' and working a long day was easy. He smoked between 10 and 15 roll-ups a day and had tried to give up but found the craving too much.

Things had all changed three months before the consultation. ‘I feel rough, doctor,' was his opening gambit. Jack had lost weight as a result of his reduced appetite and he felt ‘knackered'. He had suffered with what he thought was a smoker's cough but it had deteriorated in the last two months and he felt short of breath when he really exerted himself.

First instinct

I looked through his records and it was clear that he was normally a fit man. He hadn't been to see us for six years and there were just a couple of A&E attendances for minor trauma at work. His symptoms of anorexia and weight loss combined with an increased cough were of concern.

Differential diagnosis

• Lung cancer

• Asthma (late onset)

• Tuberculosis

• Sarcoidosis

• Fibrosing alveolitis

• Asbestosis

• Cardiac dysfunction

Getting on the right track

Examination of the chest was fairly unexciting with the occasional fine crepitation audible in both lower zones of the lungs. There was no elevation of the jugular venous pressure or peripheral oedema suggestive of heart disease. Severe cardiac disease may cause cachexia but there was no evidence of this. Interestingly, there were a couple of glands palpable in the left supraclavicular fossa.

The hidden clue

I had assumed that the bluish colouration to his nose was just the result of an outdoor existence. However, with the examination the nose made sense.

The next step

Ten days later, his chest X-ray result came back. ‘Bilateral hilar lymphadenopathy with a suggestion of infiltration' were some of the words used. A referral to our local chest physician was followed by a lymph node biopsy and confirmation of a diagnosis of sarcoidosis. The nose was a complication called lupus pernio and treatment with steroids was started.

Dr Mike Wyndham is a GP in Edgware, north London

Is the bluish tinge to the nose a clue? Is the bluish tinge to the nose a clue?

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