April 6, 2026

Lethargy - Case 2

What would Amie do when a 34 year old male presents with a 6 week history of tiredness and fever?

Find out how Ben managed this case on the post take ward round.

As you listen, ask yourself: can you figure out the diagnosis? What would you have done in the situation?

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Email: a.burbridge@nhs.net
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Disclaimer: All patient stories discussed in Home of Medicine are informed by real patient interactions. However, all identifying details have been removed or appropriately modified to protect patient confidentiality.

This podcast is intended for education and professional development and should not replace independent clinical judgement or specialist consultation.

Transcript

WEBVTT

00:00:11.919 --> 00:00:18.239
Hello and welcome to a new episode of Home of Medicine Podcast in association with RTP Edinburgh.

00:00:18.399 --> 00:00:19.199
My name is Dr.

00:00:19.359 --> 00:00:22.399
Ben Lovell, and I am a consultant in Acute Medicine working in London.

00:00:22.480 --> 00:00:24.559
And here is my wonderful co-host.

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Hi, I'm Dr.

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Amy Burbridge.

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Right, Amy, it's my turn to present a case to you.

00:00:31.120 --> 00:00:42.719
This is a case where you are the uh post-take consultant on the medical take, and this case is being presented to you by a resident doctor whose clerk, the patient, who's presented today in ED.

00:00:43.200 --> 00:00:46.560
So, this is a 34-year-old man.

00:00:47.200 --> 00:00:51.679
Um, reason for presentation, generally unwell for six weeks.

00:00:52.479 --> 00:01:01.600
Uh and to be more specific, uh intermittent fevers, fatigue, loss of energy, loss of appetite.

00:01:02.000 --> 00:01:06.159
He says he had the flu six weeks ago and just never shook it off.

00:01:06.480 --> 00:01:09.040
And he's felt rubbish with it ever since.

00:01:09.359 --> 00:01:17.359
And the reason for presentation today is that the last two days, he started to feel more breathless and generally just awful.

00:01:17.439 --> 00:01:19.120
And he's had enough.

00:01:20.400 --> 00:01:21.040
There you go.

00:01:21.280 --> 00:01:23.359
That's the presenting complaint.

00:01:23.840 --> 00:01:26.640
Anything particular that you're thinking there.

00:01:27.840 --> 00:01:33.519
Okay, so 35-year-old male, normally fit and well, but has been unwell for six weeks.

00:01:34.560 --> 00:01:39.760
Fever, fatigue, low energy, low appetite, and he's had the flu.

00:01:40.879 --> 00:01:43.519
And he's now breathless and short of breath.

00:01:45.359 --> 00:01:50.000
Okay, so I'm gonna be thinking, is it a post-infective syndrome?

00:01:50.239 --> 00:01:51.599
Is this post-viral infection?

00:01:51.760 --> 00:01:53.040
Post viral syndrome.

00:01:53.359 --> 00:01:55.519
Is this a respiratory condition?

00:01:55.840 --> 00:02:09.759
Has he got a pneumonia from his recent infection that has not been treated appropriately, or has basically post-viral bacterial infection in the lungs?

00:02:10.000 --> 00:02:13.439
Shortness of breath, breathless recent infection, could this be a PE?

00:02:15.120 --> 00:02:18.240
Chronic infection or chronically unwelling, is he anemic?

00:02:18.800 --> 00:02:21.199
Um is he iron deficient?

00:02:21.360 --> 00:02:22.560
Is that why he's short of breath?

00:02:22.639 --> 00:02:23.680
Is that why he's breathless?

00:02:23.759 --> 00:02:24.719
Is that why he's tired?

00:02:24.960 --> 00:02:26.319
Is this an anemia?

00:02:26.560 --> 00:02:32.240
Um, whenever I see these sort of six-week histories, I think, could this be malignancy?

00:02:32.479 --> 00:02:34.479
So is there something else going on here?

00:02:34.560 --> 00:02:39.759
Is there a lymphoma, a leukemia, a malignancy elsewhere?

00:02:40.479 --> 00:02:48.319
Because of the constellation of symptoms and how long it's been going on, am I going to be thinking about some sort of underlying rheumatological condition?

00:02:48.560 --> 00:02:50.240
Could this be vasculitis?

00:02:50.719 --> 00:02:56.159
Could this be um, I mean, it's unlikely, but it could be.

00:02:56.319 --> 00:03:01.199
So those are the sort of things that are going through my head at the moment.

00:03:02.479 --> 00:03:17.120
So I've written down here, based on one or two sentences, you've got partially treated pneumonia, PE, anemia, malignancy, favoring hematological, considering his sort of demographics, vasculitis, nothing.

00:03:17.439 --> 00:03:18.879
Do you know what would be really interesting?

00:03:18.960 --> 00:03:33.039
Is if they could, if there was the if AI or something could make a visual representation of our brains as we sort of go through things, and then like word clouds dynamically changing, and then things getting crossed out and disappearing, and new diagnosis coming on.

00:03:33.199 --> 00:03:35.919
Um, that'd be quite cinematic and interesting, I think.

00:03:36.080 --> 00:03:37.280
Uh anyway, back to the story.

00:03:37.360 --> 00:03:38.879
I no, I think that's I think that's really good.

00:03:38.960 --> 00:03:41.199
I thought PE, I thought um flu.

00:03:41.759 --> 00:03:44.479
He said six weeks ago he had the flu, never got better.

00:03:44.800 --> 00:03:45.439
But what happened?

00:03:45.520 --> 00:03:53.520
Um, I suppose the last two days maybe he had a P and that's what's going on here, but six weeks of feeling dreadful is interesting with intimate fevers as well.

00:03:53.840 --> 00:03:57.840
Um, but we need more information, I think.

00:03:58.240 --> 00:04:01.280
Rest of the history, past medical history, nil.

00:04:01.520 --> 00:04:06.800
It's a fit and well 34-year-old, doesn't take any regular medication, has no allergies socially.

00:04:06.960 --> 00:04:19.040
He lives in a flat chair with a couple of mates, um, he's a graphic designer, um, he socially drinks alcohol, and he's a social smoker, maybe a few cigarettes a week, and also vapes.

00:04:19.759 --> 00:04:25.279
And then coming to examination, he's febrile, uh, 38.1 degrees.

00:04:25.600 --> 00:04:29.360
Um, his heart rate's 105 sinus.

00:04:29.680 --> 00:04:37.199
Blood pressure's 116 over 68, spiritual rate's 18, and is sat 97% on air.

00:04:37.680 --> 00:04:40.879
Um, that was his booking in observations.

00:04:41.040 --> 00:04:42.160
So he is febrile.

00:04:42.240 --> 00:04:47.120
He says he's had intermittent fevers for six weeks, and he's febrile at the moment, which is interesting.

00:04:47.279 --> 00:04:49.199
There is inflammation afoot.

00:04:49.360 --> 00:04:52.079
Whether it's also infection is yet to be seen.

00:04:52.319 --> 00:04:56.160
But there is an inflammatory response going on here to something.

00:04:57.360 --> 00:05:01.120
So then we play the game of hunt the infection.

00:05:01.680 --> 00:05:05.439
Um his chest is clear to examination.

00:05:05.839 --> 00:05:16.399
Um, he has no signs of peripheral edema, no clinical DVT, JVP is nice and flat, abdomen is completely soft and non-tender, and he's a slim chap.

00:05:16.720 --> 00:05:19.199
No rashes anywhere.

00:05:20.399 --> 00:05:24.879
Um, and all other neurological examination was normal, essentially.

00:05:25.120 --> 00:05:31.439
Um does that put you anywhere useful now, or has that ruled out some things or ruled in some other things?

00:05:31.920 --> 00:05:33.680
Has he lost any weight?

00:05:34.079 --> 00:05:36.959
He feels like he has lost a bit of weight, but he cannot quantify it.

00:05:37.040 --> 00:05:39.199
But he says certainly he's been off his food.

00:05:39.519 --> 00:05:41.279
And any night sweats?

00:05:41.680 --> 00:05:43.680
He has actually had some night sweats.

00:05:43.839 --> 00:05:45.040
He feels quite hot overnight.

00:05:45.120 --> 00:05:46.319
What are you thinking about?

00:05:46.879 --> 00:05:49.199
I was thinking of these symptoms for lymphoma.

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Mm-mm.

00:05:50.800 --> 00:05:52.399
Um was going through my mind.

00:05:52.560 --> 00:05:55.360
Um has he noticed any lumps and bumps?

00:05:56.000 --> 00:05:58.720
He has not noticed any lumps and bumps.

00:05:59.120 --> 00:06:00.800
Any itchy skin?

00:06:01.600 --> 00:06:01.920
No.

00:06:02.480 --> 00:06:02.800
Okay.

00:06:03.199 --> 00:06:04.800
Is he sexually active?

00:06:05.759 --> 00:06:09.360
I didn't have that information at per point of presentation.

00:06:09.439 --> 00:06:10.480
But you know that's something.

00:06:10.560 --> 00:06:13.519
So when you went to post take the patient, this is something you'd be asking.

00:06:13.680 --> 00:06:13.920
Okay.

00:06:14.160 --> 00:06:14.639
Anything else?

00:06:14.879 --> 00:06:15.360
Yes.

00:06:15.920 --> 00:06:17.680
Um, any recent travel?

00:06:17.920 --> 00:06:18.399
Oh, okay.

00:06:18.480 --> 00:06:20.879
So we'll go and ask that at our post-key ward round.

00:06:20.959 --> 00:06:21.199
Yep.

00:06:21.839 --> 00:06:24.560
Anything else we need to ask on the post take?

00:06:25.360 --> 00:06:28.319
Um any recreational drugs?

00:06:29.120 --> 00:06:30.319
Rec drugs.

00:06:30.639 --> 00:06:30.959
Okay.

00:06:31.040 --> 00:06:35.519
And what are you thinking about in in uh sexually active recent travel recreational drugs?

00:06:35.600 --> 00:06:36.720
What are you screening for?

00:06:37.040 --> 00:06:38.240
Um HOV.

00:06:38.639 --> 00:06:38.959
Okay.

00:06:39.279 --> 00:06:39.759
That's important.

00:06:40.160 --> 00:06:42.079
Uh could this be HOV zero conversion?

00:06:42.160 --> 00:06:44.560
Some of the symptoms that you described could be that.

00:06:44.879 --> 00:06:49.120
Um travel, has he been abroad recently?

00:06:49.279 --> 00:06:50.639
Has he been exposed to TB?

00:06:50.879 --> 00:06:51.920
Lives in a fatcha?

00:06:53.120 --> 00:06:59.600
Um, has he been anywhere where he could be exposed to um I'm just trying to think actually.

00:06:59.759 --> 00:07:05.279
Any the travel six weeks and recreational drugs?

00:07:05.519 --> 00:07:11.279
You know, is he taking um amphetamines that could be causing the weight loss, the fever, the tachycardia?

00:07:11.920 --> 00:07:15.680
So I know they're a bit of a stretch, but you know, it could potentially be there.

00:07:15.839 --> 00:07:18.160
So why why is it a stretch?

00:07:18.399 --> 00:07:24.079
Well, it's quite uh I'm just thinking it's not very, it's probably not gonna happen, and I'm probably overthinking things.

00:07:24.399 --> 00:07:25.600
Why is it not gonna happen?

00:07:25.680 --> 00:07:27.839
And so I'm not sure what you mean.

00:07:28.160 --> 00:07:31.839
Well, because I I um I I do think sewing debt sometimes.

00:07:32.000 --> 00:07:34.959
I'm like, yeah, is he really gonna have TB?

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Is he really gonna be on amphetamines that's caused these symptoms?

00:07:38.399 --> 00:07:42.160
No, sometimes do I need to strip it back to basics and roll out common?

00:07:43.279 --> 00:07:47.920
All right, um, so I went to post-take the chap and he didn't look very well.

00:07:48.079 --> 00:07:49.680
But you don't when you got the flu.

00:07:49.759 --> 00:07:53.040
But he looked, he looked he looked over it, as the kids say.

00:07:53.199 --> 00:07:57.519
He looked tired, fed up, a slight glistening sheen to his skin.

00:07:57.680 --> 00:08:00.079
He looked sallow, he looked pale.

00:08:00.399 --> 00:08:03.680
Um he um, what else to say?

00:08:03.759 --> 00:08:09.040
Yeah, it was a smiley tachycardic, he was no longer februar because he'd had paracetamol in the ED.

00:08:09.360 --> 00:08:11.680
Um, and I did ask whether he was sexually active.

00:08:11.759 --> 00:08:14.000
He says, not in the preceding six months.

00:08:14.160 --> 00:08:16.959
Uh I asked about recent travel, and that was a no.

00:08:17.439 --> 00:08:21.199
Um, admittedly, I did not ask if he took recreational drugs.

00:08:21.439 --> 00:08:22.800
Um, apologies.

00:08:23.120 --> 00:08:25.759
And I re-listened to the chest, and yet it was clear.

00:08:25.920 --> 00:08:30.720
I mean, when we see people with infection, I feel like this is numbers out top of my head.

00:08:30.800 --> 00:08:35.759
I don't have a data, but I feel like we look for chest and urine quite quite commonly as the big ones.

00:08:35.919 --> 00:08:37.039
And his chest was clear.

00:08:37.120 --> 00:08:40.879
And there was a chest x-ray for me to look at, which was clear as you like.

00:08:41.279 --> 00:08:44.080
Um, and uh he denied any dysturia.

00:08:44.240 --> 00:08:48.639
UTI is very uncommon in a 34-year-old man, but he denied any sort of signs and symptoms of that as well.

00:08:48.799 --> 00:08:54.720
And I really pressed on his tummy, any secret abdominal abscesses I need to know about, but there was nothing there really.

00:08:54.879 --> 00:08:58.159
And his skin was all completely normal to examination as well.

00:08:59.120 --> 00:09:02.399
Uh gosh, do I send him home or do I bring him in?

00:09:03.279 --> 00:09:05.919
Ooh, I wouldn't send him home.

00:09:06.960 --> 00:09:10.000
Because I mean I'd like to do some blood tests.

00:09:10.320 --> 00:09:11.200
Oh, okay, okay.

00:09:11.440 --> 00:09:11.600
Okay.

00:09:12.080 --> 00:09:13.919
CR CRP96.

00:09:15.279 --> 00:09:15.600
Okay.

00:09:16.399 --> 00:09:18.559
HB112.

00:09:20.720 --> 00:09:26.720
Platelets 213, white cells 14, 1.4, neutrophils for 12.

00:09:27.279 --> 00:09:30.480
His urea and electrolytes were completely normal.

00:09:30.879 --> 00:09:32.240
Lymphocyte count?

00:09:32.559 --> 00:09:34.879
Lymphocyte count was 1.1.

00:09:34.960 --> 00:09:36.000
It was normal.

00:09:36.879 --> 00:09:46.000
And I did dip his urine, and the only thing it that showed up, it was negative um for nitrites, negative for white cells, two plus of blood, and that was it.

00:09:46.639 --> 00:09:47.600
LFTs?

00:09:48.080 --> 00:09:49.360
LFTs were normal.

00:09:49.600 --> 00:09:49.759
Okay.

00:09:50.080 --> 00:09:51.360
Coag was normal.

00:09:51.919 --> 00:09:52.720
VBG?

00:09:53.679 --> 00:09:56.480
VBG showed a normal lactate of less than two.

00:09:56.960 --> 00:09:58.559
And glucose was normal.

00:09:58.799 --> 00:09:59.279
Yes.

00:09:59.600 --> 00:10:00.960
ECG was normal.

00:10:01.679 --> 00:10:04.399
A mild sinus tachycardia, but nothing else on it.

00:10:05.120 --> 00:10:06.080
HIV test?

00:10:06.639 --> 00:10:09.840
HIV test, which we do a standard actually on patients on the tape.

00:10:10.000 --> 00:10:10.159
Yeah.

00:10:10.240 --> 00:10:11.679
So uh it came back negative.

00:10:12.639 --> 00:10:12.960
Okay.

00:10:15.919 --> 00:10:17.200
Blood cultures?

00:10:17.679 --> 00:10:18.159
What's up?

00:10:18.320 --> 00:10:22.159
We're done and sent, but not available on day of presentation.

00:10:22.399 --> 00:10:22.559
Okay.

00:10:22.639 --> 00:10:24.720
And did you send a urine culture as well?

00:10:25.200 --> 00:10:29.519
I didn't actually, because there was nothing on the initial screen that made me want to look for you.

00:10:29.759 --> 00:10:30.879
Yeah, back to urea.

00:10:31.360 --> 00:10:34.159
So you did so, but it's still short of breath, isn't he?

00:10:35.039 --> 00:10:37.120
But it's 97% on air.

00:10:37.360 --> 00:10:39.279
Yeah, respiratory rate's 18.

00:10:39.440 --> 00:10:42.879
Oh, would you do uh would you do POCUS of the lungs?

00:10:43.440 --> 00:10:45.120
I wouldn't because I don't know how.

00:10:45.600 --> 00:10:47.360
But somebody else might do it.

00:10:47.679 --> 00:10:48.960
And what are you looking for?

00:10:49.519 --> 00:10:53.840
So I I I I mean I've kept whittering on about this because it's my newfound skill.

00:10:54.000 --> 00:11:13.440
Um, so often when you find a chest x-ray which is completely normal, because you you're not looking at the whole of the chest, I find that POCUS, thoracic POCUS can be really helpful because sometimes you pick up on infections, you might see um hepatitisation of the lungs, which suggests pneumonia, you might see small plulifusions that you haven't picked up on the chest x-ray.

00:11:13.600 --> 00:11:17.360
So actually, sometimes it can be very helpful where chest x-ray hasn't been.

00:11:17.440 --> 00:11:19.039
So that might be an option.

00:11:19.759 --> 00:11:29.039
I think we've done an episode maybe about hidden pneumonias, but just sort of only visible on POCUS, right at the posterior part of the lung behind the diephone, not visible on the AP side.

00:11:29.200 --> 00:11:30.080
Absolutely.

00:11:30.639 --> 00:11:32.559
Ah dear, what would I do?

00:11:32.720 --> 00:11:34.559
So he's got a slightly high white cell count.

00:11:34.639 --> 00:11:39.600
He's got a neutrophilia, his hemoglobin is on the lower side of normal.

00:11:40.399 --> 00:11:43.840
Um, basically blood corteus, livers normal, chest extreme.

00:11:44.080 --> 00:11:45.679
I would look at his lungs.

00:11:46.480 --> 00:11:48.879
Would I admit, would I send him home?

00:11:49.279 --> 00:11:50.639
Would you do a D-dimer?

00:11:50.720 --> 00:11:52.240
Would you do a CTPA?

00:11:54.960 --> 00:12:03.120
I mean, I think a D-dimer, uh, the well score is, you know, you probably think this is infection, is gonna be a higher than a PE.

00:12:03.200 --> 00:12:05.200
So I don't think you're gonna do a D-dimer anyway.

00:12:05.279 --> 00:12:08.879
And also it's got inflammatory process going on, so it's probably not relevant.

00:12:09.200 --> 00:12:10.559
Would you do a CTPA?

00:12:10.639 --> 00:12:13.519
Is tachycardic recently unwell?

00:12:15.120 --> 00:12:16.480
I might, you know.

00:12:17.759 --> 00:12:19.600
That's a reasonable shout, actually.

00:12:21.200 --> 00:12:38.799
I mean, I'm not saying it's the right thing to do, but I mean, you could do anchor, ANA, complement levels, ESR, plasma viscosity, issuuminogoblins because of the slightly high CRP in white cells, looking at vasculitis.

00:12:41.679 --> 00:12:55.200
I find these cases really difficult because that's oh, they're just quite tricky to really understand what's going on, and I can have a tendency to either under-investigate or over-investigate.

00:12:55.360 --> 00:12:57.279
And where what's the middle ground?

00:12:57.440 --> 00:12:58.240
What's the compromise?

00:12:58.320 --> 00:13:00.320
What should I be doing and what shouldn't I be doing?

00:13:00.639 --> 00:13:03.759
I'm I'm deliberately being very quiet, so I'm letting you think it out.

00:13:06.480 --> 00:13:10.720
I feel like I'm in a therapy session where you just end up talking.

00:13:12.159 --> 00:13:12.960
They're staring at me.

00:13:13.200 --> 00:13:14.159
Do you know what?

00:13:15.440 --> 00:13:15.759
Okay.

00:13:17.120 --> 00:13:18.960
I'm gonna give some antibiotics.

00:13:19.840 --> 00:13:22.639
I'm gonna give some oral antibiotics.

00:13:26.240 --> 00:13:29.279
And I'm gonna do poker to the lungs.

00:13:30.879 --> 00:13:35.600
And at the moment I'm not going to do a CTPA, but I'm certainly considering it.

00:13:36.720 --> 00:13:37.039
Okay.

00:13:37.919 --> 00:13:40.559
So what oral antibiotic are you giving?

00:13:40.799 --> 00:13:43.360
Uh amoxicellin, 500 milligrams TDS.

00:13:43.679 --> 00:13:44.000
Okay.

00:13:44.480 --> 00:13:46.799
If he's not allergic to anything, which she said he wasn't.

00:13:47.120 --> 00:13:50.720
I guess he did have an atypical infection.

00:13:51.919 --> 00:13:53.840
I'm gonna go with ammoxicellin.

00:13:54.960 --> 00:13:55.279
Okay.

00:13:56.080 --> 00:14:06.080
My view, as it often is, on patients who I cannot find a source of infection for, is let's watch and wait, and it may decl it may declare itself.

00:14:06.559 --> 00:14:16.000
Um, and I think we have done a couple of episodes about this where on on day two, whoops, oh my gosh, look at this pneumonia or look at this um, I don't know, this uh nephritis or something.

00:14:16.320 --> 00:14:19.919
So I said, let's bring him in, give him something broad spectrum.

00:14:20.000 --> 00:14:25.679
I went for IV uh kef, which is our broad spectrum, which is our antibiotic for infection of unknown source.

00:14:25.840 --> 00:14:31.039
Um, and I say, let's sit on him overnight, take lots of blood cultures, and let's see what will be will be.

00:14:31.600 --> 00:14:36.000
Um and I brought him in and I saw him again the next morning.

00:14:36.080 --> 00:14:39.200
And interestingly, the next day, his CRP had gone up to 150.

00:14:39.360 --> 00:14:47.519
He was persistently febrile, um, but otherwise, he looked similar to as I saw him before.

00:14:47.759 --> 00:14:57.679
Um, and I think it was close of play on day two, where I was like, hmm, I'm really not sure what the direction of travel is for this man.

00:14:57.840 --> 00:14:59.759
You know, I went to our morning MDT.

00:14:59.919 --> 00:15:03.200
Ever wants to know what's the estimated discharge day for all your patients?

00:15:03.279 --> 00:15:06.799
I'm like, for him, just just say two days because I don't I don't know yet.

00:15:06.960 --> 00:15:08.159
I've not made the diagnosis.

00:15:08.320 --> 00:15:10.960
We're still treating him with vitamin T, which is time.

00:15:11.200 --> 00:15:12.799
And we'll we will see what happens.

00:15:12.879 --> 00:15:15.840
And I think it was close of play that we got the phone call from Micro.

00:15:16.320 --> 00:15:20.559
And they said that all three of his blood culture bottles have grown the same bug.

00:15:20.960 --> 00:15:22.240
Staph aureus.

00:15:22.639 --> 00:15:22.960
Do you know?

00:15:23.120 --> 00:15:24.799
I mean, you were gonna say staph aureus.

00:15:25.120 --> 00:15:25.600
Did you?

00:15:25.840 --> 00:15:26.240
Huh?

00:15:27.120 --> 00:15:29.360
Because I've been thinking endocarditis.

00:15:29.759 --> 00:15:30.399
Why?

00:15:31.600 --> 00:15:35.039
Because it came into my head about one minute ago.

00:15:35.360 --> 00:15:37.600
And I've been doing that's great, but uh why?

00:15:37.759 --> 00:15:38.320
What's the reason?

00:15:38.399 --> 00:15:41.039
People have been listening, going, why did why did it come into your head?

00:15:41.200 --> 00:15:44.159
Why did your consciousness produce endocarditis?

00:15:44.240 --> 00:15:45.200
It must have had some data.

00:15:45.519 --> 00:15:48.480
Because, okay, so I was thinking, this sounds vasculitic.

00:15:48.559 --> 00:15:50.720
Endocarditis is a vasculitic process.

00:15:50.879 --> 00:16:02.320
It's been going on for six weeks, he's been losing weight, he's been fatigued, his CRP is slightly up, his platelets are a little bit low, white sulcant neutral is a bit high, a bit short of breath.

00:16:03.279 --> 00:16:07.120
It just thought, mmm, this could be endocarditis, infective endocarditis.

00:16:08.480 --> 00:16:13.279
And staph aureus, what do you make of that as a potential causative organism for staph aureus?

00:16:13.600 --> 00:16:14.720
For endocarditis.

00:16:15.200 --> 00:16:16.639
It's not common, is it actually?

00:16:16.720 --> 00:16:18.639
It's more common in drug users.

00:16:19.279 --> 00:16:19.840
Mmm.

00:16:20.320 --> 00:16:22.960
So it could still not be endocarditis.

00:16:24.399 --> 00:16:26.480
But now I'd start to look for endocarditis.

00:16:26.559 --> 00:16:27.679
I'd want to do an echo.

00:16:27.840 --> 00:16:29.039
I'd want to look at his heart.

00:16:29.120 --> 00:16:31.360
But he said there was no heart murmur, but it doesn't necessarily mean.

00:16:31.679 --> 00:16:32.320
I didn't say that.

00:16:32.480 --> 00:16:33.600
I did not say that.

00:16:34.159 --> 00:16:36.399
I said nothing about his heart sounds.

00:16:36.559 --> 00:16:36.799
What?

00:16:37.120 --> 00:16:45.039
Because I because it because heart sounds were not presented to me on the post-tate ward round, and I didn't listen to the heart on the post tape ward round.

00:16:48.240 --> 00:16:50.159
Okay, so this could be endocolitis.

00:16:50.240 --> 00:16:50.879
He could have a murmur.

00:16:50.960 --> 00:16:52.399
Let's listen to his heart.

00:16:52.720 --> 00:17:17.039
So I go to the bedside, um, I listen to his heart, and he's got a pan-systolic murmur, which was not hit up by the clerking doctor and was not picked up by my good self, because I don't always completely re-examine a patient at the posting round if I think I've had enough information um for what I need to move forward, and that we can talk about that maybe.

00:17:18.319 --> 00:17:29.119
And um we did manage to arrange an echo, and the echo showed vegetation on the tricuspid vowel with moderate associated TR.

00:17:29.519 --> 00:17:32.319
Was he a drug user, an intravenous drug user?

00:17:32.720 --> 00:17:34.720
I hadn't asked him, had I.

00:17:36.880 --> 00:17:41.039
No, you didn't ask about recreational drugs travel or sexual activity.

00:17:41.440 --> 00:17:44.079
I I went back and asked about sexual activity and travel.

00:17:44.160 --> 00:17:51.039
I didn't ask about recreational drugs, because this is a fit and well 34-year-old, highly educated graphic designer.

00:17:52.400 --> 00:17:57.680
I was sort of I was sort of pushing you a little bit because you said, oh, maybe I'm being over a bit silly, it's not likely.

00:17:57.759 --> 00:18:02.160
And I was trying to sort of pick up why it's unlikely this man might take recreational drugs.

00:18:02.319 --> 00:18:04.559
Um and I was wondering if if you were thinking the same thing.

00:18:04.720 --> 00:18:06.079
I was subconsciously thinking.

00:18:06.319 --> 00:18:07.119
I probably was.

00:18:07.359 --> 00:18:09.279
But let's let's get down to it.

00:18:09.519 --> 00:18:13.200
So he gets diagnosed with tricuspid valve endocarditis.

00:18:13.279 --> 00:18:21.200
He gets placed on our standard endocarditis um regime, which was, I think, amoxicillin, flucloxicillin, and gentomycin.

00:18:21.680 --> 00:18:25.119
Um he has a myrma, he has a vegetation on transthoracic echo.

00:18:25.200 --> 00:18:32.720
And then on questioning, this man does inject heroin off and on, and has done so for many months.

00:18:33.279 --> 00:18:42.559
I didn't know because I didn't ask, because of my own representative bias, which is a very fancy name for saying lazy stereotyping, then.

00:18:42.799 --> 00:18:45.759
This man couldn't be an intravenous drug user.

00:18:45.839 --> 00:18:54.480
He's a well-educated gentleman who has got a high-pressure job, turns up for work every day, is very articulate and very uh convincing of himself.

00:18:54.640 --> 00:19:00.720
Um, probably I don't need to ask about does he inject opiates um on a regular basis?

00:19:00.960 --> 00:19:02.640
And there was the hole.

00:19:02.880 --> 00:19:08.960
The other Swiss cheese hole was the lack of murmur detection um at the point of Clarking.

00:19:09.119 --> 00:19:20.640
And that's why he got keferoxine for 24 hours, which is not the right antibiotic for what he had, um, and caused a little bit of delay in getting to his diagnosis.

00:19:21.440 --> 00:19:40.319
He did not have any splinter hemorrhages or any clubbing, but um, I thought it was worthy of reflection because I could have clinched this diagnosis in AE if I'd asked the right questions and used the myethoscope in the right direction.

00:19:40.480 --> 00:19:46.079
Um, but I didn't, because I clearly have a bias, an archetype.

00:19:46.160 --> 00:19:54.000
Let's call it an archetype, because that sounds nicer than a stereotype, about someone who um uses intravenous drugs, and he did not match it.

00:19:54.160 --> 00:19:56.079
Therefore, I did not pursue it.

00:19:56.400 --> 00:19:59.839
You wanted to ask about recreational drugs.

00:19:59.920 --> 00:20:06.480
Um, so clearly you suspect everybody, anybody's potential to be a drug use a drug user.

00:20:06.720 --> 00:20:10.640
But it it did not fit my own representative bias for this particular patient.

00:20:10.720 --> 00:20:14.160
And that's something that I've been thinking about a lot ever since then.

00:20:15.119 --> 00:20:21.680
Hmm, that's did you go into his drug use a little bit more with him?

00:20:22.640 --> 00:20:24.240
I did a little bit.

00:20:24.480 --> 00:20:29.839
It was something him and his flatmates were doing um off and on.

00:20:30.079 --> 00:20:34.720
They didn't can consider themselves to be drug addicts because they didn't do it regularly.

00:20:34.960 --> 00:20:37.759
It was just when they wanted to party.

00:20:38.960 --> 00:20:39.440
Wow.

00:20:39.839 --> 00:20:40.240
Yeah.

00:20:41.599 --> 00:20:44.079
So inject heroin.

00:20:44.799 --> 00:20:45.759
Well, okay.

00:20:45.839 --> 00:20:46.960
That's that's new for me.

00:20:47.119 --> 00:20:48.400
Oh, okay, uh, thank you.

00:20:48.720 --> 00:21:01.519
Because I guess I always thought that if you used heroin it because it was so addictive, you you'd start to use it more and more and more and more, and it wouldn't be easy to not take.

00:21:02.000 --> 00:21:03.039
But I don't know.

00:21:03.680 --> 00:21:08.960
But I think I mean there are um functional addicts out there who who can hide it, who do take on the daily.

00:21:09.039 --> 00:21:13.200
And I guess there are people who socially shoot up.

00:21:13.279 --> 00:21:15.279
But it was something I wasn't very familiar with.

00:21:15.599 --> 00:21:16.400
Gosh.

00:21:17.519 --> 00:21:18.160
Wow.

00:21:19.039 --> 00:21:22.880
And recovery from the infection, how did he get on?

00:21:22.960 --> 00:21:24.240
What was his valve like?

00:21:24.559 --> 00:21:25.839
It was not in a good state.

00:21:25.920 --> 00:21:34.079
And this gentleman eventually got referred to our tertiary cardiothoracics unit for a valve replacement because the terracuspid valve was partially destroyed.

00:21:34.400 --> 00:21:34.960
Gosh.

00:21:35.200 --> 00:21:39.599
Yeah, so he had surgery and made a good recovery as far as as far as I can make out.

00:21:39.839 --> 00:21:48.720
Um and uh I I don't think that the the 24-hour delay after six weeks of of vegetation caused any harm or outcome to him.

00:21:49.039 --> 00:21:50.799
But I think it was a good learning case.

00:21:50.880 --> 00:21:57.519
And um I I I very deliberately didn't tell you about his murmur on the examination because I I wasn't told about it.

00:21:57.599 --> 00:21:59.119
Not deliberately, I just wasn't told about it.

00:21:59.200 --> 00:21:59.759
So my brain.

00:22:00.079 --> 00:22:00.720
Clicked over it.

00:22:00.799 --> 00:22:07.119
And I was intrigued back that when you were recounting the case just now to yourself, you said, so he hasn't got any murmurs on ascortation.

00:22:07.279 --> 00:22:08.559
And I think that's important.

00:22:08.720 --> 00:22:09.599
That's not true.

00:22:09.759 --> 00:22:12.079
I just didn't tell you about his heart examination.

00:22:12.240 --> 00:22:18.480
And it's interesting how by not getting that information, our brain sort of synthesizes it as that this the sign wasn't present.

00:22:18.799 --> 00:22:26.720
Part of our jobs as consultants on the post-tate ward round is to listen incredibly carefully, spot gaps, and just say, sorry, murmurs?

00:22:26.799 --> 00:22:28.880
Anything on heart examination?

00:22:29.039 --> 00:22:33.759
And things like that, just so we can fill in any tiny little gaps in the history, which I hadn't done in that case.

00:22:33.920 --> 00:22:37.039
Because if we don't, then maybe our subconscious could fill in the gaps for us.

00:22:37.119 --> 00:22:40.480
And we assume if it ain't mentioned, it's because it wasn't there.

00:22:40.720 --> 00:22:43.200
But we need to hear that it's not there.

00:22:43.599 --> 00:22:44.400
Do you know what I mean?

00:22:44.640 --> 00:22:46.319
This is the art of post-taking.

00:22:46.480 --> 00:22:48.400
I never got taught how to post take a patient.

00:22:48.480 --> 00:22:53.680
I've sort of had to sort of invent my own way of doing it, as all as all acute consultants do.

00:22:53.759 --> 00:22:56.799
But this was a learning point for me about how I conduct my post take ordinance.

00:22:57.279 --> 00:23:02.160
And I certainly do them very different, I think, to you.

00:23:02.319 --> 00:23:08.079
Um, I think I need to learn from you actually, Ben, because I don't think my post-taking wardrounds are particularly good.

00:23:08.319 --> 00:23:11.119
Um I'm so slow.

00:23:11.519 --> 00:23:12.799
I've talked about this before.

00:23:12.960 --> 00:23:18.559
I I have to take the history and re-examine everything and everyone.

00:23:19.200 --> 00:23:22.480
Um and it's but it paralyzes me.

00:23:22.960 --> 00:23:26.559
Like I'm just uh yeah, I'm overwhelmed by post-taking now.

00:23:26.720 --> 00:23:31.920
Maybe I've been doing it for such a long time that I'm just I need a break from the post take.

00:23:32.000 --> 00:23:32.400
I don't know.

00:23:32.640 --> 00:23:34.400
In acute medicine, that's what we do, isn't it?

00:23:34.559 --> 00:23:35.200
Day in, day out.

00:23:35.279 --> 00:23:36.160
We are post-take.

00:23:36.319 --> 00:23:37.519
That's that's exactly what we do.

00:23:37.599 --> 00:23:45.759
And I think it's really difficult cognitively every day to see new patients.

00:23:46.240 --> 00:23:57.039
Because every day we are we hear new histories take on all this information, and there's so much to synthesize and so many decisions to make because nothing's been made for us so far.

00:23:57.200 --> 00:24:01.119
We are the decision maker, and that can be really difficult sometimes.

00:24:01.680 --> 00:24:04.079
It also requires a large amount of trust.

00:24:04.319 --> 00:24:06.880
You say you're very slow, I'm very, very fast.

00:24:07.279 --> 00:24:12.880
And that's not because I'm that's not better, but that's uh I I take a lot on faith.

00:24:13.039 --> 00:24:16.720
Um, and I say, so so you're telling me you detected X and Y.

00:24:16.799 --> 00:24:19.759
This is the blood, this is the X-ray, and you're convinced this is the diagnosis.

00:24:19.839 --> 00:24:21.920
Okay, now my job is to go and double check.

00:24:22.079 --> 00:24:22.640
Hello, Mr.

00:24:22.720 --> 00:24:23.039
Smith.

00:24:23.200 --> 00:24:23.839
Nice to meet you.

00:24:23.920 --> 00:24:25.680
I'm Ben Lovell, I'm the consultant.

00:24:25.759 --> 00:24:29.440
I've been hearing all about you from insert a resident doctor's name here.

00:24:29.599 --> 00:24:31.119
I'm so sorry you've come into the hospital.

00:24:31.200 --> 00:24:34.240
I understand you've had a nasty cough and we've diagnosed you with pneumonia.

00:24:34.319 --> 00:24:35.680
How are you feeling today?

00:24:35.759 --> 00:24:39.839
Um, and you've been unwell for two days and you've been coughing, and then you had a fever, and here you are.

00:24:39.920 --> 00:24:44.799
And and I rely on the patient to jump in and say, no, no, no, not two days, or no, that's not right.

00:24:44.960 --> 00:24:53.119
Um, but I I repeat the information to the patient in front of them and the resident doctor, just so everyone has a chance to go, no, you got the wrong end of the stick there.

00:24:53.279 --> 00:24:54.480
And do I miss stuff?

00:24:54.559 --> 00:24:56.240
Or look at the case we're doing today.

00:24:56.400 --> 00:25:06.559
Um, when you take a lot of things on trust, on faith, um you have to sort of double check, you think you're coming from the right diagnostic direction as the initial clerking doctor.

00:25:06.799 --> 00:25:11.440
But I find that I can't, I can't re-examine from scratch, not totally.

00:25:11.759 --> 00:25:15.680