Abdominal Pain

SPEAKER_00 0:12

Hello and welcome to the Home of Medicine Podcast, a podcast in association with the Royal College of Physicians Edinburgh. I'm Dr. Amy Burbridge, and I am joined by me.

SPEAKER_03 0:23

Hi, I'm Dr. Ben Lovell. Great to be back.

SPEAKER_00 0:26

Ben, I've got a case for you. So I'm going to just dive straight in. Are you ready?

SPEAKER_03 0:32

Yes, I'm ready.

SPEAKER_00 0:34

Okay. So this is a case that I've seen many times over the course of my medical career. But I'm going to talk to you about one particular case that stays in my mind. But it's a recurrent presentation that I think we all probably see actually in acute medicine. So, or in any medicine to be fair. So I'm going to talk to you about a gentleman who's 52 years old and he came to hospital with abdominal pain.

SPEAKER_02 1:00

Okay.

SPEAKER_00 1:01

He'd had abdominal pain on and off for two weeks, but it was getting progressively worse. The pain is located, he points to sort of epigastric, just well, to be fair, he points to the middle of his stomach. So I often find when people say they've got abdominal pain, when you ask them to point it out, unless it's sort of like left or right up a quadrant, it's just a general, they sort of rub their stomach and sort of rub their abdomen and go, it's all over. So sort of pain was sort of generalized all over the abdomen. It felt a little bit worse in the epigastric region. Um, and actually said that the pain was very typical of his pancreatitis.

SPEAKER_02 1:44

Well, that's useful. Case closed, pancreatitis. Okay, so listen to the patient, they're telling you the diagnosis. He's obviously listened to the podcast.

SPEAKER_00 1:52

So that's the end of the case. Thank you all for listening. Goodbye. Um, no, okay. So we've got a 15 year old man with abdominal pain on a history of pancreatitis. So tell me what's going on in your head.

SPEAKER_03 2:06

Okay, so what we want to be wary of here is premature closure and not saying, Oh, hurrah, we've got a pancreatitis here. Let's go down that pathway. Keep a mind a bit open, we'll do our due diligence and let's take history and examine the patient. So he said, Oh, it feels like a pancreatitis. I'm gonna just file that for now, and then I'm gonna come back to that with gusto in a bit. But right now, I just want to find a bit more about the abdominal pain. So things I'm gonna ask about is um describe the pain for me. Sharp stabbing, colicky makes you roll up in a ball into a fetal position. What kind of pain?

SPEAKER_00 2:38

Okay, so um he well, he's first of all, uh as I said again, he said the pain is very typical of his pancreatitis, it's been there on and off for two weeks. Yeah, although he does say that now it's getting better. So he's heading for two weeks, but it's getting better since it was over the last sort of couple of weeks. He says that the pain is very sharp in nature. Yeah, it feels like somebody's stabbing him in his abdomen or his stomach, tummy. Does it go anywhere else? No, not really. No, sort of well, it's just generalized abdominal pain. It doesn't point for one particular area, slightly worse in the apigastric region. Yeah, eating makes the pain worse. Yeah, he has not been eating because of the pain and is now only sipping water. He's not vomiting, he's not experienced dyspepsia. Although sometimes he dry heaves, but there's nothing to bring up because he's not really been eating.

SPEAKER_03 3:49

Okay, so it's um epigastric area is the worst. It's stabbing, um, and it's worse on eating, so we're avoiding food and it's just sipping fluids. He's not vomited, okay. You don't have to vomit. They usually do vomit with pancreatitis, but that's okay. Um, and just thinking about what else it could be is he got a peptic ulcer disease? But you told me there's no history of gourd, and he's not someone who takes a lot of NSAIDs or aspirin. Um, and maybe we'll talk about alcohol intake, anything there? Okay, that might come out of the pancreatitis conversation, maybe. Okay, um, all right. And is his bowels opening okay?

SPEAKER_00 4:25

So he's passing urine and flatus, and he's burping a lot. He's had no diarrhea, but he's not, he cannot remember the last time he properly opened his bowels for a good motion.

SPEAKER_03 4:40

And is that normal for you, sir, when you have your flare-up of pancreatitis or your bowels stop working like that?

SPEAKER_00 4:45

No, not really, actually. It was quite weird. I feel constipated.

SPEAKER_03 4:48

He said that's a little ping for me. And what I mean there is we just want to make sure nothing's obstructed. So when people have nasty stomach pain that makes them vomit or feel like they can't eat, um, before we uh make our diagnosis, you want to make sure nothing's there's not a plumbing issue and something isn't blocked off, twisted, obstructed, perforated, or otherwise stenos or strictured. Um, so if he's not making any kind of um he's passing flace, they but he's kind of the last minute of bound movement. Number one, is severe constipation a causative um problem to this whole presentation? And that's why he's getting these terrible pains and can't keep any food down, or is a constipation a secondary problem? And are we sure he hasn't got some kind of intra-abdominal pathology which is obstructing his GI system? So I'd be interested in things like abdominal distension, any new masses? Is his stomach bloated because he can't empty his stomach? Um and anything else? And then I'll have a good feel of his tummy a bit later.

SPEAKER_00 5:44

But anything from that point of view that might be obstructing him, any new masses or swellings or he didn't comment on any masses, his stomach felt bloated, and he says that when he presses on his own stomach, because he thought if he pressed on it, he might get him to poo. It almost brought him to tears with the pain. And actually, he said that sometimes when he takes deep breaths, in fact, it's getting more difficult because of the pain.

SPEAKER_03 6:11

That's a little bit alarming, isn't it? Um, I'm not well, I I don't get alarmed. That's a little bit, let's say a little bit intriguing. Um it does make me think about do we have to do some cross-sectional imaging of his abdomen just to make sure there's nothing obstructive going on. Um, all right then.

SPEAKER_00 6:27

So can I just stop you there, Ben?

SPEAKER_03 6:28

Yeah.

SPEAKER_00 6:29

What in that sentence that I just told you about him made you think of obstruction?

SPEAKER_03 6:36

When you first said he can't remember the last minute bowel movement, that's atypical, I would say, for the general population. Okay. We keep a diary of our bowel movements. So we someone said, What was your last one? We could usually make a punt, couldn't we? The average person on the street. And then when you say that his abdomen feels bloated, and when he presses on his bloated abdomen, it causes severe pain. That makes me worry about gastric outlet obstruction. And is his stomach completely swollen and distended with gastric fluid? It'd be surprised that he hasn't vomited because that's got to go somewhere, or that that gastric lake, as they call it on OGD, that has to go somewhere. So if he's not been vomiting, that's unusual. But just makes me wondered if something has blocked.

unknown 7:15

Yeah.

SPEAKER_03 7:16

And his belching, you mentioned belching and burping, can't keep solids down. And maybe he'll start vomiting tomorrow or something. But that's what made me think about obstruction.

SPEAKER_00 7:26

Okay, okay, yeah, absolutely. So to be fair, obstruction was also what was going on in my head. Well, that's the sort of thing I was thinking of. Um, he wasn't aware of any fever, but felt very sweaty and clammy. He wasn't sleeping very well because of the pain, didn't have any dizziness. Now, of interest, he said around two weeks prior to this admission, he thinks he bumped himself and he was playing with his children. He denies any fall, injury, or trauma, but he thinks that some when he he bumps his abdomen. And he's really keeps coming back to this event where he bumped his abdomen and he cannot remember exactly what happened, but he thinks the pain started after this.

SPEAKER_03 8:15

So it makes you wonder what's he trying to tell us there, like almost subconsciously or consciously. He's trying to make some kind of point there, isn't he? Yeah. That there is a correlation, a time correlation between that incident. Um, all right then. I mean, this is uh he I do often say to patients, what do you think happened then? What do you think is going on? But it sounds like he already answered that question without being prompted. He said, I think I've got pancreatitis. Or did he have another theory that maybe needed us to draw out a little bit and just say, what do you think is going on with that bump he had to the stomach and now all these symptoms? Anything at all? Just help to give me a steer.

SPEAKER_00 8:50

So he then said to me, I stopped drinking alcohol two weeks ago. And I feel that the pain came on then. And the reason I stopped drinking was because I had a fall, and I think I fell or bumped my abdomen because I was drinking a lot of alcohol, and I've had a problem with alcohol in the past.

SPEAKER_03 9:14

Okay, all right. I think that opens up the door nicely to the next stage of past medical history. And at this point, I would be intrigued to find out about the pancreatitis. So am I right in in drawing a line between the alcohol use and the pancreatitis before? Is it alcohol-induced pancreatitis he's had? Okay.

SPEAKER_00 9:32

Absolutely.

SPEAKER_03 9:33

What sort of time period are we talking?

SPEAKER_00 9:35

Four to five years. He's had a diagnosis and recurrent admissions with chronic pancreatitis, secondary to alcohol intake. He's also known to be a cocaine user. And has a background of anxiety and depression, although he denies any recent cocaine use. And by recent months, I meant.

SPEAKER_03 10:02

Okay. And he stopped drinking cold turkey two weeks ago.

SPEAKER_00 10:06

Absolutely.

SPEAKER_03 10:07

Did he go through withdrawals or not?

SPEAKER_00 10:09

He said he's done it so many times that he he just gets on with it. He knows when he needs to stop drinking, he stops drinking, manages the symptoms of it, and gets on.

SPEAKER_03 10:22

Well, well done for that, I'd say. Um, not easy to stop. Uh not everybody gets severe withdrawals when they stop alcohol. I think only maybe something like a third of people who take alcohol daily actually experience withdrawals. So not every you don't have to go through withdrawal when you stop drinking. Um and has he ever been diagnosed with any kind of chronic liver disease uh in the context of alcoholes? Okay.

SPEAKER_00 10:42

No.

SPEAKER_03 10:43

And the medications, what's he taking? Yes, because he has extracryon pancreatic insufficiency due to the recurrent pancreatitis. Okay.

SPEAKER_00 10:53

And a metrazole.

SPEAKER_03 10:55

Okay.

SPEAKER_00 10:56

That was it, nothing else.

SPEAKER_03 10:59

All right, and no allergies, I assume.

SPEAKER_00 11:02

He's allergic to penicillin.

SPEAKER_03 11:03

Oh, I assume wrong. You know what they say when you assume, yeah, yeah.

SPEAKER_00 11:08

What made you assume that, Ben? What was going through your head when you just went, I assume there's no allergies? Like I don't know.

SPEAKER_03 11:16

Maybe a desire to continue.

SPEAKER_00 11:18

I don't know. But isn't that interesting? Do you find it double checked it? Do you find sometimes that you bel when you you know maybe you are maybe at the end of a day or it's been really busy, and you go, So I assume no, you haven't got any allergies? And you use negative questions instead of open questions. Yeah, so you say no chest pain, and I'll be like, Oh no, but actually they have.

SPEAKER_03 11:41

And you do you see what I mean when we use those negative questions, no chest pain, no shortness of breath, instead of saying I think I think that's okay sometimes if you're if you're using it uh in a conversation, um, you know, because you're saying in the in you're not saying out loud, but you're sort of intimating, correct me if I'm wrong, but no allergies. Um, obviously, one shouldn't take one's uh complete medical history like that. I'd say you've got none of these, I assume, because you are going to run into difficulties. But I suppose if you're if you're doing it collaboratively with the patient and they feel able to interject you, you're not saying in such a forceful way, they've everything, God, he's saying all the wrong things here, but he sounds so busy and angry and important. I'd better not interrupt this doctor. So maybe that's something to do with bedside maneuver as well.

SPEAKER_00 12:30

Potentially, and I have to say, it's something that if I observe a trainee or a student doing, I'm like, no, that makes me feel icky. But then I do it myself with patients. So I wonder whether is that something that we learn to do during our career, or that we feel more comfortable doing in our clinical reason processes as we become more senior, potentially.

SPEAKER_03 12:53

Definitely, and there's a whole episode on it in isolation to do about that. Things we don't tolerate in trainees that we do all the time ourselves, does that make us hypocrites or have we earned the right to bend the rules? You know, like driving with only one hand on the steering wheel or something. You don't tolerate that in a learner drive. Once you pass your tests, people do all sorts of stuff, which I'm not saying is right, but uh, I think that's sort of human nature a little bit. Certainly, when I'm working very quickly on my own, let's say I'm I'm doing um I'm covering on an industrial action day and I'm and I'm acting as you know, the clerking doctor, there'll be things that I do that I allow myself to do because I'm marking my own homework and I know what I mean and I know why I did it. Whereas if um, let's say uh a registrar presented that work to me, I'd say, I don't love that you cut a few corners here, it seems to me. Well, I didn't cut the corners really, I left that on purpose. But it looks, it looks medical-leagueally in this note like you cut corners. So there is a little bit of hypocrisy there. We do tolerate things in ourselves that maybe we want to get we we want our trainees to get it right before they start finding their own way through through life and their career. But you want we want them to meet the the the agreed standard of work before they start deviating, and I think that that deviation often occurs at or we allow it to occur at CCT. Once you're a consultant, you you you can do your own thing then. But until then, I would like you to do things the agreed way, keeping all the simple things done well and the basics, because uh that's that's training. Do you know what I mean?

SPEAKER_00 14:21

So I do. I'm just gonna challenge the what do you mean by agreed way? Who agrees it? Like, what is the agreed way?

SPEAKER_03 14:30

I suppose part of that is received wisdom of the ages, such as this is how we've always done it and this is how we should do it, because this works and has is tried and tested for many years. For example, if someone started muddling up the order of of a history, for example, started giving me social history before they gave me past medical history. I might think if a consultant, if I did it, I might think, but I know why I did that, I had a reason, and and this is the butt but if it if a trainee did it, I said you've got things back to front there, and that's not the agreed way we do things. And I don't think you're at the stage in your career where you can start flying solo and changing things up like that. Because I want to make sure we don't miss things, I want to make sure you don't miss things. I want to make sure you get things right for you and for the patient as well. But this is me just talking off the top of my head. This is just my own meandering uh stream of consciousness.

SPEAKER_00 15:18

So thank you for your stream of consciousness, Ben.

SPEAKER_03 15:21

You're very welcome.

SPEAKER_00 15:22

I think we should any what else do you want to know now? So let's go back to our 52-year-old man with abdominal pain.

SPEAKER_03 15:28

Yeah, okay. So I think I've got a good history there. I was about to do social history, but you told me drinks, but two weeks ago um stopped, occasional cocaine, but not for a very long time. Um, and you've mentioned children. And just who is he as a human being? Just help me see him as a person. What does he do? What's he like? What's what makes him a real person?

SPEAKER_00 15:48

I'm really glad that you asked that because I think when we understand an individual and we're curious about them as a person, as a human, I think it really helps us set the scene. It's almost like telling a story, isn't it? And I believe that what I've started to see is that lack of curiosity and interest, and I started to seep into medical practice. And I wonder whether that's because we're now so time pressured. One of the questions I love asking people, even if they're 96, is what job did you used to do? You know, who do you live with? Or if I see a couple in their 90s and they're married, I'm like, how many years have you been married for? How have you stayed so how have you been married for so long? And you learn so much about people that I think that really helps set the scene and helps sort of tell a story. Because what we're doing when we take in histories is we're identifying their story, aren't we? We're building that narrative within our brain. And I guess what we're doing is building illness scripts, which is one what we want everyone to do. So uh this man um is on his um second marriage, he has children from a previous marriage, and he's been married to his new partner for a few years. He works as a plumber and he's been able to maintain a full-time job as a plumber throughout his issues with alcohol. He's never had a formal detox, but has always done that himself and has been successful. Um, he smoked many years ago, but hasn't smoked, you know, for about four to five years. What's interesting is he describes himself as a clubber. And when he was growing up, he loved clubbing um and still likes to. I guess when I met him, I was really intrigued by he still had that vibe of being in that sort of era of ibha, of clubbing, of pashi, you know, nightclubs and stuff. And I got that from him. It was fun, he was really fun to talk to, really fun to be around.

SPEAKER_03 17:53

Wow. I mean, my clubbing days are well and truly over.

SPEAKER_00 17:57

I don't think I really ever had any.

SPEAKER_03 17:59

I did in my heyday. One day I'll tell you all about it. I used to love love the club. Um, all right then. So I think I've got a good sense of who he is, and just to tag on to what you said before about humanizing people, it it does help us keep them as human beings in our mind. It stops us talking about things like um the abdo pain in bed four.

SPEAKER_00 18:16

Oh, I yeah, yeah.

SPEAKER_03 18:17

But but also it helps me remember them because I'm I work in a specialty where I see a lot of patients in a shift, and at the end of a shift, I think, who on earth was that one? Did I go, oh, that was that woman who used to live in Jersey and has the huge uh German shepherd who knocked her over, then all of a sudden I remember him and I can visualize them very, very clearly.

SPEAKER_00 18:34

Absolutely, yeah. And that's how I remember patience. It's not from the presenting complaint or the CRP, it's often, oh, that was the person who used to play for Wolverhampton Wanderers in the 1960s. And then you link it and you're like, okay, so that was where he came in. And it's yeah, I find that personally which easy way to remember people, and like you say, it humanizes them, doesn't it?

SPEAKER_03 18:56

It just sits in your brain. Someone says, Oh, you know that patient you saw earlier, the COPD patient. I've seen five COPD patients today, that means nothing to me. And and I'm gonna you're leading me down a dangerous path, but I'm gonna get them mixed up and treat the wrong patient. So so yeah, let's who was that person I saw earlier today? Now I think it's time to examine him, please. Okay. Um, so looking at the end of the bed, how does he how does he look?

SPEAKER_00 19:18

Sweaty. He looks unwell. He was he found it difficult to sit down. And was, you know, when you see a patient and they're like, but they're standing up, sitting down, like quite agitated. And he said that his pain in his tummy was so bad he found it really difficult to sit still. Quite sweaty, as I said. Um he looked to me, to my, I was gonna say untrained eye, but I guess I am trained by now.

SPEAKER_03 19:50

Highly trained, eye.

SPEAKER_00 19:51

Highly trained, hopefully. He looked like he was withdrawing from alcohol. Well, I did wonder, yeah. But he he said he hadn't had a drink for two weeks.

SPEAKER_03 20:02

Okay. What were his vital signs?

SPEAKER_00 20:05

Respiratory rate was 18. Oxygen saturations 99% on room air. Blood pressure 95 over 72.

SPEAKER_03 20:18

Okay, a bit low.

SPEAKER_00 20:19

Pulse 102 beats per minute.

SPEAKER_03 20:22

A bit quick.

SPEAKER_00 20:24

Temperature 37.6 borderline. My mouth is clear.

SPEAKER_03 20:30

Yeah, yeah, yeah.

SPEAKER_00 20:31

Chest was clear.

SPEAKER_03 20:32

Um how did his hands feel? Peripheries sweaty. Cold?

SPEAKER_00 20:38

Not really cold and wasn't shaking, to be honest. You know, you know, sometimes you see people who have delirium tremens who are withdrawing from alcohol, but are quite shaky, but he wasn't shaky, but he was just agitated in how he was walking around. But he said it was because of the pain. And what was very interesting, he hadn't been given any pain relief because substance misuse was doc. Well, I don't know, but substance misuse was documented in his history. And I sometimes feel that that results, and we've talked about this before, in patients not being given adequate access to pain relief because they've had a previous substance misuse or have a substance misuse history.

SPEAKER_03 21:34

But withholding opiates from someone who's in acute pain, I hope everyone listening to this agrees is completely against medical ethics. And we simply cannot do that at all. So hopefully that I hope that wasn't the reason he had his uh painkillers uh withheld.

SPEAKER_00 21:49

No, but I no, and I'm sure it wasn't, but I have certainly, over my many years of practice in very variety of different places, have seen that discussed and mentioned. And alluded to.

SPEAKER_03 22:00

Yeah, so have I. So have I. Yeah. Yeah. Especially when patient is asking for patients asking for oromorph, but has a drug. It's like, well, okay, they're in a lot of pain. I think we're very suspicious when patients know the preparations of drugs. When people say, I need oromorph, please. Then it makes you think, how do you know that name? How do you know that what that drug is? The average person doesn't. And I think people get a bit cynical. All right, so you've got a slightly sweaty, slightly tachycardic, slightly hypotensive man. It doesn't look great. He's not tremulous. He's not distorted or confabulating. He's not in the grips of the DTs. No, and uh he's a bit agitated and can't sit still because of pain. All right, volume, fluid volume status.

SPEAKER_00 22:41

Well, well, he he looked well hydrated to me, to be honest. His mouth was maybe a little bit dry, but I wasn't worried about yeah. His blood pressure was obviously a little bit low, but he didn't look to me like he was extremely dehydrated.

SPEAKER_03 22:55

Right. Can I please um palpate his abdomen? What did you find there?

SPEAKER_00 22:59

He yeah, he doesn't want you to do it though.

SPEAKER_03 23:02

I'm gonna.

SPEAKER_00 23:03

You're gonna do it. Okay. So um yeah, and I did it very tender all over the abdomen, incredibly tender. Um, guarding in the um umbilical region, para-umbalical region. Felt to me, I felt there was guarding in the the um lower quadrant of the abdomen, the right lower quadrant of the abdomen. But um I'm you know, just to be fair, he was in so much discomfort that it was very difficult to palpate his abdomen.

SPEAKER_03 23:33

What I'm thinking now for progress is have we missed an acute abdomen? Um, should he have gone to the CT scan and possibly been discussed with the surgeons rather than coming to me, a bumbling physician? But let's press on. Um, but I'm a bit worried about these abdominal findings now. I'm thinking about perforation, I'm thinking about obstruction.

SPEAKER_01 23:53

Okay.

SPEAKER_03 23:53

Um, all right then. Uh I had a really intelligent thought, but it's gone out of my head, so maybe it wasn't so intelligent. Um, any uh blood test results, please?

SPEAKER_00 24:01

What would you like?

SPEAKER_03 24:03

Um let's start with uh is HB.

SPEAKER_00 24:07

12 120. Sorry.

SPEAKER_03 24:10

Yeah, 12 and old money. And it's 12 and old money.

SPEAKER_00 24:14

104.

SPEAKER_03 24:15

Oh, no. And his Y cell count? 12.2 Okay, and his neutrophils.

SPEAKER_00 24:23

Eight.

SPEAKER_03 24:24

Okay, not much to get too excited about there. Mark um from Besides Penia. Let's go to his usernese, please. So here's sodium.

SPEAKER_00 24:31

136.

SPEAKER_03 24:33

So normal. Uh his potassium.

SPEAKER_00 24:35

5.4 bit up.

SPEAKER_03 24:38

Uh do you do urea?

SPEAKER_00 24:40

We do do urea, yeah. It was 14.

SPEAKER_03 24:41

Yeah. Oh, that's high. Um, and then creat.

SPEAKER_00 24:46

132.

SPEAKER_03 24:48

That's a bit high as well. Now I don't know the gentleman's baseline. You have not suggested that he has any kind of CKD. So I'm going to make an educated assumption that his creatinin should be baseline normal, and this is an AKI with an elevated creatinine in urea. Um maybe he is a bit dry then. Um, and CRP?

SPEAKER_00 25:07

221.

SPEAKER_03 25:09

Nice. Okay. So a big inflammatory response there. Did you do a lactate on a VBG or an ABG?

SPEAKER_00 25:16

We did do a VBG, yeah, and the lactate was 2.2.

SPEAKER_03 25:21

So that's just borderline, isn't it? 2.2 is sort of the upper limit of normal, really. But is the uh altogether it doesn't look so good. So I'm going to summarize. I have a man here with two weeks of pain, abdominal pain, which has been getting worse, associated with valves not open and poor oral intake, with a background of previous flares of alcohol-induced pancreatitis. He has to me signs of an acute abdomen with a very elevated CRP response and a borderline lactate, and possibly an AKI. So my impression is going to be in his writing as I think one query acute abdomen, two, likely AKI, three um background of ETOH induced pancreatitis. Did you get an amylase?

SPEAKER_00 26:20

I did.

SPEAKER_03 26:21

Was it up?

SPEAKER_00 26:23

1084.

SPEAKER_03 26:25

That's pretty diagnostic, actually. In my head, 500 is sort of a this is not evidence-based, but in my own head and my experience, amylase of less than 500 can be a bit sort of nothing, really. But more than that, you are thinking about pancreatitis. So over a thousand. Maybe this little pancreatitis, but I still think it's time to scan him because has he developed severe pancreatitis, which is now necrotizing? Has he developed an abscess or a walled-off area of infection which requires source control, such as a surgical drainage? Um, and what else? Could it have led to obstruction? Um I mean, I I think I think that's enough reasons to get the CT scan. So my planner now is number one, nil by mouth. Number two, CT abdopelvis urgent. Number three, start IV fluids. And because you say clinically he looks sort of euvemic, but there's that AKI is up, and he has not been drinking much. I'm just going to say eight-hour liter um his tartman's to start with, because I'm not resuscitating him from a proof point of view. Now, what am I going to do about antibiotics? Mild tachycardia, 37.6, big CRP. Do you know what? I'm going to do that. Start IV kefyroxin, which is our broad spec antibiotic of choice in my institution for now. Um, revisit after CT scan. Uh, but he's definitely he can have a day, a dose now. Does he trigger for sepsis, as we say? Um, not really. No.

SPEAKER_00 27:56

Um I mean, if you look at his observations, the lactates was it it was 2.2.

SPEAKER_03 28:02

2.2, yeah. It's a soft trigger.

SPEAKER_00 28:05

It is, yeah.

SPEAKER_03 28:06

Um, revisit after CT. Number five, full escalation. That's part of my general bump in everybody's plan. Oh, well, not full escalation, but I have a decision about treatment escalation plans. Full escalation um of treatment and then immediately lapsis. I'm gonna say yes, I think he's more pro-thrombotic. There's the economy evidence he's hemorrhaging. That bump on the stomach is not anticoagulant. He won't have ruptured a spleen or anything there. Everybody had a retroperiteneal bleed with no coagulopathy. Did you have a coag on him?

SPEAKER_00 28:41

Um, yes, we did. Coagulation was normal.

SPEAKER_03 28:43

Normal. His platelets are low, but only 104. Yeah, VTE prophylaxis, please, and that's an oxopar and 40 milligrams.

SPEAKER_00 28:51

Okay.

SPEAKER_03 28:51

And then that's point six, and point seven is let's just do some C UR scoring just to make sure we don't we don't miss anything, but not to give Claudairs a popside for now. Um, good, and then point eight review in two hours with above. There you go. That's my post-tate wardround.

SPEAKER_00 29:12

Okay.

SPEAKER_03 29:13

How did I do?

SPEAKER_00 29:15

That's what it was very, very good, very comprehensive, but there's one thing that you missed off.

SPEAKER_03 29:19

Okay, let me go back and look.

SPEAKER_00 29:22

That you're it's it's probably too obvious that oh PR exam. Oh, well, I mean, every patient should have a PR examination if required. No, what what one medication haven't you given him?

SPEAKER_03 29:40

Oh, you're here we go. Yeah, you're exactly right. Point number nine analgesia.

SPEAKER_00 29:45

Yes.

SPEAKER_03 29:46

Um, can start with one gram paracetamol and um oromorph PRN, that would be 10 milligrams.

SPEAKER_00 29:57

But you said you were gonna you said you were gonna put him nil by mouth.

SPEAKER_03 30:01

You're right, and I think five mils of clear fluids oromorph should be fine. If he was an ex if that didn't work, I'd have no compunctions about offering him some subcutaneous morphine injections as well, um, to get to get him pain-free. So, but I'll start with the basics and then I'll reassess his pain and say, has that kicked in or not?

SPEAKER_00 30:20

So, what about if um one of your differentials was obstruction and perforated viscous? So, if we think he's obstructed or perforated and we give oral medication, will it work?

SPEAKER_03 30:33

But you're asking if if he's gonna absorb anything. Yeah, it's a good point. He hasn't vomited, you said, right?

SPEAKER_00 30:38

No, he said he feels sick, but he hasn't vomited. Dry heat.

SPEAKER_03 30:41

Yeah, yeah, yeah. I still think I would give a trial of oromorph. Paracetamol, we can give IV. It costs about £100, but we can certainly give it IV. And I would try them with oromorph. If you either vomited the oromorph, had no relief from the oromorph, then I would say, let's give you parental painkillers for now. But um, I think if you asked an ED consultant, they probably would go straight in with the injectable morphine route because that's their bread and butter and they're used to it. Whereas on the general medical boards, we're we're that's not our culture so much. We like to start low, go slow. Um, but I wouldn't I wouldn't leave this man not reviewed for a period of time. Um, and uh it would be great if the oromorph did help and we we could avoid giving anything that's uh parental unless we had to, because of course the onset and offset of the parental ones are quite quick. And if someone is reliant on boluses of IV um morphine, for example, to get pain control, they work instantly. But um, experience tells me they tend to wear off all of a sudden, and it takes a heck of a long time to get your next dose because you have to ask for it, the nurse has to prioritize it, then she has to double sign it out, draw it up, bring it over. Um, and they tend to have more pain gaps like in between doses when they're reliant on IV preparations or parental preparations than the oral ones, which have more um subtle onset offset times. So that's just that's one of the factors into why.

SPEAKER_00 32:01

Yeah, and I was about to challenge you actually before you mentioned the pain gap, and I think that's an incredibly good point, actually. Because I I did and tend to go for um intravenous pain relief in these types of patients. So I went straight for IV morphine, but you're absolutely right, actually, is that pain gap can sometimes be quite big and it wears off quite quickly. So that's a really good point, and I'll take that forward actually.

SPEAKER_03 32:26

And I guess And it can be a really bad one as well, because when it when it wears off, it wears off with a thump.

SPEAKER_00 32:32

Yeah. And I guess that we should start to think about patient-controlled analgesia, PCAs, which we don't use enough, I don't think.

SPEAKER_03 32:42

Well, that is partially because it's a big training uh intervention to get everybody ready to look after PCAs. Um, we don't have them in our AMU because it's a big burden on nursing times, and you really need a nurse who's sort of like two to one in a patient to make sure that they can manage the PCA. Whereas, you know, we have five to one nursing ratio like any medical ward. So um, partially it's about making sure doctors are trained up in safe prescription of it, knowing the indications, contraindications, and that's very difficult in um the world of rotational medicine because you're constantly teaching new doctors, which is not their fault, obviously. But also you need a nursing and a pharmacy workforce who are able to meet the demand as well.

SPEAKER_00 33:23

Good point. Okay, so where are we now? What what's what investigation do you want to do? What's your plan?

SPEAKER_03 33:30

I want that CT scan, please.

SPEAKER_00 33:31

Okay, what do you think it's going to show?

SPEAKER_03 33:34

Um let's say I think it might show something like severe um necrotizing pancreatitis with um with impending obstruction of uh part of the duodenum and um and a collection. I don't know. This is all stuff it could that could cause severe pain and abdominal distension.

SPEAKER_00 33:53

Yeah, absolutely. Okay, so I'm gonna tell you what the um what the CT did show.

SPEAKER_03 33:56

Yeah.

SPEAKER_00 33:57

The CT showed perforated appendix.

unknown 34:04

Do you know?

SPEAKER_03 34:04

I wondered about that when you said right lower lower quadrant. And I remember all the way back from medical school, appendicitis starts off with central abdominal pain, which then migrates down to the right lower quadrant. Um when it when the locally because uh it starts essentially because the embryological of the mid-gut at the mid-gut, yeah, and the high gut irradiates to the to the umbilicus, but then as local inflammation becomes very severe, you get local pain in the air of the appendix and the right lower quadrant. So they did flip through my brain. Um and we did miss well, not we, but uh it I use the passive voice. On this uh on this occasion, but thank goodness they um they they met a clinician who was able to make the diagnosis. And I think the antibiotics, therefore, would have been helpful. Yeah, that's really interesting. So, what happened next?

SPEAKER_00 34:57

It is really interesting, isn't it? And what happened next is um I picked up the phone and spoke to my surgical colleagues and said, I have an acute abdomen. Um, are you able to come and review this gentleman's got a perforated viscous, he's got an appendicitis. Which happened. The patient had his um appendectomy, he was fine. What interested me about this case, and I think this is a point for discussion, is that this gentleman, when he came in through the emergency department, had been referred to the surgical team. Oh they didn't see him because it would just be his normal alcohol-related pancreatitis, it must be. So they don't need to see him.

SPEAKER_03 35:41

It's um, I'm always mindful that I don't become overcritical of colleagues without knowing the full story. Because I've learned that lesson to my detriment over the years in my career. I've flown off the handle before and I've fired off emails and all sorts, and then it comes back that actually, Ben, you were not in possession of all the facts and you actually look like a bit of a wolly now. So I try, I try not to. Um, and at the same time, that's a shame that that happened to that man. Um I wonder if this is could this be over-reliance on um is it good old Osler who told you the patient was telling you the diagnosis?

SPEAKER_00 36:20

Yeah, potentially.

SPEAKER_03 36:22

Maybe it maybe it should be listen to the patient, they are trying to tell you the diagnosis, right?

SPEAKER_00 36:28

They are giving you the information that might help you formulate the diagnosis. Yeah, and you're absolutely right. You know, if you've got a patient who comes into hospital and says, I'm in pain, it feels like my pancreatitis. Yeah. At what stage do you go? Oh, okay, we must be pancreatitis, or do you go, oh, let me just ask you a few more questions? Because sometimes I've tried that and the patient's gone, but I'm telling you what it is. I just want some pain relief. And I'm like, okay. So it just helps it just, I guess, makes you think about how how much do we challenge that initial diagnostic um diagnosis from the patient when they're telling us what it is.

SPEAKER_03 37:06

Um premature closure, as I said at the beginning. Where I see this a lot is with chest pain. And it's when someone comes in with chest pain, which is super atypical, it it's on the left, they've got a tender chest wall, their ECG is normal, their troponyms normal, their chest x-ray is normal, everything's fine. You can reproduce the pain and palpation, and they say to you, but this is exactly what happened when I had my massive heart attack in 2024, this exact presentation. And that that means something, I think. Um and sometimes that changes my mind. Sometimes that makes me move from discharge to ambulation or even admit for observation sometimes. And the patient is saying, I'm telling you, it's exactly how it was before. I know it's atypical, but this is typical for my previous heart attack, and I'm terrified I'm having another one. Um, and that that's the context I see in sometimes. You must have seen the same.

SPEAKER_00 38:01

Yeah, and I absolutely chest pain in particular is one where that well, this is the same as my last heart attack. So I must be having a heart attack. And I'll be like, oh, okay, but everything's normal, like everything was normal last time.

SPEAKER_01 38:13

Yeah.

SPEAKER_00 38:13

Okay, so what do I do? Do I what do you do?

SPEAKER_01 38:16

Yeah.

SPEAKER_00 38:16

Yeah, you know, do you and I always I tend to admit because the patient's usually right, yeah, particularly when it's something as serious as this, you know. I'll say, okay, we'll admit, we'll observe you, we'll do ECGs, we'll do another troponin. And sometimes, yes, they absolutely are right. You know, they do have a blocked LAD or a circumflex, and I'm like, oh gosh, they're troponin's.

SPEAKER_03 38:38

Sometimes they're not, though.

SPEAKER_00 38:39

Sometimes they're not. But isn't that thinking?

SPEAKER_03 38:43

I think if it when it's happened more than once, when you have a recurrent attender and they keep getting seen, although there is good evidence that these recurrent attenders do come to harm at the end of the day because that things get missed. But I I certainly have said to patients before, I hear what you're saying. This feels exactly like the pain you had with your heart attack. I think it's very reasonable that your body, the body keeps the score, your body remembers that pain and and is being reproduced this time. So it's very natural you think that. And that's why I've been so careful today, and I've done all these extra tests. I'm so reassured by the tests. Whilst I know you're having pain in keeping with the same kind of pain you had with your heart attack, you are not currently having a heart attack. And I really hope that reassures you a little bit. And I have done that before and discharged patients or at least ambulated them, i.e., sent them home and booked them into a follow-up appointment in ambulatory care in Estec um a day or so later, and given them the emergency number and all of this sort of thing, taking it my head off. Um, but that that's I think that's brave, and I'm not always in a brave mood, and I don't expect um the resident doctors I'm training to be that brave and to know how to make that decision. Um, and that's why I always say when I'm on postatement, I will never tell you off for admitting a patient because obviously you thought that was safe because they often they they present patients pre-phase with oh, this was a really soft admission, I'm really sorry about this one. So you never have to say that. Please don't say that. So now now I'm now I'm only thinking this is gonna be nothing. You've you've influenced me. Let's just keep let's let's just be, you know, robots and present the uh the case and I'll meet reach some conclusions and ask some questions at the end. But I'll never give you a hard time.

SPEAKER_00 40:23

What you uh alluded to there was that Daniel Kahneman labelled it as noise. Um the noise in the decision-making process that we often it's around us, but we don't really know what it is. So, for example, it's a Friday afternoon, or it's a Sunday morning at four o'clock, or it's really noisy, or I'm really hungry, or really tired. And we've talked about this before, actually, where our own inner mood, feelings really affects how we make decisions.

SPEAKER_03 40:56

Yeah, of course. Otherwise, we wouldn't be human beings.

SPEAKER_00 41:00

Exactly. So I've been in situations where I have seen trainee doctors, locally employed doctors, being sort of, I guess, not pulled apart, but really questions as to why they did this, why they did that, in a way that makes me feel uncomfortable. And I'm like, let's just take this back a bit. This was three o'clock in the morning. They were exhausted, nobody wants to be awake at three o'clock in the morning, our cortisol levels are really low. I don't think we should ever criticize people who practicing in a way that they think they're doing the right thing at the right time, they're not deliberately making bad decisions or doing things that are incorrect.

SPEAKER_03 41:42

Yeah, no, I completely agree. Um, and if we are giving residents a hard time, I don't I don't want to be all touchy-feely about it and saying we can only ever give give positive feedback and shower them with praise, because I don't think I don't think that's respected amongst trainees. I think trainees, you know, they're they they want to hear what they could do better next time.

SPEAKER_00 42:03

Yeah, absolutely.

SPEAKER_03 42:04

And and I think the people they respect, the people I respected when I was learning are people who would give it to me kind of straight but kindly, um, and say things like, Look, I appreciate your your reflecting, Ben, that things didn't go the way you would have liked in this case. Let's work out what you're gonna do next time to make it go the way you want.

SPEAKER_01 42:21

Yeah.

SPEAKER_03 42:21

And I think that is welcomed by most people, but maybe trainers, we're not so great at saying it. And as for the handover viber in front of a room full of people, that should have gone out with the arc. And what's interesting to Lee is that the GMC survey every year, which is an incredible in one of my roles as the deputy uh director for education in my trust, and GMC is a massively powerful tool that gets analyzed to death, both external to the trust and within the trust itself, gets sliced and diced and looked down at every answer of two decimal points and really analyzed, and we have to make answers for every bit. One of the questions they ask is, handover, do you find handover to be an educational experience in your trust? And I've always puzzled over that because what does an educational handover look like? If someone's coming off the dregs of a night shift and all they want to do for home, and I launch into a mini sort of seminar, they're gonna want me to die. I would have done. But and and again, if you if you ask a few sort of educational Socratic questions, you know, again, people are gonna say, I'm I can't, I'm exhausted.

SPEAKER_00 43:25

Yeah, exactly.

SPEAKER_03 43:27

So I I still haven't quite cracked that. So if anybody knows what an educational handover looks like that people actually like, please write your answers on a postcard and send them in because I'm still trying to crack that particular nut after 20 years in medical education.

SPEAKER_00 43:39

Yeah, and I've I've been asked on many times to try and make handovers educational, and I've tried lots of different ways of doing it. You know, here's a session on I don't know, DKA, and these people just want to go home.

SPEAKER_03 43:52

Yeah, maybe just message of the day or something.

SPEAKER_00 43:55

Yeah, one thing. What's the one thing that I want you to take away today? Is I don't know, neutrophils is spelt NEU to you know, there's something really simple.

SPEAKER_02 44:04

Oh, you're absolutely keeping it loaded. I'm keeping it really simple, yeah.

SPEAKER_00 44:08

But you know, I can't take anything on after 13 hours at work, let alone a physiological concept. So why do we expect our trainees to take that on? I think handovers are for safety of the patient, safety of the doctor to make sure that they are okay before they go home and they're not being harmed physically or mentally by what's been happening. But I think trying to force, enforce education in a way that it's not a natural educational environment. I learn from handovers just by listening to what people are saying rather than saying, list five causes of fever, which is just never gonna No, no, no, no, no.

SPEAKER_03 44:51

And I I remember that. One of the only times I ever, ever cried at medical school was a handover like that. Right. Name three causes of acute renal failure after a after hip replacement surgery in front of a room full of people, and I completely choked. I had nothing to say. And the things he said to me, Are you sure you're a medical student? Do you really think you belong here? All that kind of stuff. And it's the only time I went into a toilet cubicle and had a cry. Never again. But um, I have very strong feelings about that.

SPEAKER_00 45:21

Yeah, and it's it's just not the way that well, it's not teaching, is it? That that's just humiliation.

SPEAKER_02 45:26

I was humiliated, yeah.

SPEAKER_00 45:27

Yeah, exactly. Yeah, thank you very much, Ben. Loads of learning points there. So maybe in the handover, this our podcast should just be in the background. So it's like you could you could learn by osmosis.

SPEAKER_03 45:39

Mood music.

SPEAKER_00 45:40

Mood music.

SPEAKER_03 45:41

Shut those bloody idiots that buddy's fucking hand over and go home. Yeah.

SPEAKER_00 45:46

Right. So again, Ben, thank you as ever for your fantastic insights into the world of acute medicine. Thank you very much to everybody who's listening. Please rate, review, and subscribe to the podcast. We are doing so well with our numbers and downloads. Like it's just crazy how impactful the podcast is. So we just want to keep growing and growing and growing it, just so as more and more people can learn something or take one little nugget away from this podcast. A massive thank you to everybody who supports us, and a huge, huge thank you to the Royal College of Physicians, Edinburgh. Thanks for listening. Goodbye.

SPEAKER_02 46:21

Take care.