Another UTI?

SPEAKER_03 0:12

Hello and welcome to the Home of Medicine Podcast, a podcast in association with the Royal College of Physicians, Edinburgh. I'm your host, I'm Dr. Amy Burgeridge.

SPEAKER_00 0:23

And I'm your other host, I'm Dr. Ben Lovell. And I just wanted to say before we dive into our case for today, welcome, welcome, welcome to anyone who's listening for the first time. And if you're wondering what you've stumbled across, this podcast, Home of Medicine, is a podcast that is completely unscripted. And when we turn up to record, neither of us have any idea what the other person's going to do or say. And what we do is one of us brings a case, one case per episode, and we present it bit by bit. And the listener and you at home work through the case as we're presenting it and you try and work through the diagnosis as we do in real time. And the purpose of this is we really wanted to show how consultants think. Because particularly when you're training in medicine, sometimes consultants come out with plans and ideas, and you think, how did they get from A to B? And we wanted to make those thought processes explicit. We wanted to talk about clinical reasoning, we want to talk about diagnostic uncertainty and just how we navigate those pathways and come to the ideas and the conclusions that we do. And as you will learn, how consultants sometimes get it wrong. So we're not holding ourselves up examples saying you should be like us. We just want to show you this is how people who've got 20 years of practicing medicine under their belt work through clinical cases and patient care to the end result. And we hope you enjoy listening along and trying to guess the diagnosis with us. And on that note, it is your turn, I think, to present a case to me.

SPEAKER_03 1:49

Absolutely. So um this is a I found this a really um interesting case. It's a case that I've seen within the last year. So it's quite fresh in my mind still because to be honest, I'm still working through the process of what happened. So I saw a 64-year-old female, she came to hospital via the emergency department with confusion. Now I know that confusion, we've discussed it a lot, and it's a very common presentation in hospital. Now I took a history from her and her husband. Her husband was sitting there, and initially I didn't think she was confused actually, um, when I saw her, although the emergency department initially said that she was. When on further questioning, she said that she was very tired and she'd been tired for around 24 hours prior to admission, but she said she had no other symptoms at all. And I asked every single symptom and she denied it. However, after she'd been in the hospital for about 12 hours, she had urinary retention, she had a distended bladder, it had over a thousand mils of urine in the bladder. She was treated with antibiotics because it was felt that actually the confusion was because of a urinary retract infection, she'd gone into urinary retention, and she was also constipated. So the initial working diagnosis was urinary retract infection, constipation, and the management is going to be antibiotics and laxotips. I'm going to stop there.

SPEAKER_00 3:43

Not that it helps me think about 64-year-old with confusion. We talked a little bit on a recent um episode about delirium and uh UTI delirium, which is an incredibly common phenomenon within acute medicine, either as a correct diagnosis or as a kind of a um diagnosis because we can't think of anything else. So let's call it a UTI and confusion and treat based on that. And we talked a little bit about um the knee-jerk reaction to prescribe uh a bit of nitrofurantone or some trimethoprin for for confusion in older adults because why not? It might do good and it won't do harm. And we both expressed a little bit of unease with that approach because it means there's a heck of a lot of antibiotics flowing out there in the acute medicine world, which maybe aren't needed. And one thing I remember saying was, how old do you have to be to have a UTI with delirium? And there absolutely isn't a cutoff age. To get delirious with infection, you just have to have a vulnerable brain. So um, someone who maybe has had a previous cerebral insult, like a stroke, or they might have a mild form of dementia or early memory loss, which could then turn into um a dementia process. And all of that being said, 64 to me is quite young. And you can get delirious with a U-ti at 64, but usually in the context of someone who has other illnesses, and it doesn't take much of an acute insult to develop into a delirium. Um, so that's my thought. And I just thought that down when I was writing down her age. Um, I'm not quite sure about the antibiotics in this one because you've said she's gone into urinary retention, and then you told me a good reason why she's constipated. And constipation is a really common cause of urinary retention in older adults because of the pressure from um if you have uh fecal loading in the rectum, can squeeze the outlets of the bladder and the urethra, and then they can't pass urine. And and usually catheter, a bit of fecal disimpaction, um, with laxatives and maybe something PR, and then once they've had a good bowel movement, you can take that catheter out again. So I'm quite intrigued why antibiotics were gone for, you know, why people thought, oh, this is a UTI. Um, because UTI can cause um urinary retention as well. You get inflammation in the urethra, it closes up, they can't pass urine. But you you seem to have a really good explanation for the urinary tension. And urinary retention is a cause of delirium. So within that sort of self-contained, sort of very, very limited history, is this someone who got severely constipated? And the constipation plus the urinary retention due to the constipation caused uh an acute episode of confusion, and all they needed is some disimpaction, getting their bowels going, getting the bladder emptied, and things would sort of melt away and they go back to baseline again. But I'm wondering if you had some other really good evidence for infections such as a fever, dysuria, and elevated inflammatory markers or anything like that. That's my initial reaction.

SPEAKER_03 6:40

Yeah, yeah, absolutely. And to be fair, that is exactly my sort of thought process as well. Now, as I say, I was talking to her and her husband, and it was quite a different it wasn't, and I don't like to say difficult to take the history. Um, there was a lot of talking from both, which is fantastic. But it's sometimes therefore you really have to really focus in on what is being said and truly listen, which can sometimes be challenging in a very busy, very loud acute medical unit. There is always noise. As I said this before, whenever I'm with a patient, the hoover's going, or that you know, the cleaner that cleans the floors, um, like that big machine. Uh there's beats going off, there's phones going off, there's shouting. And I don't know whether it's the older I get, but I'm having to really try and close out that external noise. But it's it's really made me think trying to make these decisions when it's so loud be really challenging. So it was very loud, but I asked the questions again and I identified, and she said that she'd been lethargic, and actually, she wasn't able to move her legs. She said that her legs felt very, very weak, and there was a lot of pain in them. And this pain in her legs had been building up for two to three weeks, which wasn't really responding to any pain relief. The pain was located around her calves, her ankles, and her knees. And as I said, she couldn't really lift them. She also, on further questioning, said that she had some pain in her lower abdomen and her back, and it was the lower back as well. It was like the sacral iliac region. She did say that she was constipated and hadn't really had a good handle of her bowels for around 12 months. So this constipation had been on and off for around 12 months. She also said that she was sleeping all the time. She was finding it easy to get to sleep, and she was able to sleep. She might wake a couple of times in the night to go to the toilet, but apart from that, she was sleeping well. She wasn't eating as much, and she'd noticed a little bit of weight loss. But the thing that I noticed when I was talking to her, she was anxious, really anxious, and was the anxiety because of being in the hospital and the noise, because I have to say, sometimes I feel the noise can really affect me. Um and her husband also said that actually she she was very anxious, and there was they were really worried about the anxiety. And on further questioning, she said that around a year ago she started to believe that there were two men on the internet who were trying to take her house, her sister's house, and her family's house. She was started on Respiridone, she'd been seen by the crisis team, and it was felt that these were delusions. She truly believed that there were two men on the internet, and I asked her to describe them, but she couldn't really describe them very well for me. She said there was a big man and a smaller man, and they were talking to her all the time. And her husband said to me, Oh, they've all gone there, that's all sorted. And I said to her, What when was the last time these men spoke to you? She said, Oh, this week they're still talking to me. And I was like, Okay, so now we've got a patient who has constipated leg weakness, but now there's this additional symptom of two men talking to her on the internet. Now, I find this difficult because actually there are a lot of people out there, a lot of on the internet, who may actually have been doing this. So, how do we know whether this is real or not real? And I was so at this point, I was like, I have no idea what's going on.

SPEAKER_00 11:00

Um, you took a you were a little bit more interest than I would have done about this. Describe these two men after being I would have um I've gone in that much detail. Oh gosh, I've written down so much stuff. Um at the moment, a unifying, satisfactory single diagnosis is eluding me. I'm going to discompartmentalize it into Bs. Okay. And um, number one, you say leg weakness. For how long did you say sorry?

SPEAKER_03 11:28

Two to three weeks.

SPEAKER_00 11:30

Okay. Leg weakness plus urinary retention that localizes to the cord. Um, has she got cord compression? Has she got cordialquina syndrome? Okay. Um, she's got sphincter dysfunction and leg pain and weakness. So do we need to think about cord imaging?

SPEAKER_02 11:45

Yeah.

SPEAKER_00 11:46

That's thought number one. Thought number two potentially a cord lesion on the background of not eating or drinking very much and losing weight? Is this a new cancer, which uh somewhere, a metastatic malignant process, potentially with spinal mets, which is causing cord compression? That sort of ties those two things together. Um, so I need to do a really thorough neuroexam of the lower limbs to see whether this can rules in or rules out my idea that she could have cordialquina, um, which has led to the urinary retention and to the leg payment to the leg weakness. Um not eating, losing weight, anxious, sleepy all the time. Well, somnolens is a side effect of respiridone, but she's been on that for a year and she's been feeling tired for 24 hours. So unless she cranked up the dose or took a bit too much of it in the last 24 hours, we can't blame the sleepiness on the respiridone. Again, we could blame it on some kind of malignant process, parineoplastic process.

SPEAKER_02 12:47

Yeah.

SPEAKER_00 12:48

Um so that goes over there. And then metabolic stuff. I think we probably need some bloods. Are we interested in calcium levels? If I'm thinking about bony destruction, bony mets, um, cancers. I ought to do with thyroid function. Um, if she was profoundly hypothyroid, I mean that could cause confusion, it could cause the slot somnolence. Um, however, she should really be losing weight. Um, so it doesn't quite go, but I definitely need to get some thyroid function tests here. So my plan at this point would be a really good neuroexam, um, looking at the lower limbs, particularly, and getting some blood tests, looking at um her metabolic function and endocrine function, see if she's anemic, um, any other signs of of a sort of smoldering malignancy which might uh raise a flag for further investigations.

SPEAKER_03 13:39

Okay, excellent. So I will talk you through those then. So um just before we move on to that, her past medical history, I forgot to mention, is hypertension, hypothyroidism.

SPEAKER_02 13:52

Ooh.

SPEAKER_03 13:53

Um, and she'd had in her teens, she'd had quite significant mental health problems um and had been diagnosed with depression and anxiety.

SPEAKER_02 14:05

Okay.

SPEAKER_03 14:06

Um, as well as the episode a year ago where she'd been under the crisis team with her delusions.

SPEAKER_02 14:11

Yeah.

SPEAKER_03 14:13

So on examination, her respiratory rate was 16, oxygen saturations 99% on air, blood pressure 152 over 73, pulse 64 beats per minute and regular, temperature 36.5.

SPEAKER_02 14:31

Okay.

SPEAKER_03 14:32

On examination, her heart sounds are normal, chest was clear, abdomen was soft with some tenderness in the supra pubic region. So neurological system. First of all, I looked at the upper limbs, and the power in the upper limbs was five out of five. It did feel, however, that the tone was increased in her upper limbs, which was a bit unusual, but I don't know whether that was just me. And I also noticed a bilateral fine tremor in both hands. The reflexes are present and they were normal. Now, when we went into the lower limbs, I found this quite difficult to assess primarily because she was unable to do much because she said that pain was so bad in her legs, and she said she couldn't lift either leg. So I tried to lift the legs, but there were she was unable to keep them up within the air. Um, so not a great examination from my perspective. Tone was normal, sensation was intact in the lower limbs. So I was normal, you said home was normal, absolutely. Cranial nerves were normal. Completely normal. At the time I saw her, she wasn't confused and her GCS was 15 over 15. I was unable to assess her gait because she couldn't leave her legs. Um she also I also noticed two bed sores as well on on her bottom of her back and a bottom, which to me would indicate that she'd probably been in bed for longer than 24, 36 hours. Absolutely. So I have to say, the neurological examination didn't yield much for me, apart from the upper limb was normal and the lower limb. As a combination of pain and possibly weakness, there was bilateral weakness at that point. She was very emotionally labile. She was crying and anxious, then all of a sudden was very calm and settled.

SPEAKER_00 16:41

So did you say her lower limb examination the power was?

SPEAKER_03 16:46

I would probably put it at three out of five.

SPEAKER_00 16:53

You did have like okay, fine, fine, fine. And any okay, you said maybe slightly increased tone in the arms. I'm just thinking, are we got upper motor or lower motor signs here? Reflexes and plantars?

SPEAKER_03 17:05

Plantars were normal and reflexes were normal.

SPEAKER_00 17:08

Okay. And tone was might be maybe a bit up with a tremor in the upper limbs, but was normal in the lower limbs, but the lower limbs had had weakness, which sounds like a lower motor um problem. Well, of course, cord requiring it does give you lower motor symptoms. I I'm still thinking about an MRI of the cord at this point because this is one with unexplained um um unexplained weakness in the legs with with with sphincter dysfunction. So um I I think I still am going to do an MRI imaging of of the spine at this point, lumbosecular spine. Um, anything else that's going on? Has she taken too much respiridone? Well, she could have more than the ligand syndrome, but she ain't febrile. Her tone is a bit of crease, but she's not got super high tone. A CK might be useful here. Yeah. But it would it would cause the tremor. Um, so um I would just make sure she's not accidentally overdosed on the or intentionally overdosed on the respiridone. Um, is she taking any other psychoactive medications?

SPEAKER_03 18:09

Her medications at the moment are so levithymoxy, amlodipine, metazapine.

SPEAKER_00 18:15

Oh, okay.

SPEAKER_03 18:16

So a torvostatin, um, levaturacetam, paracetamol, nortriptaline.

SPEAKER_00 18:24

So there's quite a few sedating drugs actually. Metazepine is very sedating. That's we actually give it to people with depression with insomnia at night time to help them sleep. Um, nortriptyline, absolutely, and what was the other one you said? Oh, Kepra, levituractam. So all of those taken in excess. Yeah, that that that'll be interesting, actually. Is this actually a case of toxicity? So I would want to know how she knew she was taking her medications appropriately because that would cause a few things. The anticholinergic effect of the metasepine and the nortriptaline could put her into urinary retention. So that might work with that as well. So I want to make sure she hasn't accidentally or intentionally taken too many tablets. Um, and I did have another really oh, we've already mentioned thyroid that we're going to check as well, and her blood tests you're gonna tell me in a minute. Um and that's where I'm sitting at the moment.

SPEAKER_03 19:14

Okay. Do you know what I did? That would be good if you did.

SPEAKER_00 19:19

End of case.

SPEAKER_03 19:22

Problem solved. No, I um saw the increased tone of rigidity in the hands, and I said, Has your writing got smaller?

SPEAKER_00 19:32

Oh, oh, okay, okay.

SPEAKER_03 19:34

Um, and it was that classic case of trying to make a diagnosis fit the signs. And I was like, Oh, she must have Parkinson's disease. Oh my word. I'm great. I've diagnosed it. Well, I you uh needless to say, she probably doesn't, but um, that was in the moment when I examined her hands and her and noticed that rigidity. I was like, this is cockwell rigidity, this must be Parkinson's.

SPEAKER_00 20:00

And of course she's on Resperidone, which is an atypical antipsychotic, and that would it like Parkinsonism. Okay.

SPEAKER_03 20:06

Exactly. So that was where my mind went. Um, and as sometimes you get, you know, when you think of a diagnosis and you think, oh, that's a good one. And then you sort of stop thinking about other diagnoses, um, which is what we call premature closure. Um, when we take histogas and examine patients. But so that was in my thought process, and I'm not saying that that's the only diagnosis that I came up with, but that's certainly the route that I took. So you wanted some blood tests. So her white cell count was 16.6, neutrophils of 13, sodium 140, urea six, correctinine 60, CRP less than 4.

SPEAKER_00 20:47

Or normal, okay.

SPEAKER_03 20:49

Yeah.

SPEAKER_00 20:50

Any uh bone profile or thyroid function at this point or not yet?

SPEAKER_03 20:53

Not done yet.

SPEAKER_00 20:55

Okay. No.

SPEAKER_03 20:56

But her platelet count was slightly elevated, actually, at 564. But apart from that, everything was normal.

SPEAKER_00 21:04

Okay. Um, the only other thing uh when you said, I forgot it to say at the time, I remember now that when you said emotional ability, you see that with neuron disease, and she's got a mix of upper and the uh neurology symptoms. Uh that's the other thing. I just have a vivid memory of when I was a first-year medical student uh in uh Newcastle. And they in between lectures, they brought a patient in um to take a history so to talk about a disease, and it was a man with motor neuron disease, and um he was in cr I remember he just cried and then he laughed and cried and laughed during the consultation. We all were all, you know, 18, 19 year olds, we hadn't seen any medicine yet. We all found it very shocking. And I remember when he left the room, the lecturer saying, Um, you notice the emotional ability, it is a hallmark ability, and that stuck with me for 25 years. Anyway, just a thought. So, what are we gonna do now then? I still well I still probably would think about chord imaging here um and a new quality review. And I really want to nail down is she taking her tablets as prescribed? Is there a DOSID box I can interrogate or anything like that?

SPEAKER_03 22:08

Good thought. I didn't ask about a DOSID box, actually. The family's their husband said that she was taking a medication, but you know, whether that was the case or not, whether the patient was actually taking them is another question. It's very difficult, isn't it, to really know about compliance. But yeah, good thought. So you need to tell me what your next step is. You said you want to do an MRI.

SPEAKER_00 22:35

I would. I would, based on that information, if she's telling me that her legs are weak, they look weak on exam, and she's retaining your I'm gonna I want to see what's going on with her cordial quina. Um I'd do that first and I'd admit her for that test and also for observation and probably a neurology review as well. If that MRI came back normal, um I probably would start thinking about should I should I look for cancer here? Do I need to do a CT abdopelvis as a sort of a cancer hunt, as a malignancy screen and see whether there's a malignant process going on here, as well as get the LFT's bone profile and thyroid to function at the same time. And if that revealed no results either, then only at this point would I probably start thinking about getting um uh asking our mental health liaison team, our liaison psychiatry team, to offer to say whether this is something that could all be underneath the structure of some kind of depressive um episode with delusions, which she has got a history for. But I don't really want to call them yet until I've I've worked her up from an organic point of view.

SPEAKER_03 23:39

Okay. So my note that I'd written was um similar to what you said actually. The unifying diagnosis is unclear. Presentation could be an underlying psychiatric condition. However, I'm really worried about these Parkinsonism symptoms, which could be related to drug-induced, or is this, as she said, corda aquina? But I also wanted to do a CT head just to have a look at what was going on. But the first thing that she had done her MRI spine showed no significant dispulges, normal vertebral alignment, normal marasignal. The only abnormality is a pre-sacral fluid collection.

SPEAKER_02 24:35

Oh that stumped me.

SPEAKER_03 24:37

I I could tell you I actually looked stumped. It stumped me.

SPEAKER_00 24:43

Fluid uh collection.

SPEAKER_03 24:45

Like three centimetres by six centimetres.

SPEAKER_00 24:48

Three by six. Did it causing any neural compromise or compression? Did they give a punt about what it could be?

SPEAKER_03 24:55

No. Um and it just said there was no ovarian mass. They didn't comment anymore. They said it was there was no evidence to suggest dysclitus.

SPEAKER_00 25:08

Is that I mean, is this a coincidental finding or is that causing problems here? It's a bit of a coincidence she's got a mass in her sacrum, and then she's also got weakness of the limbs, and she's gone into urinary retention. I wonder what would make this look clearer. A dedicated MRI pelvis, potentially? Um, do we need to give the gynee team a call? Um, I'd have to have a think about how I'm going to investigate that because it seems a bit too um coincidental for me to part. Oh gosh, what an interesting incidental finding unrelated to presentation. It seems to be involved somehow.

SPEAKER_03 25:44

It's really complicated, isn't it? And the um she had a CT abdo pelvis, as you suggested, and it showed no evidence of malignancy at all, apart from the pelvic, this sort of pre-sacral collection.

SPEAKER_00 25:59

And did they call it a collection on both MR and CT imaging? They called it fluid collection.

SPEAKER_03 26:04

They did.

SPEAKER_00 26:05

They didn't say abscess or anything.

SPEAKER_03 26:06

No, it was collection.

SPEAKER_00 26:12

Sacral collection. Um I mean, collections need to be aspirated and analysed, and I how are we gonna get to it? It's not gonna be with me, with the old uh the old physician. So pre-sacral, it's a pelvic phenomenon. I w I probably would speak to Giny actually and say, is this something you've seen before with endometrial pathologies? Um, is this something that could be amenable to to some kind of aspiration? Is it amenable worth doing some kind of ultrasound, like a transvaginal ultrasound, just to try and image it clearer? She's got no signs of infection, right? Her CRP's low, she's afebrile. It's not as if she's had PID, which has developed into a walled-off abscess or anything like this. It would be very strange. You said she's got super pubic tenderness, but she's not someone who's said she's had any signs of a chronic um uh gynee infection in terms of discharge or or pain. Um, so that might be my next port of call.

SPEAKER_03 27:12

Okay. Yeah, I agree. I'm just gonna throw something else in there now. Oh, well, no more.

SPEAKER_00 27:17

Go on.

SPEAKER_03 27:19

So, CT head was done.

SPEAKER_02 27:22

Yeah.

SPEAKER_03 27:22

Which showed a large left frontal intraparenchymal hemorrhage.

SPEAKER_00 27:30

Large left frontal okay.

SPEAKER_03 27:32

With vasogenic vasogenic edema.

SPEAKER_00 27:35

Right. I mean, in many ways, that's quite straightforward, isn't it? You get the neurosurgeons on the phone. Um I've noticed in the last couple of years if you have vasogenic edema and some mass effect, even with a bleed, they do actually recommend dexamethasone now. But traditionally, you only gave that with solid masses. Um, and that actually might help take some of the heat out of the vasogenic edema and actually improve her cognitive function a little bit and wake her up a little bit, make her symptomatically improve. Um why she had she had no head trauma, has she?

SPEAKER_03 28:08

No.

SPEAKER_00 28:08

A spontaneous intra So it's it's hemorrhagic stroke essentially.

SPEAKER_03 28:13

Yeah.

SPEAKER_00 28:14

Yeah. Um a spontaneous uh intra intracerebral intraparenchymal bleed is a hemorrhagic stroke, which is a rare form of stroke because most strokes, as we know, are ischemic. Um so do we speak to Hassu? Gosh, I'm making a shopping list of people to call here, and I don't like why doing things on my own. Um her clotting function, her clotting is okay, her plate is slightly high.

SPEAKER_03 28:37

Slightly high. Her INR, pro thrombine timer within normal, um, and she wasn't on any um anti-claylets or anything like that.

SPEAKER_00 28:45

Hmm. So at this point, I'm thinking about who am I going to call for the head? I'm gonna be probably ringing stroke. That is what they're there for. And would they recommend anything like a CT angiogram to look for a bleeding point? Um, obviously, it's not one for surgery because you can't operate on a diffused perencimal bleed. It's not like there's one bleed which can come out in a burr hole. Um, and she's going to need careful neuroORBs in a in a Hassio environment, um hyper-acute stroke environment because careful blood pressure monitoring and and all that sort of thing. Um, a swallow assessment, a careful physio assessment. But I tell you what, an acute brain hemorrhage should not cause bilateral leg weakness.

SPEAKER_03 29:27

Exactly.

SPEAKER_00 29:28

Um because it's a hemispheric. What side did you oh left? So it should, of course, for her right-sided weak-sided neurology. So it doesn't tie in with her presenting neurology at all.

SPEAKER_03 29:41

Exactly. So initially the response was, oh, we've got a diagnosis. Yeah, yeah, yeah. We've got this, yeah, and we know what's going on. And I was like, no, no, no, because that they're not linked. Like the legs and the CT scan findings aren't linked. The MRI was normal. What about this presacral collection? You know, what is this? There are so many things going on now, so many. And I think when you have so many diagnoses like this or so many problems, you can get lost, can't you? You can sort of not entirely sure what's going on. And I find it really helpful. We do this quite a bit, to now write exactly what are the problems and what we found in books that I think notes, you mean. Yeah, yeah. In front of me.

SPEAKER_00 30:30

Oh, yeah, I completely and do you, you have to write it yourself. Do you not find?

SPEAKER_03 30:35

Absolut I mean, I still write with a pen and paper at work. So even though we've got um electronic patient records, I still use a pen and paper to do my problem solving. But I find I find that typing for me doesn't give me that cognitive space that writing on a piece of paper does. And I know that's just that's personal to me. So I will write it down and I will go through um what the problems are, what my investigations are, and then trying to think of different diagnoses or unifying diagnoses and trying to put it together like a puzzle. Because I can't do puzzles on a computer. I'm still doing my Sudoku on paper. So, you know, when it comes to problem solving in medicine, I have to do it on paper. I'm in the I'm very old-fashioned.

SPEAKER_00 31:24

I don't mind doing it. We we don't have paper notes. We like you, we have electronic notes, and I don't mind typing it out. So that's fine, but I've got to do it. Um, and you know, when you're an award round and you're with a nice resident doctor and they and you have to say, Look, can you shift your up the way, please? I need to do I can write that down. What do you want me to say is that I've got to write it because it's something goodness they must be bored just standing there watching me, you know, two-finger type at a computer very slowly for about 10 minutes. But that that's the only way. And then at the end I go, right, and then problem four and then problem five, j-f-lif, could be related to problem three, need to this. And I go, right, I think I've worked it out now, I've done it. Sorry, that was really boring for you. But if I dictated that to you and you typed, it wouldn't have gone through the right pathways on my brain. And also, I don't like dictating to resident doctors like their stenographers, you know, or or it's not what they're there to do, really. Um, and uh I'd rather just say, you know, I actually we have with these computers and wheels, and I say, turn it around to me. I dank the height up because I'm always a foot taller than everybody else. And then I say I just need to type this out myself. No, delete that line. That doesn't make sense. Oh, that needs to be cut and pasted over here. And then even if at the end I still haven't got the diagnosis, so I've achieved something. I'm like, at least I've got this sorted in my brain. So now I know where the problem sits. Whereas before I just felt a bit lost and helpless and like I wanted to sit down in a cup of tea, which isn't useful for the patient.

SPEAKER_03 32:52

Yeah, I do exactly the same thing. Um, but what I what I found apart from I'll write it on paper still, what I find helpful at the end of that is to then I'll write problem representation and I'll like do two to three lines to unify the whole thing, and I'll talk about it whoever's I'm working with that day, and I'll ask them for ideas. So trying to make decision making, just like team thing, um, and sharing my ideas and getting their ideas, and sometimes they'll say something of like, right, amazing, yes. Write that one down, very good. Uh, because it's something I just haven't thought about or uh so further.

SPEAKER_00 33:31

It takes a lot of time. I've always got one one I say, oh gosh, I'm really falling behind here. I hope the next three patients are all straightforward. Yes, like permeas or something, so I can catch up. It takes, you have to really step out of your, you know, out of the moment and take the time to do it.

SPEAKER_03 33:47

You are stepping into your type two thinking, your slow thinking.

SPEAKER_00 33:51

Yeah.

SPEAKER_03 33:52

And as doctors, we often consultants who've had lots of experience, we practice type one thinking, fast thinking, pattern recognition to step out of that and and consciously go into type two thinking, that takes cognitive bandwidth and it takes time. And for me, it can sometimes take 20 to 30 minutes for me to really get into that space and really think properly. And we all know that time is a very precious commodity, so it's trying to utilize that. Um, but to be in this case, I did. I think I probably spent from beginning to end around one hour because it was so complicated for me, and I just needed that space to really think about it.

SPEAKER_02 34:38

Yeah.

SPEAKER_03 34:39

So at the moment, we've got a CT head, which shows an intraparenchymal bleed, we've got an MRI, which shows a pre-sacral collection, we have a slightly elevated white cell count and neutral count with a normal CRP, and we have a background history of delusions. Um, that's she'd been under the care of the crisis team recently, uh, with well within the last 12 months, which had now settled. What do you want to do next?

SPEAKER_00 35:08

You're looking at me expectantly, like I'm about to say something intelligent. Um, what do I want to do next? The only other thing I was thinking of is we keep saying, Oh, I can't work out the unifying diagnosis. Do I eat one?

SPEAKER_03 35:23

Exactly. That probably isn't one.

SPEAKER_00 35:26

She probably she might have two or even three separate pathologies which have converged at the same time. And I'd I'd hate to waste a lot of brain time going, how can I force a sacral collection to fit with her? So, I mean, it may be she's had this sacral collection for a long time, and it hasn't bothered anyone at all, and she hasn't had any symptoms, and then she's acutely separately to that developed a spontaneous bleed, um, a hemorrhagic stroke. Um the leg weakiness, I don't know, but I'm just thinking that maybe it's not going to fit into one in one satisfying diagnosis here.

SPEAKER_03 36:08

And do you remember Hickam?

SPEAKER_00 36:09

Yeah, of course, but tell me, go on.

SPEAKER_03 36:11

Hickam's dictum.

SPEAKER_00 36:13

Yeah.

SPEAKER_03 36:13

A patient can have as many diseases as they damn well please. Yeah. And I think that's really we often think about the one unifying diagnosis, Occam's razor, you know, but actually now multimorbidity complex medicine is way more common than having one condition that explains everything. So I agree with you. I think this patient's probably got two, three or more conditions without one particular unifying diagnosis. Absolutely. Shall I tell you what happened?

SPEAKER_02 36:51

Please.

SPEAKER_03 36:54

Um as is the case in acute medicine. We often look after our patients for 24 to 48 hours and then they are transferred to elsewhere. She was discussed with the neurosurgeons who said dexamethasone, as you suggested, uh, to help with that vasogenic edema, but there was no further intervention. She was transferred to a uh another ward, and initially the plan was to do an interventional radiological um pelvic collection drainage.

SPEAKER_02 37:29

Yes.

SPEAKER_03 37:30

To I of this PSA called pelvic collection drainage to identify what it was. But actually it didn't happen for a variety of reasons, so she started to get better. A repeat CT scan a few days later showed that the collection had reduced in size. So the plan therefore was to not was to just wash and wait from a collection perspective.

SPEAKER_00 37:51

Right.

SPEAKER_03 37:52

And the leg weakness was still not being accounted for by the brain changes and the CT head. She was referred to neuropsychology, soleiaison psychiatry. Yeah, and again, very difficult really to identify what the cause is, but they felt that there was probably some underlying psychiatric problem here as well. It's still a work in progress, Ben.

SPEAKER_00 38:25

Okay. So summarise like in in a couple of sentences.

SPEAKER_03 38:29

Yeah, I will try and summarize. I guess this will be with a bit of my thought process in it, but as I was chasing it up um recently. So the unifying diagnosis remains unclear. Right. The presentation could be explained by an underlying psychiatric condition causing functional logical symptoms in the lower legs. Because we've wrought the MRI was normal.

SPEAKER_00 38:53

So we're saying that the legs weakness was actually uh it wasn't due to an organic pathology or a compression or a neuropathic frozen. Yeah, okay. It was due to her not being not not moving her legs.

SPEAKER_03 39:05

Potentially, rather than trying to keep searching for. Now, my thought process of Parkinsonism and Respiridone was sort of poop-pooped and put to one. So I was like, fair enough. You know, um, okay, I I take that on boards. Maybe I'd just jump to the conclusion, but you know, I'm still thinking the Respiridone, but anyway. Um could it all be due to did she have a water infection? I don't know. She had a raised white cell count, she had a neutrophil count, potentially. I'm gonna throw something else in here, Ben. Now I when I saw her originally, I spent a long, long time going through her notes and asking questions and all this. For somehow, I don't know how this happens. I missed the fact that five years previously she'd had a hemorrhagic stroke. Caused by Can you think of anything that might increase your risk of hemorrhagic infection?

SPEAKER_00 40:10

Oh an arteriovenous malformation or something?

SPEAKER_03 40:14

She had cerebral amyloid angiography.

SPEAKER_00 40:19

No, you meant cerebral amyloid amyloid amyloidosis.

SPEAKER_03 40:23

Amyloidosis.

SPEAKER_00 40:24

What did I say? Angiosis. Angiography, which she probably had to diagnose it, yes.

SPEAKER_03 40:30

Cerebral amyloid. Yeah.

SPEAKER_00 40:33

Ah. Okay. Um fine. Yes, that does cause, but it bleeds, it causes um personality change.

SPEAKER_03 40:41

Absolutely, yeah.

SPEAKER_00 40:43

It's a cause of dementia. Um, I mean, whose responsibility was it to know that? In your in your electronic records that you use, does it not throw these past medical history diagnoses up at you when you log on or no?

SPEAKER_03 40:56

No, I couldn't find it on there. Um When I'd gone onto her um past records from the general practitioner, I for some reason there was very little on there. So I didn't do probably enough deep delve investigating into that as I should have done. Again, time limited probably.

SPEAKER_00 41:19

Um how you say you say that, but one of my bugbears is people who do do a massive deep dive into all the previous medical history for acute presentations. And and I'm and I'm saying, so what's the plan for this patient? And they're saying, Oh, I'm just um I'm just up to uh I'm up to 1993 when they had a toenail remove. I'm like, what on earth? They're coming with pneumonia. Come on, come on, focus, focus, focus. This is this is the relevant stuff. And you know, if you're gonna develop a um you you've got to learn how to tune out what's not relevant, what is relevant now. So I actually chastise people who do that. So I probably miss this as well. Not chastise, I'm very lovely, but I would say, well, I think we can refocus our efforts here. Uh come on, let's focus on what the Q presentation is. But um I I and with our electronic record that we use, the signal to noise ratio for for data is really off. You get everything, their life's story. So the art of of a history has changed from what I learned, which is make sense of what the patient tells you. Now it is try and make sense of this massive autobiographical every blood test they've ever had to focus on on what's going on now. Um so and and I'm very um uh cognizant of the fact that when that when I was training, if the patient didn't tell you something, then you didn't write it down, you didn't know. If you forgot to mention, whoops, I did have a stroke last year, you know, and spent several days in ITU, but they didn't tell you, didn't go in your history. Um and we were all very surprised later on when we found out, and that was just that was just medicine. Whereas now we have so much of it um information at our fingertips. The the the heart bit is what do you leave out rather than than what do you include? Anyway.

SPEAKER_03 42:55

You would not want to do a war round with me, Ben. You'd be like, Amy.

SPEAKER_00 43:00

Okay.

SPEAKER_03 43:01

She did grow E. coli in her urine 17 years ago, but I'm not sure that's relevant.

SPEAKER_00 43:07

No. I'd have had a word.

SPEAKER_03 43:10

I'm not an acute physician, I think I'm a chronic physician.

SPEAKER_00 43:14

But, but this is important because people are listening to two consultants with two different ways of doing things. Who's right? Trick question. We're both doing what's right for us. Because we figured out what works for us as consultants. And this is why I really do like postgraduate medicine, because you're not trying to make people uniform and do things a certain way, you're trying to encourage people and teach people to work out what works for them and help them do it efficiently and safely so the patients get the best outcomes. And I kind of like that we have different ways of running a wardrobe because that people can listen and I don't know going, oh, Ben's way sounds rubbish. Um, I'm gonna be a bad consultant. We can say, well, then maybe you're more of an Amy, and that's uh that's the kind of consultant you're going to be. And that's great if you can make that work for you, which you do.

SPEAKER_03 43:58

Well, and I think. Over time, I've changed as well. So I think as I move on in my career, I probably am a bit more thorough because I'm I'm really worried about, you know, missing things. And I've definitely changed when I was an early consultant to who I am now. But also I think that's being a consultant and a as a and a resident doctor, it's it is, I hate the phrase, but it is a journey, and you are developing into the type of doctor that sits with you, that follows your core values, that follows your morals, and that's authentic to you. And I think that's really, really important. But I could still learn a lot from you on your wardrobe, I'm sure.

SPEAKER_00 44:39

One thing I like to say, because I do a lot of teaching for medical registrars, and I say a lot of the training and the professional development you undergo as a med rate is working out what kind of consultant are you going to be.

SPEAKER_01 44:50

Yeah.

SPEAKER_00 44:50

So keep your eyes open. See what's around there. Deal the bits you like. We love it. That's what that's it. You know, if you like the way someone does something, you use that. But look for your role models, audition your role models carefully, and then work out what kind of consultant you want to be.

SPEAKER_03 45:07

And what kind of consultant you don't want to be.

SPEAKER_00 45:10

Don't want to be. Yeah.

SPEAKER_03 45:11

Yeah.

SPEAKER_00 45:12

Yeah. Negative role modelling is very powerful. People say, I'm never going to do it that way when I'm a consultant. Yeah.

SPEAKER_03 45:17

I see. That's what they do when they watch me. They're like, oh God. I don't know. I don't know. Um, I am a thorough, I think is the phrase, rather than slow, although I am, which results in me taking time. Anyway, um, I'm now at peace with that.

SPEAKER_02 45:34

Good.

SPEAKER_03 45:35

So that was actually that when when we when I reflect on that case now and how we spoke about it, it feels a bit all over the place and a bit disjointed. That is exactly what happened. Medicine isn't A to B. It's a round the corner, go on the toll road. It's all of these different things that are thrown in at you at different ways. And sometimes it does feel a bit messy and a bit disjointed. And I think that's that's medicine.

SPEAKER_00 46:07

That's a nice example of that. You don't always get the diagnosis on the post-takeboard round. Yeah. Sometimes I do write things along the line of, I think there is a diagnosis to be made here, but I haven't quite got it yet, or something like that. Um, but yeah, sometimes it's a bit messy. And I think a lot of our cases we present are wrapped up in a bow at the end. It's like I isn't, you know, because it's realistic.

SPEAKER_03 46:33

Absolutely.

SPEAKER_00 46:34

Well, that turned into a bit of a bumper episode, but I really enjoyed a conversation we had. People are really getting um getting their value there. And what I'm gonna take away from that is you can't always fit. Well, you can try, but it's not all the right thing to do to fit everything into one diagnosis. Because that using what we call confirmation bias, discounting evidence that goes against your cover diagnosis, including bits you do, like picking things at a buffet, sometimes it really takes you down the wrong road. So I really like the um the sort of complexity of that case.

unknown 47:04

Good.

SPEAKER_03 47:04

I'm glad. Well, thank you to all our listeners out there, old listeners, new listeners, a massive thank you to the Rural College musicians of Edinburgh for supporting us. Please rate, review, and subscribe our podcast. Thanks for listening. Goodbye.