Unexplained Shortness of Breath

SPEAKER_01 0:11

Hello and welcome to a new episode of Home of Medicine Podcast in association with the World College of Physicians Edinburgh. My name is Ben Lovell. I am a consultant working in acute medicine in London in the UK, and I'm joined by my wonderful co-host again today.

SPEAKER_02 0:27

Hi, um, I'm Dr. Amy Bearbridge. I am a consultant in acute medicine, um, and I'm now a director of professionalism at Lincoln Medical School, which is still very new and sounds very strange to me to say.

SPEAKER_01 0:41

But it's lovely to hear.

SPEAKER_02 0:42

Yeah. So you have a case for me.

SPEAKER_01 0:45

Yes, I do. And this is um this is what I call an ambulatory care case, because that's the old language, but I think you would call this STEC, wouldn't you? Same day emergency care. We officially rebranded, but you know, you you stick with what you learn with. So we're in STEC, and this is a patient, it's a a young man, he's 29, sent him by the GP because he's um, well, let's say slightly breathless and feeling a bit weak, not his normal self. Uh, and the GP referral letter was quite sparse, normally fit and well, young man at the age of 29, feeling a bit weak and washed out over a period of about three weeks and more breathless than usual. Please see and assess query PE. That was the referral. So I went to the waiting room to call the gentleman in to the clinic to make my assessment. And um the patient stood up and followed me in and looked the absolute picture of health. A strapping young man, very healthy looking, um, very well built, obviously very athletic, shining with good health, really, follows me into the uh into the assessment room. And we sit down, I say, tell me what's been going on. And he says, I'm just not my normal self for about three weeks. Um I'm more tired than usual. Um, I'm not um able to run as far as I could when I go for a jog, which is strange. Um, sometimes I just feel flat. He said to me, I feel like my engine's gone. And I don't have the oomph and the wherewithal that I normally have. I'm normally a very fit and active person, but I'm just unable to do what I could normally do. I'm stopping halfway up flights of stairs, uh, which I've never had to do before. And I said to him, Did you have some kind of viral illness which preceded all of this? And he said, No, no, no, no sort of acute febrile sickness or anything like that. And it came on, he reckons, about three weeks ago, not overnight, but it's been getting slowly worse day by day. So that's the the hook, as it were, of the case. What are your immediate uh thoughts uh on on the data so far?

SPEAKER_02 2:55

So I've got a 29-year-old male that has no past medical history of note. Um has had a three-week history of gradual breathlessness, feeling weak. And the GP has referred him into queria pulmonary embolism.

SPEAKER_00 3:12

Yeah.

SPEAKER_02 3:13

And on your initial sort of end of the benogram is that he looks very well. He looks like a picture of health, but he says that he's tired, he can't run, and that his engine is flat and gone empty. And I certainly know how that feels sometimes. Exhaustion, he just can't do anything. So, am I worried? Um probably not, to be honest initially. Um, you said that he looks well, gradual breathlessness over three weeks, queer PE. So that I guess I need to think about why did the GP think this gentleman had a PE? Has there been any risk factors, any recent travel, any family history of any blood clotting, DVTs, any PEs, any history of coagulation, cascade disorders, either fam familiar or himself? Any long call travel that he's been on? So I want to ask those questions. The weakness, is he anemic? You know, why is a 29-year-old man anemic? Um, has he changed his diet recently? Has he had a change in bowel habits? Has he vomited blood? Had he passed blood from the back passage? Has he had any hemoptosis? I mean, basically, I want to ask every single question from every single system because it's such a it's not a woolly or a vague presentation, but weakness is has he is he breathless on rest? You said on exertion, but is it there at risk? Can he lie flat at night? Does he wake up at night gasping for breath? Is he wheezy? Any chest pain, any widespread body pain, any weight loss, any night sweats? Basically, the list is endless.

SPEAKER_01 4:57

All right, all right. Okay, lots of very, very good questions. Um, yeah, so this is this is tired all the time. I remember learning about this in medical school. I think it's one of the biggest presentations to primary care, actually, or at least it was back in the day when I was a trainee. Um, yeah, T-A-T-T, tired all the time. Um, and causes of tired all the time. I go through the similar sort of cycle that you did. I think um hematological, so anemia, I think endocrine, so I think is it a new undiagnosed diabetic, or if their thyroid gone off and they're hypothyroid? Um, I think about occult malignancies, very rare. Ask a few questions about those. Um, and of course, I think the main culprit in all of this is psychological. Um uh is it life? But you you don't make too many assumptions at the front door, and you there's a few things I like to go through first before I come back and say, listen, what's going on in your private life and your personal life? Anything that you think could be adding to this feeling of tired all the time? So a pretty similar process to you, really. So I asked him a lot of questions. Any chest pain? No, no pleuritic pain, which would make you think PE, no central cardiac-sounding chest pain. But then again, why should a 29-year-old ever have cardiac-sounding chest pain? Um, I asked about things like weight loss and appetite. Appetite's okay, hasn't lost weight. And he would know this because he is someone who tracks his fitness very well. He goes to the gym, um, very muscular, uh, looking at his, I don't know, what do muscular people do? They add up their fat contents and muscle and macronutrients. Yes. Yeah, he was doing all of that. Um so he's he he wasn't losing weight. He said that um, I said, Are you breathless all the time? He says, No, it's when I'm trying. So it's at the gym, it's going up the stairs, it's going for a run, but when he's still, he's not so breathless. He had not experienced any PND or orthoclene, and he had not noticed any ankle swelling at all. I thought about has he potentially got a new undiagnosed small airways disease, an asthmatic? Um, do you wheeze? Do you have a cough overnight? Is the breathlessness worse overnight or first thing in the morning? But there were no real patterns that I could find. He didn't have a history or any other atopies, such as hay fever or eczema or allergies that would go with the new small airways disease diagnosis. So that's respiratory. We've done endocrine, we've done cardio, we've done a hemoscological, I haven't got my blood results back. Um, you said at the beginning, would I admit this person? And my thought was there is no way this man is being admitted to hospital. Nothing can come to light in this ensuing consultation that would make me admit this man to hospital because he does not need hospital treatment. And we can manage this as an outpatient because he looked healthier than me. He looked very, very well. Wasn't needing oxygen, wasn't needing anything intravenously, as far as I was aware. And to answer your other question, what made the GP think this could be a PE? It's difficult because you don't get to have that conversation, do you? They just when the patient comes to the paper. So was the GP just thinking, gosh, what could cause breathlessness in a young person? It's not going to be angina or COPD, so let's say query PE. Maybe it's something I can hang a diagnosis on to get them seen by an esthetic doctor. Uh, but I couldn't elicit any triggers for a venous thromboembolic event, such as all the things you've said, recent surgery, coagulopathy, thrombophilias rather, um, long haul flights, or immobility, nothing like that. And he hadn't noticed any any calf swelling that would that would indicate a DVT.

SPEAKER_02 8:39

Does he take steroids? Anabolic steroids?

SPEAKER_01 8:43

Why do you ask?

SPEAKER_02 8:45

Because anabolic steroids that you can purchase maybe at um, I don't know, at some gyms I know sell them, um, and you can buy them off the internet. Um so I'm gonna think about this. So steroids, they're often when you buy a steroid that may be off the internet or over the counter or illegally, they aren't often just steroids. You don't just often get the anabolic steroid portion, it's often mixed with other medication as well. So sometimes testosterone, sometimes insulin, sometimes oestrogen. So it's not often the anabolic steroid that you think you're getting. So has this individual got some steroids? Is he taking them? Has it caused some esophageal irritation that has led to inflammation, that has led to some bleeding and some iron deficiency anemia, which has led to breathlessness? Yes, that is a stretch.

SPEAKER_01 9:46

I asked him drug history, doesn't take any medications. I asked him, do you take any other drugs, any recreational drugs at all? Flatly denies it.

SPEAKER_02 9:55

Okay, so I mean I'd uh I guess what I don't want to do here is make assumptions that somebody who is very muscular um is using steroids or abusing steroids. And there are some telltale signs. You might get um some, you might be lots of like acne on the back or quite spotty, um, you might get quite muscular upper body. Um sometimes they have erectile dysfunction or testicular atrophy. Although, to be honest, that's probably not something I'd start to ask at the very beginning of the consultation, but it's something I might be thinking about. But if he says he hasn't been using anything over the counter, then I have to believe him initially. And then maybe I'd re-come to it again if things didn't work, if things didn't make sense, if it didn't fit an illness script, if he didn't fit a picture that is familial to me, then I'd probably challenge that.

SPEAKER_01 10:54

Fair enough. Uh so shall we examine him?

SPEAKER_02 10:58

Yes, please. I'd like to know his observations.

SPEAKER_01 11:01

Yeah. So heart rate 112. Ooh. Regular. Blood pressure 146 over 91. Okay. Respiratory rate 22. Oxygen level is 96% on Romaire, and his temperature is 36.7.

SPEAKER_02 11:23

Did he have a glucose done?

SPEAKER_01 11:25

Uh he did have a glucose done, and it was normal. It was on the VBG. It was normal.

SPEAKER_02 11:30

And the reason I'm asking that is if he's on steroids, that can sometimes cause that catabolism into high glucose. Okay, I mean, those observations are worrying. He's got it's tachycardic, he's got it's slightly hypertensive, his respirator's high. So whether his saturations are okay, with those observations, actually, yeah, this could be a PE.

SPEAKER_00 11:52

Fair enough.

SPEAKER_02 11:53

But the blood pressure is quite high. So, what could be causing the high blood pressure? Could it be the steroids that he's taking that are activating the cortisol within his inadrenal gland? You're gonna get some more aldosterone, which is absorb basically taking more water on or causing hypertension, or is it something weird and wonderful? But I want to know what examination, what else have we got on examination?

SPEAKER_01 12:18

Okay, so he's very well built, um, very lean. Um, he uh was a bit anxious, but but not pathologically so. Um, understandably anxious, considering he wasn't feeling very well. He had no extra work of breathing, and on examination of the chest, his heart sounds were normal. His JVP was not elevated, and there was no peripheral edema either at the ankles or at the sacrum. His chest sounded clear. There were no masses in the abdomen and no lymphoadinopathy detected. He did not have pale conjunct either. Um, a gross neurological examination was normal, and there were no thyroid masses I could palpate at all when I was feeling for the thyroid.

SPEAKER_02 12:59

Did he have a rash anywhere?

SPEAKER_01 13:02

No.

SPEAKER_02 13:02

No, any acne?

SPEAKER_01 13:05

No. No, no, and I should say I um he is social history, was it he was a personal trainer and model part-time.

SPEAKER_02 13:16

So like a fitness model.

SPEAKER_01 13:18

Yeah, so he was very well kept. Oh, I've just thought. Not the kind of person who would who would tolerate a bit of acne, I think.

SPEAKER_02 13:25

Okay. Is he buying I'm just um Manjaro, Azempic?

SPEAKER_01 13:32

That is a really good thought because I think a lot of people are, and I think there's a stigma to it that people will say they they haven't when they have.

SPEAKER_00 13:41

I agree.

SPEAKER_01 13:41

And I've I've had a couple of um patients recently who've actually presented with euglycemic ketoacidosis, and I've said to them, absolutely no judgment to make sure I treat you properly and give you the right medications. Are you taking Manjaro or Zempic? Because we know that can trigger this biochemical abnormality that we're seeing in you. Absolutely not, no way. Oh, okay, okay, I believe you, but um, it is a good is a more and more valid question, I think. Because I think the people who are taking the GLP1 drugs, who because you don't really need much to get hold of them in the UK now, you can find them online at a clinic. Um and we're starting to recognize um some what used to be case report data, but it now is amassing into critical mass, and some really good data that the about the side effect profile of these drugs, which are largely extremely safe, but we are recognising um some patterns.

SPEAKER_02 14:31

Hmm. Okay. None the wiser. Um, okay. Hmm. So I've written two words, I've got three things down. I've got thyroid. This is what I've wrote. Thyroid, fear chromocytoma, drugs, manjaro, azempic. So obviously that's where my thought processes are going. But um I would like some blood tests, please.

SPEAKER_01 14:57

Yeah. So we did some routine bloods, FBC. I've got a hemoglobin of 180.

SPEAKER_02 15:02

180.

SPEAKER_01 15:04

180.

SPEAKER_02 15:05

Oh, that's high.

SPEAKER_01 15:06

I've got a white cell count of 7.2 and platelets of 312.

SPEAKER_02 15:13

Okay.

SPEAKER_01 15:13

On his usenese, I have a sodium of 137, potassium of 4.6, and a creatinine of 111. So a little bit high, but a little bit high, but very commensurate with his body, uh his muscular mass, you know?

SPEAKER_02 15:30

Yeah.

SPEAKER_01 15:30

Um, and his LFTs, his ALT was 122, which is uh slightly up, his Alk FOS was 88, and his bilirubin was 14, 14.

SPEAKER_02 15:41

Did you do a CK?

SPEAKER_01 15:43

I didn't actually.

SPEAKER_02 15:45

I'm just thinking of muscle breakdown and okay.

SPEAKER_01 15:49

Um CRP was six. Um, yep, thyroid function came back, and he was U thyroid, so TSH was in range.

SPEAKER_02 15:58

Okay. You said his glucose was also within normal limit.

SPEAKER_01 16:06

Yep. Yeah. I also did an ECG, which just showed a bit of sinus tachycardia. Um did you do a D dimer? No. I you maybe I should have done for my PE, but my my well score was was was very low. My suspicion of PE was through the floor.

SPEAKER_02 16:28

I mean, his pert would be zero, wouldn't it?

SPEAKER_01 16:31

His pertinent.

SPEAKER_02 16:32

No, it wouldn't. Perk, pert.

SPEAKER_01 16:35

Um I think it would be more but it with a tachycardia. Well, sh shall I shall I do it now? Let me just uh have a quick look.

SPEAKER_02 16:43

Pert, what am I thinking? Calling it PERT. Pulmonary, I mean it's really like criteria, perk, not pert. Yeah. Okay.

SPEAKER_01 16:52

Homer calculator. Right. Age over 15, no, heart rate over 110, yes. Yes. Sats on remain less than 95, no, leg swelling, no, hemoptosis, no, recent surgery, no, previous PE, no, hormone use, he says no. So that gives him a score of one.

SPEAKER_02 17:09

So we can't rule it out.

SPEAKER_01 17:10

We can't rule it out. Any criteria positive, the perk rule cannot be used to rule out a PE in this patient. Well, I probably should have done a D dimer then, shouldn't I?

SPEAKER_02 17:20

Did you do a chest x-ray?

SPEAKER_01 17:22

Yeah, I did. Clear lung feels, no consolidation, no pulmonary edema, maybe very mild. I don't know, maybe mild cardiomegalycardiothoracic ratio might have been a bit uh larger than 0.5.

SPEAKER_02 17:38

Oh gosh. So you've got a 29-year-old who's breathless, who's tachycardic, and is actually not anemic at all. In fact, he's polycythemic.

SPEAKER_01 17:53

Yes.

SPEAKER_02 17:54

Is he a smoker?

SPEAKER_01 17:56

No.

SPEAKER_02 17:56

Alcohol?

SPEAKER_01 17:58

He says almost not.

SPEAKER_02 18:00

Okay. Is he uh part got a partner?

SPEAKER_01 18:03

Um he did have one female female partner, yeah.

SPEAKER_02 18:06

Okay, um, just thinking about I always think about sexually transverse diseases, HIV, I always don't um any foreign travel, but you said he hadn't had any travel.

SPEAKER_01 18:16

No. It's funny, isn't it? I was a bit stumped. I was almost I was almost tempted myself to say to cut him free and basically say, look, I've really investigated you here, and I come up with nothing except a mile tachycardia. Come on challenge me.

SPEAKER_02 18:35

So have we investigated him? Have we? Are we happy that we know the cause of the tachycardia? No. Are we happy that we know the cause of the polycythemia? No. Are we happy that we know the cause of the hypertension? No. So there are too many things here that I can't fit together. They're quite disparate, but I can't answer why they are like that. So this is where I get my this is a bit odd. I'd want to just double check about drugs again, about the steroid usage, maybe. Um, any amphetamine usage, although again, not as common as it used to be.

SPEAKER_01 19:21

I think it's a good I was in a similar place. So part of me was saying, I've investigated you enough. I've not found anything concrete, yeah, yeah, uh pathological, anything that's pathognomonic of a condition. Look, go back to your GP if this doesn't settle, but maybe it will settle and whatever it was, give it a bit of time. On the other hand, I had a few little pink flags, no red flags.

SPEAKER_02 19:43

Yeah.

SPEAKER_01 19:43

You allow it to be a bit tacky card, I get a bit hypertensive when you're in the hospital. It's a stressful place to be, right? But but maybe it was something I shouldn't ignore. Um the only thing I thought I'd do, Belt and Brace's approach, I had not done to work this this uh gentleman up, would be an echo. Just to make sure there was no cardiac cause for this.

SPEAKER_02 20:04

And you can do that to us, can't you?

SPEAKER_01 20:06

Do you mean me personally?

SPEAKER_02 20:08

Yeah, you can do that. You're trained, aren't you?

SPEAKER_01 20:10

I can, but I rarely do them because um because uh yes, if you want to do a proper 45-minute echo uh and look, you know, the LV strain rate and diastolic function and all that sort of thing. Um, I'll let the professionals do it. So I said, I'm happy for you to go home, but let's get an echo. Our next echo slot in Estee, we have a couple of slots today. Um, the next one is on Tuesday, and today's Friday. So go home over the weekend. If you become unwell, come back to us anytime. But I think you'll do until Tuesday. Come in, we'll do this echo on Tuesday morning, we'll get the results there and then, and we'll just make sure we've not missed anything else. And that was my plan. And I felt that was quite reasonable. And I knew that I'd admit him for an echo, an inpatient echo. I really didn't have the justification to do that. Uh do you agree?

SPEAKER_02 21:01

Yeah, I yeah, I mean, I I've got a couple of questions. Number one, what was his MCV and hematocrit?

SPEAKER_01 21:11

Right, his MCV was normal, it was the high 90s, and his hematocrit was slightly elevated, but I think I can't haven't got the exact number.

SPEAKER_02 21:20

Okay.

SPEAKER_01 21:21

What are you thinking?

SPEAKER_02 21:23

I was just thinking sticky blood. I don't know. I don't know what I was thinking to be honest. And the other question was something to do with blood pressure. Would you give him medication to reduce his blood pressure because he was hypertensive?

SPEAKER_01 21:40

Not in a million years.

SPEAKER_02 21:41

No, me, me either, but I just wanted to check because I know that some people may give give treatment for that blood pressure.

SPEAKER_01 21:49

I handed my badge first and quit. I I feel quite strongly about this. We should not be messing around with people's high blood pressure in an outpatient uh setting or or in an acute setting. uh health event when they are hyperadrenalined and hypercortisols. Absolutely. They go home, that amylodopine kicks in in 18 hours time or whatever its half-life is, and then he's 70 over 30 tomorrow morning and he can't get out of bed. So do do that at your peril. But I've certainly never been one for the stat amylodopines and I really encourage listeners not to go down that route either.

SPEAKER_02 22:21

Yeah and I I completely agree. Unless it's hypertensive urgency or hypertensive emergency, which is obviously two very different things. I do see a lot of nitropine usage because it has about a six hour um onset of action versus amlodipine. But again there's very little evidence again around that. And I've seen patients come in and you check the blood pressure and it's high and you check it again and it's high and you keep checking it. And the blood pressure's of course going to go up because they're in a stressful environment so I'm fully on on board with that. Okay, so you I I agree with you actually I think that you did the right thing.

SPEAKER_01 22:56

Good. So Tuesday comes he comes back in has his echo and he just pull up his result here findings. Severely dilated left ventricle I knew you were going to say that global hypokinesis with no regional wall motion abnormality left ventricular ejection fraction approximately 20 to 25%.

SPEAKER_02 23:22

Oh my gosh.

SPEAKER_01 23:23

Mild LV hypertrophy no significant valvular disease uh an RV function mildly impaired how does a 29 year old healthy man end up with a heart this week hereditary okay that could be one option maybe um drug use I would keep going back to drugs and I don't know why that's is that a cognitive bias of mine maybe potentially Ben I don't know so we would do obviously a genetic screen for inherited cardiomyopathies as you say we would do a viral screen looking for viral cardiomyopathies and of course he needs a cardiac MRI doesn't he and these patients often end up getting cardiac biopsies as well after their cardiac MRI under cardiology teams to see if they can work on why he should have this dilated what looks like a dilated cardiomyopathy. You keep going back to drugs.

SPEAKER_02 24:25

I'm sorry and that's a big bias of mine isn't it and I don't know why.

SPEAKER_01 24:29

Okay let me well maybe I'm going to reinforce your bias I went back to him and I said I know we've talked about this and you don't take any recreational drugs I really have to know do you have do you take any supplements do you take any performance enhancers do you take anything from the gym and it all came out I know it you called it okay yeah so um yeah he he uses performance enhancing drugs PEDs this is what is often used now instead of the gold word anabolic steroids although of course they are the same they're mixed with everything aren't they they're mixed with other drugs as well aren't they let me give you a crash course in performance enhancing drug use. This gentleman was he admitted to using cycles um uh which means they go through uh six to eight weeks of taking um very high intensity anabolic steroids to for muscular gain then they drop down to a maintenance dose or a very low dose or occasionally no dose at all and they do this to make sure they don't switch off their own endogenous testosterone production because they don't want to suppress the axis too much. This is Jim Bro science. It's actually very very in-depth they uh he also does something called stacking stacking means where they take multiple different PEDs anabolic steroids together to maximize muscular gain. And he was also doing and that that cycling where you take a big dose then you go drop it down is often called blast and cruise. So you blast the steroids then you cruise in a lower dose you don't lose all the gains that you've made. He's been using them intermittently for years. He was also taking letrozole and anastrazole to lower his estrogen he said and this is because um very commonly people who take anabolic steroids are aware that in the body you um they undergo aromatization into estrogen which could cause problems such as erectile dysfunction and gynecomastia so therefore a lot of people will also take aromatase inhibitors maybe you're familiar with letrazole and astrazole we give them to women who have hormone receptive breast cancers in order to inhibit um the that um aromatization process of testosterone into estrogen. So he was heavily heavily into this we do know that prolonged anabolic steroid use can cause cardiomyopathy due to unknown mechanisms probably direct myocardial toxicity is associated with fibrosis and remodeling of uh of heart muscle also hypertension that polycythemia we noticed the HB is quite common with testosterone use as well actually where you get um elevated hematocrit as well um unfortunately the the side effects are multiple with these drugs um cosmetics you might say balding acne but also um testicular atrophy endogenous suppression of urine testosterone as I've mentioned um mood changes depression even psychosis this isn't just about cosmetic drug use this is uh they are potent endocrine and cardiovascular agents and they're out there and they're actually really really common and they're getting more and more common amongst healthy young men who attend the gym and you could go into a huge rabbit hole about why that should be it's associated with the rise of social media getting the Instagram perfect body uh reality television um there are there are uh I find quite childish names such as which sort of I don't really give due justice to what's going on but something called bigorexia where they look in the mirror and they see a skinny person but in fact they're incredibly muscular so they're chased always chasing the higher high um and when I spoke to him and said your life is going to be very different now you can never ever take these drugs ever ever again he was destroyed he was absolutely destroyed I don't know who I am without without my body and my gym like this is my job I'm an influencer I have thousands of followers online um I can't give this up is my identity I don't think I ever could even if you've told me that I've cut my life expectancy by 2025 years I don't think I could stop doing this because I'm nothing if I get skinny or if I lose my muscles if I lose my self-identity was a very very strange intense conversation.

SPEAKER_02 28:59

Have you encountered this before I haven't I have seen um quite a few men who are taking anabolic steroids but not to this level or maybe I didn't delve into it enough. It's really scary isn't it I mean that but I get it I I get it because there is a lot of there's body shaming out there you know there's a lot of social media has a lot to answer for and I really worry about the younger generations coming up and seeing this and how you know body dysmorphia and how you're perceived. Yeah it's incredibly sad.

SPEAKER_01 29:45

It is it is and I think it isn't athletes I always thought it was athletes you know who got banned because they were chasing the ultimate records you're trying to break their own personal best they're not and the users that we're going to see are not elite athletes they're just ordinary young men who are chasing an impossible body standard absolutely impossible body standard so what what happened to my guy he he he needed to start um some treatment he had to start the four pillars of heart failure management ACE inhibitor or inch though um a beta blocker an MRA spinolactone and SGLT inhibitor he had to um stop taking all of his anabolic steroids I did follow him up his notes up and when he attended um a cardiology follow-up a few months later his ejection fraction had improved 40 to 45 percent so some recovery yeah but this is lifelong medication for him now um and at the age of 29 I mean he could be somebody who in his middle age is looking at a heart transplant massive massive surgery so what did what unlocked it you said steroids practically from the get-go and the patient denied it and I think what we need to do is of course we approach it with a non-judgmental tone and attitude from the point of view saying I only want to make sure I give you the best treatment that you need that's why I'm asking I'm not gonna tell anybody I'm not gonna shame you I'm not gonna judge you but I think what unlocked it in this case was no drugs no recreational drugs because he didn't see this as a recreational drug yes so you've got to say if you have really big muscular individuals with a very low fat mass uh very very lean the questions are are you taking any hormones are you taking any supplements are you taking any gym uh gym drugs are you taking any testosterone are you taking any anabolic steroids so you've got to name them because they might not classify them in their own minds as a drug where was he buying it from was it on the internet? Yeah you gotta you could I you could Google I I won't teach any listeners how to do it you could Google steroids in the UK and you could go to a website and you can buy Lord knows what you're buying these labs are not high grade um labs these are labs in people's kitchens uh and what the content is of the pills that you're popping or injecting um is absolutely anyone's guess it's a really really really dangerous road to go down because these are sort of homemade labs but um but there you go would you like to know some of their names I was doing some research yes please yeah okay so the big one is testosterone obviously T they call it Tren Tren Tren T-R-E-N Tren very big in the gym locker room short for Tren balone it's actually a very potent veterinary steroid that causes severe hypertension but massive gains uh dian bol called D ball or D is another big one as well that one's quite hepatotoxic so they know they've got to keep an eye on their LFTs and a lot of them take milk thistle to go with it because they think it'll sort of purify the liver. Decca D E C A. This one's more associated with sexual dysfunction. Winnies that's short for Winstrol are you taking Winnies then uh that that one is linked to hyperlipidemia and lipid changes. Another big one is HGH, human growth hormone which is uh injected and is linked to insulin resistance and cardiopathy and echromegallic features yikes. So uh they're really common ones and what you might see as well is the letrozole and the anastrazole which I mentioned which they use to avoid the estrogen uh effects and you might see them using something called clen which is clenbuterol.

SPEAKER_02 33:28

Clembutyol is actually a beta agonist a bit like sarbutamol but it's it acts on the um uh adipocyte receptors and it helps you burn fat so they often take it as a supplement but this of course can cause tacky um cardias and arrhythmias and things just like um a nebulae salbutamol can so now you know you're gonna say listen you told me you're not taking any drugs I see you're a very very well built person you go to the gym are you taking tea trend winnies D Ball any clen now you're down with all the lingo we can ask the right questions yeah it's um bit depressing isn't it it is but it also makes me wonder how many people I may have missed who have been taking these medications that I haven't asked specific questions and you know me I'm always about open questions um letting the patient talk but I think it's also really important when we have cases like this to be very specific do you take I I had a patient years ago who um had lead poisoning and had been yeah had been buying medication off the internet um and do you take any medication on the GP? No do you take another counter no didn't ask if I bought anything on the internet yeah so sometimes you have to be really specific don't you about the questions that you're asking.

SPEAKER_01 34:48

Yeah. And that should be our next question. I'm when I learned social histories I asked about smoking and drinking. Yeah and then I had to learn to say and any recreational drugs because I wasn't taught that bit really at medical school and now I have to learn to say and are you buying any other drugs or supplements or hormones on the internet including Manjaro or anabolic steroids because I think that's something that we are going to be seeing more and more yeah I agree absolutely wow that was a really really interesting case thank you so much Ben it didn't go where I thought it was going to go of which is why medicine is continually brilliant and interesting because I have learned I've been a doctor for 20 years and I learned something new today. So you never stop learning good you never stop and I and I hope our listeners have have have learned something they find useful going forward. And I think that's taken us to the end of the episode so thank you so much Amy for playing along thank you so much everyone for listening of course please do tell all your friends about this podcast and do take a second to to rate or leave a review on whatever Apple platform you're listening to us on because it helps us grow our podcast and reach new listeners. Thank you so much everybody have a wonderful rest of the day and goodbye.

SPEAKER_02 36:06

Goodbye