Excessive Sleepiness

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DR BEN LOVELL 0:12

Hello and welcome to a new episode of Home of Medicine Podcast in association with the Royal College of Physicians, Edinburgh. My name is Ben Lovell, and I'm joined by my co-host, the lovely Amy. Hello, Amy.

DR AMIE BURBRIDGE 0:24

Hi, Ben. How are you?

DR BEN LOVELL 0:26

I am very well. Well, I say I'm very well. We just had a very long pre-recording conversation about how tired we both are, and we've not been very well lately, but I'm raring to go today. Have a case for you.

DR AMIE BURBRIDGE 0:36

Fantastic. Great. Go ahead.

DR BEN LOVELL 0:38

So I have for you a woman who presents through the emergency department to the medical take overnight. She is 68 years old, and her presentation, strapline, as it were, presented complaint is Sleepy and Falls.

DR AMIE BURBRIDGE 0:54

Oh, I know that feeling.

DR BEN LOVELL 0:55

I know. It could be me. That'd be the title of my autobiography, Sleep and Falls. And um, the doctor who actually clerked her overnight said it was a really tricky history because she is so drowsy and she kept nodding off during the consultation several times, and she was very vague. And unfortunately, no collateral history was available from a relative or a well-wisher. But they managed to elicit the background that she had a fall. In fact, she had three falls on the day. And uh she did bump her head where she went down on one of them, but there was no visible injury, and the patient didn't report any pain, and it wasn't apparently a nasty, nasty head injury. She was found on the floor by her son after what he thinks was about a two-hour lie. And the patient was not really giving a history beyond that. Um on real pushing, she thought maybe her legs gave way, but she wasn't quite sure. Apparently, she denied any pain. When she woke up, when she was woken up, she was um oriented enough to give a history, but then she would just snooze back to sleep again. Um, and in fact, she she was referred by the emergency team as falls, admit under medics for assessment by the therapy team in the morning, the physio team to see what is the cause of the falls. And try as they might, the admitting doctor overnight really couldn't get much more of a history from the patient than that. So not much meat on the bone there. Any particular flashes of insight or or intrigue for you on that very, very small doctor's history?

DR AMIE BURBRIDGE 2:38

Um okay, so I've written lots of things as usual. Do we have any past medical history from her?

DR BEN LOVELL 2:46

I certainly do. And it's great that we managed to get this on the record, which is um a big computerised record of London GPs we can access brilliant and actually pull up past uh medications and such like.

DR AMIE BURBRIDGE 2:58

Okay.

DR BEN LOVELL 2:58

I suppose the main headlines from the past medical history is recurrent UTI. So bad she's actually under urology, where she's been to an MDT where they've done imaging of a renal tract and couldn't find any structural reason why she'd have these recurrent infections, but numerous urine cultures have grown round negative rods in association with symptoms. So a decision was made at a previous MT MDT to put her on long-term prophylactic coamoxoclav. So that's what she takes. She also has a history of schizophrenia and anxiety, and she is treated on some psychotropic medication for that. And thirdly, she has hypertension.

DR AMIE BURBRIDGE 3:37

High blood pressure. Okay. Does she take anything for the high blood pressure?

DR BEN LOVELL 3:40

Amlodamine.

DR AMIE BURBRIDGE 3:42

Okay, and what about for the you said she's on um antipsychotics. What does she take?

DR BEN LOVELL 3:47

Yeah, so her drug history is olanzepine, which she takes nightly. She also takes trazodone, which is a sleeping agent at bedtime.

DR AMIE BURBRIDGE 3:56

Quite powerful, one is as well, isn't it?

DR BEN LOVELL 3:58

And it's old school. Uh she takes diazepam, two milligrams three times a day, as needed for anxiety.

DR AMIE BURBRIDGE 4:06

Yeah.

DR BEN LOVELL 4:07

She takes the co-amoxiclav prophylactic dose, which is 375 milligrams once a day.

SPEAKER_02 4:12

Okay.

DR BEN LOVELL 4:13

He's got the amylodoprina mentioned previously. And uh, she takes atorvastatin, 40 milligrams at bedtime, and she also takes a lanzopr for a bit of gastroesophageal reflux and no known allergies.

DR AMIE BURBRIDGE 4:27

So has this happened before, or is this the first presentation of being sleepy and falling?

DR BEN LOVELL 4:33

First time that we could find looking at the uh electronic health record.

DR AMIE BURBRIDGE 4:38

Okay. So the thing that's screaming out to me, and as usual, I have this is weird and I have no idea why, is cytochrome P450. Your face looks like you're chewing a wasp. No, I'm just because I was thinking, she's on uh Lanzoprasole, statin, coamoxiclab, allanzepine, trazodone. Is there some drug interaction here? There's a lot of medication that she's on that I'm thinking, you know, is she's on so many medications that are going to be making a sleep, could be making a fall, could be making a blood pressure change. But I'm gonna park that to one side because medication is always something that we should think about. But um, let's think about what else could be going on. So she is my problem representation is a 68-year-old female with schizophrenia, recurrent UTIs, and hypertension has a one-day history, an acute history of sleepy and three falls and a head injury, but no obvious head injury visible. Okay. Any chest pain that you found out about? No. No chest, is she short of breath? No. No, any headache?

DR BEN LOVELL 5:57

No.

DR AMIE BURBRIDGE 5:58

No, okay. Any visible injuries on her legs?

DR BEN LOVELL 6:03

Uh no, no. Any bruises? No bruising.

DR AMIE BURBRIDGE 6:07

No, okay. Um fever?

DR BEN LOVELL 6:15

Yes.

DR AMIE BURBRIDGE 6:17

Ooh, okay. What's the temperature?

DR BEN LOVELL 6:20

38.5.

DR AMIE BURBRIDGE 6:22

Ooh. Any urinary symptoms?

DR BEN LOVELL 6:27

That's a fun that's a it's it's a funny one.

DR AMIE BURBRIDGE 6:30

Yeah.

DR BEN LOVELL 6:30

Because of course that's the first thing gonna ask. Is this another one of your current UTIs because you're febrile and and and and maybe not very well? And her answer was vague enough to say, I always have urinary symptoms. Okay. It's it's I've always got infections and I always have dysteria and frequency. That's my normal.

DR AMIE BURBRIDGE 6:48

Okay. Any cough?

DR BEN LOVELL 6:50

No.

DR AMIE BURBRIDGE 6:51

Any bowel symptoms, diarrhea?

DR BEN LOVELL 6:53

No.

DR AMIE BURBRIDGE 6:54

Okay. So for for the fever, I'm thinking, yeah, she's got UTI, so we'd want to make sure that it isn't that. But we don't want to make an assumption that just because she has UTIs, this is a UTI. So is it viral? Is it bacterial? Is it fungal? Um, unlikely to be fungal unless she's immunocompromised, which there'd be no reason why particularly she would be immunocompromised. Um, we've asked a lot of the fever questions. Any joint pains, joint aches?

DR BEN LOVELL 7:26

No.

DR AMIE BURBRIDGE 7:27

No. Okay. Um, social history. Who does she live with?

DR BEN LOVELL 7:33

She lives with her son.

DR AMIE BURBRIDGE 7:34

With her son, okay. Okay.

DR BEN LOVELL 7:37

And uh she is mobile independently around the house, doesn't go out so much. Um, she's an ex-smoker since 10 years, doesn't drink alcohol. Um, okay. She likes to watch TV and she likes the soap operas as her favourite.

DR AMIE BURBRIDGE 7:51

Okay. Any drugs, any you know, past medic, um illicit drug usage.

DR BEN LOVELL 7:57

Not that we detected on this cloud. Okay.

DR AMIE BURBRIDGE 8:01

Okay. Okay, I'd like to examine her actually.

DR BEN LOVELL 8:06

Very well. So the the main sort of thing on examination was that um she was drowsy, but her GCS was 15. And I find this is sometimes one of the limitations of G it's meant to be your best school. And after you've sort of been bellowing in someone's ear and given encouragement, and you get the GCS of 15, you might read that on paper and go GCS 15 every year. Yeah, of course. But of course, it doesn't capture the fact that she just couldn't finish a sentence. She was like, you know, the door mouse of Addison Wonderland nodding off at the end of a sentence. Um and uh her blood pressure was 116 over 80.

DR AMIE BURBRIDGE 8:44

But did you do line and stand in blood pressure?

DR BEN LOVELL 8:46

He was too sleepy, too sleepy.

DR AMIE BURBRIDGE 8:48

So that was that was lying down blood pressure.

DR BEN LOVELL 8:50

It was supine, super high blood pressure. Her sats were 95% on air, and her heart rate was 83 and regular, and her blood, oh I said blood pressure, and her respiratory rate was 20, 21.

DR AMIE BURBRIDGE 9:03

That's quite high.

DR BEN LOVELL 9:04

Her heart rate.

DR AMIE BURBRIDGE 9:05

No, her respiratory rate of 20-21. It's on the higher side.

DR BEN LOVELL 9:09

Um, and I mentioned her temperature was 38.5, so that's a vital science. Um, I've mentioned her GCS, her chest was clear, uh, her abdomen was soft and non-tender, and there was no renal angle tenderness that might sort of bely uh a brewing pylone nephritis, and she didn't seem to have such pubic tenderness that you might get with bad cystitis. Um, her fluid status appeared to be uvalemic, no edema, heart sounds were normal. And in terms of a neurological exam, it's quite tricky to do on someone who doesn't engage, but certainly no focal neurology was detected. Just this very strong desire to be asleep. Um albeit it was three in the morning, and she'd had she'd had a few drugs which three in the morning. So that was about and no visible injury, I should say, as well. Hips moved very well, no visible shortening or external rotation of the legs.

DR AMIE BURBRIDGE 10:08

Did she have any hyper reflexia?

DR BEN LOVELL 10:10

She did not. What are you thinking about?

DR AMIE BURBRIDGE 10:13

I was thinking of neuroleptic malignant syndrome. Yeah. Um, but her blood pressure's okay, although the temperature is high, but it seems like she's been on a lanzarpine for a very long amount of time. So it would be unlikely, but it's something that would be in my head. Does she have a gas fire?

DR BEN LOVELL 10:31

Oh, I didn't ask.

DR AMIE BURBRIDGE 10:32

Okay. I'm thinking carbon monoxide poisoning.

DR BEN LOVELL 10:37

I don't know.

DR AMIE BURBRIDGE 10:41

I was just thinking, you know, what could be making her feel drowsy? Um, I mean, I'm probably thinking it's the middle of the night when she's had Tracidone and diazepam, to be fair. Um, am I overthinking things, which I always do? The examination doesn't really tell me much. I guess it does tell me a lot, actually. It tells them that she doesn't have any crepitations, her abdomen's fine. Neurologically, from the examination we can do, there isn't any signs of hyporeflexia, hypertonia. Her blood pressure's okay, she's a little bit hypoxic, but she was an ex-smoker, and her respirator's a little bit high, and she um has a high temperature. I really want to do a blood gas.

DR BEN LOVELL 11:20

What are you looking for?

DR AMIE BURBRIDGE 11:21

I want to know what her lactate is, and I want to know what a CO2 is, is um you know, she is. I guess could this be sepsis? Not really, because her heart rate's low and respirate's okay, blood pressure's fine. So I do want to see what a lactate is. That's also helpful in your eleptic malignant syndrome. If you've got somebody who's been um having a lot of muscular activation, the lactate can be high, um, along with CK. So check a lactate and uh CO2, please.

DR BEN LOVELL 11:55

I had the same idea because it's part of my drowsy patient workup. You want to make sure they're not narcosed, CO2 narcosed. Yeah. So we did the blood gas. Her lactate was only 0.9, and her PCO2 and her pH are both in normal range. So she wasn't retaining CO2, which was a thought that I had as well.

DR AMIE BURBRIDGE 12:14

Yeah. Okay, so now I'm thinking drowsy for pyrexia. Is this a cerebral infection? So, meningitis and kephylitis. That's sort of, but would I go straight for an LP? No, I wouldn't. I'd do some blood tests and a head scan.

DR BEN LOVELL 12:33

A head scan, you've got a CT head, right?

DR AMIE BURBRIDGE 12:35

I want a CT head, yeah. Yeah, I think it's really important. She's had a fall, she's drowsy. Um yeah, 100%. I want to see what's going on in their head.

DR BEN LOVELL 12:44

Fortunately, the emergency team had already um done a CT head and neck, which is protocol for an older adult who falls from their height unwitnessed, and particularly if we think there's some consciousness of pep thereafter. And the CT head and neck was normal, and there was no C spine fracture and no injuries report hemorrhage or subdural that could explain this, which was reassuring. Blood tests. CRP was 146, and her um sodium was 138, her potassium was 3.3, and her creatinine was 41.

DR AMIE BURBRIDGE 13:20

Okay.

DR BEN LOVELL 13:22

Oh, go on, you're gonna quote.

DR AMIE BURBRIDGE 13:23

I was gonna say urea, but then I remember you don't do urea. We don't get I know, I know.

DR BEN LOVELL 13:29

We can add them if you want to work out a Blackford score, but otherwise we don't get WT. Looking at her full blood count, her white cells were 12.9.

SPEAKER_02 13:38

Okay.

DR BEN LOVELL 13:38

Her hemoglobin was 119, and her platelets were 133, and her neutrophils were 9.3.

DR AMIE BURBRIDGE 13:50

Liver function?

DR BEN LOVELL 13:51

Yep, bilirubin was seven, LT was 19, Alcoss was 120, albumin was 28.

DR AMIE BURBRIDGE 14:05

Okay, so you've got high CRP, slightly low potassium, white cell and neutrophils on the higher side, platelet's a little bit low. Liver function's normal. What I always think about, and we've talked about this in the podcast before, is when you've got a CRP 146, you're not sure where it's from, think abdomen, think billowy. Um, but the liver functions are completely normal, and her abdomen was soft and on tender, so sort of goes against that. Do we have any previous microbiology on this lady? I mean, you've mentioned E. coli, um, but what about anything else?

DR BEN LOVELL 14:42

Well, I didn't mention E. coli. You must have heard it. I said gram-negative. Now that's interesting. So her previous urine cultures grew multiple gram-negative rods.

DR AMIE BURBRIDGE 14:52

Uh rods, okay.

DR BEN LOVELL 14:53

Yeah. And I think from memory they were sometimes klebcellus, sometimes E. coli, but fully sensitive to chymoxyclave, which is why she was on the prophylactic long-term hermoxicladerapy.

DR AMIE BURBRIDGE 15:05

Okay. So I guess with that temperature, you'd do a blood culture as well, although you're not going to get those results back, are you? Um, straight away. ECG?

DR BEN LOVELL 15:18

ECG showed normal sinus rhythm.

DR AMIE BURBRIDGE 15:20

Okay. And the reason I do an ECG is she had a fall, she was drowsy. Was this a cardiac arrhythmia? Um, potentially, that we'd need to be thinking about and ruling out. An ECG is only giving you give you a snapshot, isn't it? It's like a photograph of the heart. It's not a video of the heart. Um, but that was normal.

DR BEN LOVELL 15:39

Oh, I quite like that. I hadn't thought about that before. So next time I book a halter for someone, I can say the reason we're doing this 4872 hour halter is because we've just got snapshots of your heart, but I wanted to along a video of your heart does over time. I'm gonna pick I'm gonna steal that. That's quite nice.

DR AMIE BURBRIDGE 15:53

You know, Ben, I've never used that ever before.

DR BEN LOVELL 15:56

Oh, and I was at its inception, how exciting. Where's that come from?

DR AMIE BURBRIDGE 16:01

Yeah, do you think it's because we're both sleep deprived and we're not quite this is what do you know? It's actually quite good that we're both really tired because this is what happens to clinical thinking in the middle of the night, isn't it? Or when you're at the end of a long day, and you know, what often when we do our podcasts, we are raring to go, we've had our caffeine, you know, we're fully switched on, but today both of us have had lack of sleep.

DR BEN LOVELL 16:29

I hope we're still doing an entertaining episode. You're right, because you must have seen that those studies which showed that being um severely sleep-deprived is equivalent of like a gin and tonic in terms of reflexes, reactions. I sadly know a few people who graduated in my year medical school who had you know the car accidents driving home after night just exactly none were too severe, but your thinking is slowed and your reaction times are slowed. And if you are trying to think quickly and quickly for a patient who's very hard, well, you can't help but um make some assumptions about what might be going on there.

DR AMIE BURBRIDGE 17:04

And I have to say, when I'm looking at this case now, compared to some times when I may be not as tired, my cognitive processes are slowed down. Um, compared that might be age, but I haven't aged that much, have I, in the last month, to be fair. I can't just blame it all on that. But I wonder whether that has contributed to it. So, what I'm gonna do in this situation when I am tired and I do have cognitive overload and I have to still make clinical decisions and make a treatment plan. So I think even my problem list for this patient, she's she's feverish, raised CLP, raised weight cell count, everything else seems pretty normal. Um, it is the middle of the night, so the drowsiness could be Do you know what I'm gonna do? I'm gonna let her sleep. It's three o'clock in the morning, and um I think starting antibiotics isn't a bad idea. Given the fact that we've got somebody who's had frequent urinary tract infection, she's feverish. Um do we have E. coli that's going into the bloodstream? Um also, or do I treat meningitis? Well, this is a tricky one because what I'm thinking of now is is this do I give just normal antibiotics and let her sleep? Or do I LP? I'm not gonna do an LP in the middle of the night because I don't think she's got meningitis. She's not confused, it's not in careful. Oh has she got a headache? No, she's not got a headache. Okay, I'm gonna give some intravenous antibiotics, I'm gonna give some fluid, and I'm gonna let her sleep, and I'm gonna see how she's in the morning. I'm gonna check her glucose as well, actually. But glucose because she's on the lanzipine and it can cause your glucose to go up.

DR BEN LOVELL 18:54

Oh, I didn't know that. Um glucose is 5.7.

DR AMIE BURBRIDGE 18:59

Yeah. So a lanzepine interacts with the um something to do with the eyelets, uh, eyelets of Langerhans, I'm sure it does. Um and um a lanzepine can cause hyperglycemia.

DR BEN LOVELL 19:12

I never knew that. Well, thank you for that one.

DR AMIE BURBRIDGE 19:14

I mean, to be fair, I am sleep-deprived, so I might have just made that up, but I don't think I have. Um, okay, glucose is fine. IV antibiotics, IV fluids, let to sleep.

DR BEN LOVELL 19:25

All right. I mean, that's pretty much what happened. Um it wasn't me. I don't work at 3am. I I put in the many years at the 3am ships now, I I'm too old and far too senior. So I was at home, but the resident doctor who saw them said, look, recurrent UTIs, proven previous microbiology, comes in febrile, drowsy in the context of multiple cellating agents, possibly maybe a bit of hypoactive delirium in the context of a UTI. Let's not think zebras. If you let's think horses, because I hear hoofbeats, uh, or treat this as a UTI.

DR AMIE BURBRIDGE 20:02

Yeah.

DR BEN LOVELL 20:02

There was no meningism that would worry about giving us uh for CNS infection. She wasn't photophobic, she could move her neck. So they said um working diagnosis, recurrence of known UTIs, um, plan, reculture everything. And um they had a little think about two issues antibiotics, what should we give? And um, what should I do about her neuroleptic medications? And they sort of came to the conclusion well, she's not due any more of those until today. So I hadn't really got to stop them. So let's let her sleep them off, and then we'll have a ward round in the morning, a post-tate ward round, and we'll see what daylight brings. Uh and then what would you do about antibiotics? Um, she's on long-term coma oxyclave, which is shown to be appropriate for her type of infection that she gets, but she's come through, come in with like a breakthrough infection if you like. Would you give Ivy coa mox or would you switch it over?

DR AMIE BURBRIDGE 20:59

No, I wouldn't give a commoxiclave.

DR BEN LOVELL 21:00

What would you give?

DR AMIE BURBRIDGE 21:01

Uh uh. Oh, what would I give? I would consult my latest guidelines in the hospital, to be honest, because they do change quite frequently. So I'd want to ensure that I'm giving you the right antibiotic. Um what would you give?

DR BEN LOVELL 21:21

Um I thought uh the resident decided to give um IV comotoclab based on she's on a very low baby dose as prophylaxis.

SPEAKER_02 21:29

Okay.

DR BEN LOVELL 21:30

Um probably has got one of the known colonized bugs that she has in a urinary tract. So let's ramp up the dose and give it IV at least for 12 hours and see what she's like in the morning. If she's still febrile or unwell, then we can consider switching it. And I thought that was a reasonable plan.

DR AMIE BURBRIDGE 21:45

Do you remember when we used to give IV out to pen in one gram?

DR BEN LOVELL 21:49

We never did that.

DR AMIE BURBRIDGE 21:50

We did. Oh, that was a long time ago.

DR BEN LOVELL 21:53

That must have been a Midlands thing.

DR AMIE BURBRIDGE 21:55

Oh, really?

DR BEN LOVELL 21:56

If I did that, I'd have probably either a pharmacist or a microbiologist hunting me on the wall.

DR AMIE BURBRIDGE 22:00

I mean, we're talking like fifteen years ago. So it was quite a while while away. Yeah. I just remember giving one gram of IVA to Penham. Um so we've now got I'm just trying to think, what what what could this lady have that could kill her? So you know when you think of your top three diagnoses that I'm thinking of now, what's gonna kill her? Meningitis? Sepsis. What's it most likely to be? UTI? What's the weird thing that this could be that we haven't thought of? I don't know. Noroleptic malignant syndrome, which we mentioned. Or drugs.

DR BEN LOVELL 22:39

I guess you know, you don't know. She could have accidentally or deliberately taken too much of Lancet at home. She could have, yeah. We don't know. We have no test or assay for that, do we?

DR AMIE BURBRIDGE 22:48

Can we do a CK?

DR BEN LOVELL 22:50

We could. We didn't.

DR AMIE BURBRIDGE 22:51

Okay.

DR BEN LOVELL 22:52

I guess you could do at that point. I didn't think of NMS.

DR AMIE BURBRIDGE 22:57

Okay, I am um I'm stuck.

DR BEN LOVELL 23:00

Well, I don't think we're stuck. I think we've made a decent plan. You know, when when when I I do a lot of teaching and training for medical registrars, and when I talk to them about what is the source of anxiety for you about being the med rich? And I've got them say it's not knowing the answer. Yeah, yeah. We've talked about this a lot. Uncertainty. That's kind of not your job. Um your job is to give appropriate treatment based on your working diagnosis overnight, make it keep the patient safe.

SPEAKER_02 23:26

Yeah.

DR BEN LOVELL 23:27

If I can't make a diagnosis some of the time when I do a quick snapshot of your patient, why should why should I expect that of you? And I try to reassure them that way. Um, and you know, we talked about don't things reverse if you hear hoof beats, otherwise known as if it walks like a duck, sounds like a duck, it's probably a duck. And we don't want to over-investigate or over-treat patients. You're always holding a little bit of risk and holding a little bit of uncertainty.

SPEAKER_02 23:52

Oh, absolutely.

DR BEN LOVELL 23:54

But you know what? The patients in hospital, they're in a very safe place, yeah, regular observations and reading.

SPEAKER_02 23:59

Yeah.

DR BEN LOVELL 24:00

So let's see what will be will be, and let's not care. And I think I've always had the I because I'm I am an acute physician, I I'm very used to seeing patients one after the other. And I almost sort of, once I finish a patient, I go, that's done. I need the next patient now. To the point where someone says, You know that patient you saw seven hours ago. And I'm like, No, what what? Oh God, I can't remember that at all. Remind me. Because I sort of arc it and then I move on to the next one.

DR AMIE BURBRIDGE 24:25

Yeah, I get that.

DR BEN LOVELL 24:26

And I sort of put that away now. And people say, What do you think is going on? I'm saying, Well, read my notes. I decided she had a UTI, maybe this mood isn't, but I decided she needed antibiotics. Yeah. I said, Tomorrow cultures, let her sleep off and we'll see her in the morning.

SPEAKER_02 24:38

Yeah.

DR BEN LOVELL 24:38

Nothing too hard from that, really. Um, I'm on the I'm three patients down the line now, so I'm I'm focusing on Yeah, yeah, yeah.

DR AMIE BURBRIDGE 24:46

That's good, yeah.

DR BEN LOVELL 24:47

And I'm not saying that's the best way, I'm just saying that's my way, and that's how my brain does the one patient after the other um system that we work in.

SPEAKER_02 24:54

Yeah, yeah.

DR BEN LOVELL 24:56

But morning came.

SPEAKER_02 24:58

Oh gosh.

DR BEN LOVELL 24:58

I I arrive in the hospital, I do my post-take ward round. She's fine. Well, she's she's not well, but she hasn't deteriorated overnight. I notice on my post-take review that she has now new abdominal pain. She has a little bit of left iliac fossa pain and left renal angle pain. She's still spiking at 38 degrees. And um this is this made me wonder: well, is there an abdominal source of infection, which we mentioned earlier on, that wasn't quite present or or clinically apparent during the night, but now is starting to make itself known. And I thought, let's get a CT abdo pelvis. Very sensible. We're not 100% sure where the infection is coming from. And this CT abdo pelvis showed a bit of colitis, sigmoid colitis, which the report said could be infective or inflammatory in origin, very unlikely to be ischemic. And of course, clinically that makes sense. I don't think she has ischemic colitis, but normal lactate and um infective or inflammatory? Could she have a new presentation of inflammatory bowel disease, a bit of UC or Crohn's? It's probably she's got a bit of infection.

DR AMIE BURBRIDGE 26:08

Does she have C. diff?

DR BEN LOVELL 26:10

Why okay? Could do. What makes you think that?

DR AMIE BURBRIDGE 26:13

She's been on Anne Swellsy's long term.

DR BEN LOVELL 26:15

That did come to me a little bit later than you. I wish it came to me sooner.

DR AMIE BURBRIDGE 26:18

She's got bacterial, you know, she's got, she's changed her environment, hasn't she, in her bowels?

DR BEN LOVELL 26:27

Um yeah, she's been on long-term antibiotics. It's changed her normal flora. Um, it's it's altered the competition for bugs infection in her gut.

SPEAKER_02 26:36

Absolutely.

DR BEN LOVELL 26:37

Might have made a play. Um, at that point, I was thinking, look, I think we found a source here. The CT abdo did not show any perinephic stranding or any signs you find in the pilo. Um, it may still be UTI and we have now objective radiographic evidence of colitis. So let's treat it as as infective colitis. So let's get some stool cultures. At that point, I switched our antibiotics to kefer net. Um, retro. No, that's our guideline for uh yeah, for GI infection.

DR AMIE BURBRIDGE 27:11

Isn't it interesting how different parts of the country have different antibiotic guidelines? Um, obviously that's because of different um lots of different reasons. But um, I remember Kefermet as an F1 in surgery.

DR BEN LOVELL 27:26

Kefemet.

DR AMIE BURBRIDGE 27:27

Kefemet.

DR BEN LOVELL 27:28

Have they got Kefemet?

DR AMIE BURBRIDGE 27:29

Got Kefemet. Yeah.

DR BEN LOVELL 27:31

Um and I said to them, we can we get some stool culture. But at that point, she wasn't passing any stool, she wasn't having diarrhea. So I guess that slightly goes against C. diff. But I said, look, if she does have diarrhea, again stool culture as well. And then I sort of, oh, and she was a she was a bit more awake in the morning. And I thought, this is someone who loads up on sedating agents at bedtime and then you know, really goes for it sleep-wise overnight. I'm very um, but she'd woken up a little bit. And I saw her then on day two, we can just flash forward down the timeline a little bit, and she wasn't getting better. Day two, again, she was very sleepy and difficult to rouse. Her temperature was about 37, 837, 9. And I was intrigued by her CRP, which you remember was 146 on admission, and now we're at 40 hours later, it was one four three.

DR AMIE BURBRIDGE 28:21

Okay.

DR BEN LOVELL 28:22

Yeah.

DR AMIE BURBRIDGE 28:22

And she's had antibiotics. So I'm starting to think when the temperature doesn't come down and their CRP doesn't come down, it's for me, it's abdominal or cerebral.

DR BEN LOVELL 28:38

I remember when I was um much, much more junior than I am now, and I had a boss at one of the London hospitals I was training at, and one of his favourite questions he liked to bring out on the po on the board round was, what's the half-life of CRP? So it's ingrained in my end, it's nine zero. Three days always. Yes, nine nine zero. Nineteen hours is the half-life.

DR AMIE BURBRIDGE 28:58

Oh, I three days I always had in my head, but yeah.

DR BEN LOVELL 29:01

If you have removed the stimulus for CRP production, i.e. your truth infectious, it's gonna take time to come down. You should see in about 19 hours, or let's say 24 hours, let's say a day, you should see the CRP half. And it hasn't. It hasn't. So she's still producing CRP despite some really good going antibiotics. So and here's the clincher, the nursing staff report, she's now having quite profusive type seven stools.

DR AMIE BURBRIDGE 29:27

Oh, it's C diff.

DR BEN LOVELL 29:28

It's C diff.

DR AMIE BURBRIDGE 29:30

Is it?

DR BEN LOVELL 29:31

It's but that's what I'm thinking. Oh, it's C diff. She's been on long-term antibiotics.

DR AMIE BURBRIDGE 29:34

It's not gonna be, though, is it?

DR BEN LOVELL 29:37

So my plan was. Well, what would your plan be?

DR AMIE BURBRIDGE 29:42

My plan would be um to get a stool sample to make sure samples, yeah. Um and it's not just looking for C. diff, but it's also looking at other parasites over um that but that we may see within the um within the stool, you know. It could it be Salmonella Typhy, um, could it be um C. diff we've already mentioned. Um and could it be norovirus, which uh, you know, is one of those things that we see a lot of. Um there is a very particular smell to C diff, and it's like nothing I've ever smelt, and it's very different to Melina, and it's very difficult to describe, but the look of it as well is C diff. It's green almost like a greeny brown. Um and the smell, it's C diff smell, and it's it's almost sweet.

DR BEN LOVELL 30:34

Did you I can't smell it, I can't smell it.

DR AMIE BURBRIDGE 30:36

Oh, oh yeah, it's it's but then I've got a weird smell because I can smell ketones.

DR BEN LOVELL 30:42

Can you smell pseudomonas?

DR AMIE BURBRIDGE 30:44

Yes.

DR BEN LOVELL 30:45

I can't either, but people tell me that they can smell it.

DR AMIE BURBRIDGE 30:47

I can and I can smell ketones and stuff like that. I've got a really weird smell though. I can't see very well, and my hearing's terrible, but I can smell.

DR BEN LOVELL 30:54

Like a dog on the wall. Someone's got a diabetic foot ulcer on.

DR AMIE BURBRIDGE 31:00

Where is it? Um so I guess if I was thinking C diff, I mean, ideally, you should wait for a positive culture with C. diff, and often you can get quite rapid results for that. Um, if you are treating C. diff, I'd I'd think about oral vancomycin, um, is often the medication of choice. I would stop the keferoxine, because keferoxeme can, I know, can maybe exacerbate the C. diff. She's also on Lanzoprosole and a statin. Now we know that lanzoprosole can also change the environment in the bowel and make you more prone to um C. diff. And also somewhere in my head, statin, but I might have made that up, but certainly PPIs are not good with antibiotics and C. diff. So we'd stop the PPI as well.

DR BEN LOVELL 31:43

So, yes, I said let's get some store cultures. I said, Look, let's just hold these psychotropic meds because she's she's really difficult to rouse. And I don't think giving her regular diazepam is is helping our regular assessments of her.

SPEAKER_02 31:58

Okay.

DR BEN LOVELL 31:58

Um and of course, cyberum, because we don't want an outbreak on the ward, thank you very much.

DR AMIE BURBRIDGE 32:04

Yeah.

DR BEN LOVELL 32:05

And um, yeah, I I had a long think about her antibiotics. She's got a static CRP at 140 something. Her temperature's still up there a little bit. It's a suspicion, a hypothesis of C diff, but I haven't got confirmation yet. But I do see inflammation on her gut on CT. Um, and I said, look, let's just keep the antiputs going until we get the stool culture results back. Because I'd hate to stop them. It isn't C diff, it's a different bug, and then some kind of horrible abscess or perforation.

SPEAKER_02 32:37

Bitcoin.

DR BEN LOVELL 32:38

But we should get the results back pretty quickly. Unfortunately, we did get the C diff results back later in that evening. And she was, let me look at my notes, she was C diff PCR positive, toxin negative. Now, for analysis of C diff results, as you know, the PCR detects the C diff um DNA sitting in the stool. The toxin um looks for the toxin produced by the by the by the bug, but the toxin assays are actually less sensitive than the PCR for DNA. So you don't always get toxin positivity. So it doesn't exclude infections. So you have to do a bit of thinking. If someone is C diff, PCR positive and toxin negative, and they've got no real symptoms, then maybe it's just colonization or carriage of C. diff. But someone who's PCR positive, toxin negative, but having profuse diarrhea or the other infective symptoms, yeah, this is going to be C diff. And we promptly stopped the Kethimet and switched her onto orovanchomycin, as you said. And really good thought about the Lanzocpasole. I I I remember being taught that, and I and I double checked before this episode what is the data about Lanzocpasole? And actually, it's about recurrence. So there's weak evidence, but there is evidence that Lanzopozole can cause more recurrence of C diff after your infection.

SPEAKER_02 33:53

Yeah.

DR BEN LOVELL 33:54

It's good practice to withhold it a little while whilst retrieving infection. So I was on on the same wavelength as you with that one.

DR AMIE BURBRIDGE 34:00

Yeah.

DR BEN LOVELL 34:02

She was discharged five days later.

DR AMIE BURBRIDGE 34:04

Amazing.

DR BEN LOVELL 34:04

Um, and I guess um there was the only final thing was when she is a bit more with it and when the sun came in, there was a little conversation to be had because it was why did this happen to me? We've talked about the long-term antibiotic. And then, of course, their next question, which is quite reasonable, is Did the Urologist get it wrong? Is this their fault? Um, because why would they give me this medication, which has caused such a horrendous infection in the hospital state? How would you negotiate that conversation?

DR AMIE BURBRIDGE 34:37

Uh well that's a really difficult one, and I would always acknowledge the distress and say, I'm really sorry that this has happened. But also, it's uh oh god, um, it's never anybody's fault within medicine. Medical errors are never an individual's fault. It's often a problem with the system, or you know, there's multiple things that it's like the Swiss cheese. Lots of little things have happened that have culminated in this event. But ultimately, you know, she has had recurrent UTI, she's that recurrent positive urinary retract infections on sample as well, on culture. So I guess at that time, I would be like, I'm really sorry that this has happened to you. However, at the moment, we've got a diagnosis, you're feeling much better now, which is fantastic. I would uh encourage you, if you have any concerns, to speak to PALs, the patient advocacy and the liaison service, or reach out to the urology team and express your concerns. Because I don't think I'm the right person to answer a complaint about another specialty. Because I don't know, you know, we don't know what how people think or you know what what happens in consultations. So I don't think that's our responsibility to navigate that necessarily.

DR BEN LOVELL 35:57

Yeah, I think it's very important as well to avoid um splitting of teams.

DR AMIE BURBRIDGE 36:01

Oh, absolutely.

DR BEN LOVELL 36:02

To criticize other healthcare professionals, which would irretrievably damage their relationship with them because we're not in possession of all the facts. No, exactly. This wasn't like a rogue doctor made a weird decision. This was an MDT decision, microbiologists, urologists. And the way I said it was look, I think it was a really reasonable course of action for you, and it's such a shame that it went wrong. And of course, there was a little bit of risk in long-term antibiotics, but I I absolutely can see why they thought this would be something that would help you, but these miserable infections you keep getting, and it's such a shame that you had such a rare complication.

DR AMIE BURBRIDGE 36:34

Absolutely. I mean, it is it's not something we see as much anymore, is it C diff?

DR BEN LOVELL 36:38

Um so that's my patient. So I think that for me, what stood out was presentation was sleepy in the falls. That sort of was not what's going on at all.

SPEAKER_02 36:50

Yeah, yeah.

DR BEN LOVELL 36:51

The C diff, which didn't really raise its head until day two. But I was, you know, interested by some of the ways we assess patients. We don't have much of a collateral history, and with the patient is a bit too drowsy, and how we make best decisions we can in the middle of the night. And sometimes that decision is about let's keep you safe until the morning wardround when more things will become apparent. And then ultimately how we respond to changes in the patient's status, to new symptoms they develop during their inpatient stay, and then to new results from investigations that we have as an inpatient. We don't have all this information on day naught. No, we don't front door. And that's just how the world works. And as long as you remain open and responsive to information as it comes in, um, then then we we tend to get there in the end.

DR AMIE BURBRIDGE 37:38

And it's how we, you know, we generate hypotheses, don't we, on day one, and then we confirm or refute them by the tests that we do. But sometimes tests take a little while, and you know me, I love the history and the examination, but sometimes the history isn't quite as full as you would like it to be because of many reasons. So it's okay, so if I can't get all of the information from the history, where do I get the information from? And you said there was the GP records, which are really helpful, you know, family collateral history, letters, you know, it's so many different ways, isn't there? So um, that was really interesting, and it really got me thinking, and you know what? I just love medicine. You know, I don't know. It's just, you know, you have a case like this that seems so UTI, you know. I mean, everybody gets diagnosed with UTI, and they very rarely do have them. Well, they do, but not as frequent as you maybe think. And we are detectives, Ben. We are playing Cluedo every day at work, aren't we?

DR BEN LOVELL 38:36

We are playing.

DR AMIE BURBRIDGE 38:37

It is play sometimes, you know, and it's about um and if it's fun, then it's okay.

DR BEN LOVELL 38:43

In every job that must be done, there is an element. Find the fun and snap the jobs again. We said that. Mary Poppins.

DR AMIE BURBRIDGE 38:52

And every task you undertake.

DR BEN LOVELL 38:58

I thank you so much for playing my game along with me today, Amy. And really increasingly leaving us home. I hope you enjoy playing along as well and guessing with us. If you enjoyed that episode, then what you must do now is go to whatever platform you're listening to us on and leave a comment, say hi, we read everything, or rate us because that improves our visibility. Other people looking for an interesting podcast. And then when you've done that, you go and tell all your mates. Um and we're very, very grateful. Thank you so much for listening to Home of Medicine Podcast. And we look forward to uh you listening, our next play along game, the next episode. Thank you, and bye bye.

DR AMIE BURBRIDGE 39:35

Thanks for listening. Bye bye.