As the GP, you take a good history from the patient.

He is a 48 year old, white british man, previously fit and well.

Over the past few months, he has been very lethargic.  He has been managing to work fulltime, however he has gave up any form of physical exercise that he used to take part in at least five time a week as he feels far to tired!  He has also complained of some generalised abdominal discomfort.  He has lost 2-3kg in weight, but he has reduced his food intake due to reduced physical activity.  He does not complain of night sweats.

He denies cough/sputum/altered bowel habit/dysuria/frequency/headache.

He does drink alcohol, on average 14 pints, spread out throughout the week.  However this has decreased significantly over the past month.  He went on holiday to france 6 months ago.

He lives with his wife and has two teenage children.

On examination he has an easily palpable spleen, approximately 10cm below the costal margin.  There is no hepatomegaly.  You do not note any palpable lymphadenopathy.

Looking at previous “tweets”  you have decided to send off some blood tests – FBC/U&E/LFT/Ca, autoimmune screen/HIV/HEP/EBV/CMV.  No thrombotic history so hold off on JAK2 for now.

Do you agree?  How quickly do these investigations need to be completed?

Any further investigations?

What are your thoughts on differential now?