FLASHBACK episode - Shortness of breath

We revisit one of Ben's earliest episodes from 2022, when we discuss a case of a gentleman I reviewed who presented with shortness of breath. 

This is also our most listened to episode and highlights how Ben works through a case in the Emergency Department. 

Get in touch at a.burbridge@nhs.net. We love to hear from you 

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

SPEAKER_03 0:11

Hello and welcome to the Home of Medicine Podcast, a podcast in association with the European Federation of Internal Medicine. My name is Dr. Amy Burbridge. I'm a consultant in acute and general medicine, working in Coventry and the United Kingdom. And today I am very pleased to be joined by Hi, my name is Ben Lovell.

SPEAKER_01 0:29

I'm a consultant in Acute Medicine and General Internal Medicine, and I work in central London in the UK.

SPEAKER_03 0:35

Fantastic. Thank you so much for joining me again, Ben. You're now my regular sort of co-host. You've been promoted to that job. Okay, so I've got a case for you today.

SPEAKER_02 0:45

Uh-huh.

SPEAKER_03 0:47

And I'm going to set the scene. And I want everybody who's listening to close their eyes and just picture the scenario. So it's a Tuesday. It's 11 a.m. in the morning. We're in the middle of a COVID lockdown. And you're the doctor on call. You might be the registrar, the junior doctor, the consultant. And you've been called to the emergency department to review a patient. And as you're walking upstairs, you walk into the emergency department with your full PPE on. So you've got your visor on, you've got your face mask on, you've got your gown on, and it's really, really hot. It's one of those really hot, sweltery summer days. And it's just utter chaos in the emergency department. There's no air conditioning. It's very difficult to get a drink just because you're so busy and it's very difficult to sit down and take a break. You've been on your feet, it feels like for a long, long time. Getting to work that day was hard because there was really bad traffic, you couldn't really park, and you're just a bit grumpy, to be honest. You've turned up and there's lots and lots of patients to see, and it's so noisy, and there's so many patients, it feels like there's patients everywhere, and everybody's come to talk to you. Have you seen this patient? Have you seen this? When we've got 10 patients to review, and you've just got so much going on, and it just feels overwhelming. How do you feel?

SPEAKER_01 2:32

Not great.

SPEAKER_03 2:34

Okay.

SPEAKER_01 2:34

Um, I suffered, suffer's not the right word in context of what everyone else was going through, but I really struggled with the full PPE. Um, I I don't like being hot, I don't like being warm, I don't like shouting at people through layers of of cloth and and headgear and not hearing what they say back to me. And during our the, I can't remember what wave it was, but the full PPE wave when we transformed into a CPAP COVID unit, I I really, really struggled with basic decision-making processes while in the grips of being too hot, too uncomfortable, too itchy, too fed up, too thirsty. I couldn't just grab a drink of water because that would involve taking everything off and going on again. And yeah, uh, so I I'm not probably in the best frame of mind to be making nuanced clinical decisions and maybe offering, you know, the best patient-centered care with kindness and empathy, as I would be when I was feeling a bit more comfortable. And that's the honest answer.

SPEAKER_03 3:29

Yeah, and I completely agree. It really highlights the importance of human factors and being comfortable at work that I don't actually think we put enough effort into.

SPEAKER_01 3:42

Um well, they say you should be careful of the Holt, you know, the Holt criteria. H A. So you should never be making decisions or trying to practice medicine if you're suffering from any of Holtz, which is H A L T hungry, uh, anxious, late, or lonely, or tired. Or tired, yeah. Uh yeah, and lonely means you're working in isolation with no support. So I think I probably ticked three out of those boxes during the peak where we were in the full PPE.

SPEAKER_03 4:11

Yeah, absolutely. I this is um, I was known to um when it was really, really hot and we were wearing all that PPE, um, there was a shower on the wards, and I would sometimes shower in the middle of a shift. No, I just it was so hot. It was such a hot summer that I would go and go and and we've got we have um uh a shop at work that sells like spare clothes. Um, and because I was just so uncomfortable and I couldn't think clearly. I couldn't make, like you say, those nuanced clinical decisions. Okay, so I want everybody who's listening to close their eyes again. We're gonna set the scene. You walk into the emergency departments and you're given 10 patients to see, and you've got to see them within one, two hours because it's very busy and the turnovers of patients, it's it's just relentless. And how on earth do you decide which of those 10 patients you need to see first?

SPEAKER_01 5:23

And I don't know any of the patients already. I don't remember them from yesterday or anything, no.

SPEAKER_03 5:28

No, you've never no, they've not been seen before. In fact, this is the post-tate ward round. So they've not been seen by a consultant before.

SPEAKER_01 5:36

Touch base with the nurse.

SPEAKER_03 5:38

Yeah.

SPEAKER_01 5:39

And just say, I'm starting my wardround. Is there anyone you want me to see now? Who needs to go first? And if a patient, if a nurse has a sicky, then she will give you a good steer on that and say, Can you see bed four first? Or not even a sickie, but this one's discharge dependent, they're not sick, but this one must have an update from a relative who's desperate. They they might be able to give you a steer on which order to go in. Um, uh, because they know they especially they've been on shift all night, for example. If the if the nurse says, I don't mind, you go wherever you please, then all you can do is start even the elephant at the tail and say, Okay, I'll start at patient one and work my way through to patient whatever, 10, and and uh just be mindful of anything that sets off in the middle if there's a disturbance or something in one of the other beds.

SPEAKER_03 6:20

I often find in this situation I'll walk in to do the post-hate wardround, and I'm given a list of 10, 20, 30 people in the emergency department, and I can feel my anxiety sort of starting because I'm like, oh my god, there's so many to see. I'm really slow. How am I going to see them all? And you're right, when we were in full PP and you had to change, obviously, you have to change PP between each patient. It was incredibly difficult.

SPEAKER_00 6:44

Yeah.

SPEAKER_03 6:46

So you are asked to see a 65-year-old gentleman, first of all, because you're told that he's not very well. And he's in um a side room because it's in COVID and he's been diagnosed with COVID. So you're waiting for the test to come back to confirm that this is COVID or not. But that's the working diagnosis. So you go into his room, he's lying bed, he's 65 years old, he looks he's a good 65-year-old gentleman. He's short of breath, so he's dysneic from the end of the bed. He's flushed, feverish, and he just doesn't look well. He doesn't look acutely unwell, he just looks a bit off, looks a bit rough, really. A lot of a lot really like a lot of the other patients you've been seeing with COVID over the last few weeks, months. Now you take a history and he said he's been short of breath for two weeks, but it's gradually getting worse. So he has been a little bit short of breath prior to this, but nothing that's really stopped him from doing anything. And now the shortness of breath is really bad on exertion. So if he's walking around the house, if he's walking up the stairs, he's really starting to struggle with that shortness of breath. And certainly in the last few days, it's got really, really bad. He's also got some central chest pain. It doesn't feel like a crushing pain, but it's right in the centre. And when he exerts himself, he feels that this pain actually does get a little bit worse and unrest. Actually, that chest pain does ease a little bit. He's also noticed that he's feels very hot, quite sweaty, he's been off his food, he's just not really had much of an appetite for a couple of weeks. He hasn't really noticed any other symptoms um that he that he can complain of. Any thoughts?

SPEAKER_01 8:46

Did you say he's probable COVID? Yes.

SPEAKER_03 8:49

So he's been diagnosed. Well, he's he's the lightly different diagnosis that was handed over to you when it was referred was um we've got a gentleman with COVID in the side room, although we are actually waiting for the COVID PCR test to for a confirmatory diagnosis. He's had yeah, it was he's had contact with COVID at home. So his wife has recently been diagnosed with it.

SPEAKER_01 9:14

Okay, so it and the the what worked up this diagnosis of probable COVID is is the is the contact, the household contact, and and this cluster of symptoms that you described. Okay. Well, it could be COVID, it could just be COVID. Um, this is we're talking about covidology.

SPEAKER_03 9:33

Absolutely, yeah.

SPEAKER_01 9:34

Covidology, a new, a new medical subspecialty we've all had to become crash course experts on. Um and it the one thing I would say is covidology causes a massively heterogeneous bunch of presentations. Um, I've seen elderly patients just come in with abdominal diarrhea and vomiting and or just sore throats, and um you say shortness of breath on exertion, chest pain on exertion. I've certainly seen that with COVID. So, first of all, this could all be COVID, um, or it could be not COVID, or it could be COVID plus, i.e., COVID with with another, um, which has led to something else. I've seen COVID obviously cause PEs, we all have, as a pro-thrumbotic state. I've seen COVID cause um myocarditis or myopericarditis, which could account for some of his symptoms here. I've seen COVID cause um plural effusions, I've seen it cause end stems uh before. So um it could be what I would call a COVID plus syndrome, or it could not be COVID at all, and that could be a red herring. And if the COVID uh test comes back negative, we have to do a bit of head scratching and thinking. If you hadn't said COVID and you'd said two weeks of worsening chest pain uh on exertion and two weeks of working strong breath on exertion, I'd say, oh, this sounds like crescendo angina, heading towards unstable angina. So let's get our ECGs, let's get our troponins, let's get a chest x-ray. So that will be my general work of in this case as well, because I'd be sort of covering for pulmonary and cardiac and infective uh etiologies in this case. So let's get some tests if that's okay.

SPEAKER_03 11:08

Anything else you'd like to ask him or you'd like to know?

SPEAKER_01 11:11

Any signs of failure? So I mean you mentioned shortness of breath, but is he is he um has he got peripheral edema that he's noticed as well? Has he got orthocnia and PND? Has his heart started to fail? Is that why he's more breathless on exertion? Or lung conditions? Has he got any coughs, sputum? Is it just and or pneumonia um causing a bit of pleuritic pain? So um, and has he got a respiratory background? Is he using halers for COPD or asthma? Um anything else I want to ask him. Yeah, has this ever happened before? Um, and get a bit of uh character of the chest pain. So are we talking central crushing chest pain here, or are we talking about actually stabbing pain or a very tender chest wall, musculoskeletal going down the costal margin? So that sort of info I'd be collecting from the patient at the bedside.

SPEAKER_03 11:59

Okay, so he does have a cough. He's had a cough on and off for a few weeks. Um, he it's occasionally productive, um, greenish sputum, sometimes a little bit frothy. He hasn't really noticed any blood, but he hasn't really been looking for it either. So the character of the chest pain is it's central chest pain. It actually feels like it's there all the time, but it just gets worse on exertion and then settles back down to like a niggly pain. It doesn't feel like a stabbing or a pressure, it just feels like a discomfort in his chest. It doesn't feel like indigestion, so it doesn't get worse with food or anything like that. And it doesn't hurt when you press it. His past medical history, he said he has a lung problem, but he doesn't know what it is, and that it he should take an inhaler, a brown one and a blue one, but he doesn't take it because he forgets. Um, and he doesn't he doesn't feel like he really needs it. You know, actually he still walks his dog, um, no problem. Um and he can walk for a you know a mile or so. He does get a little bit short of breath, but he's still able to do that. Other medications, he doesn't really take anything. Um, he did take some vitamin D that were suggested to him by his wife because they hadn't really been getting much sunshine. So I thought that might help. Um, there's no real family history of note. Socially, he lives with his wife. Um, he's got children, they've grown up, they've moved away. He lives in a house with stairs, which is climbing, but again, that is getting increasingly difficult. Um, he does still work actually, he's a delivery driver. Um, and he's been carrying on with this throughout the pandemic. Um, so he's never really stopped working, although over the last few days, when his wife's been isolating with the COVID, he hasn't been at work. So, what would you like to do?

SPEAKER_01 13:47

Is he smoking?

SPEAKER_03 13:48

He's an ex-smoker. All that, well, he says he's an ex-smoker. And I always say to patients, um, are you a smoker? No. When did you stop smoking? Yesterday. Yeah. So, um, and it's not like you're trying to catch people out, but you really want to find out when they did stop smoking. Because if they they're not a smoker, they've stopped smoking yesterday, but they've smoked 40 cigarettes a day for 50 years. It's really important to know that. So I will always clarify when did they stop and when did they have a cigarette? Now he does admit to me that he has a little secret cigarette every now and then. So one or two a week.

unknown 14:27

Okay.

SPEAKER_03 14:28

But he was a heavy smoker, he's not anymore.

SPEAKER_01 14:30

Okay. So he's got a background of some kind of airways disease because he takes an inhaler, which sounds like salbutamol and a steroid inhaler, which you normally see with with asthma, but it could be asthma or COPD. The smoking history points towards COPD. Um, and now he's bringing up um he's bringing up phlegm. And did you say green phlegm or did I make that up?

SPEAKER_03 14:54

Yeah, yeah, he's he's got some green phlegm, it might be a bit frothy, he hasn't noticed any blood, but then he said he hasn't really, he doesn't really look at his phlegm, to be honest.

SPEAKER_01 15:01

So green phlegm, not feeling well, he's got a chest infection. That's my first, my first thought here. Um, and that points quite nicely towards that. And two weeks in the making, viral versus bacterial. You know, you they they say that it does it's not hard and fast, but green sputum equals bacteria. But um, I would certainly be looking at his other things together, like um his temperature and and and his chest signs and his chest x-ray, and making a decision about antibiotics. And I think from the information you've given me, at this point, I'd be pretty confident in that saying he's got a chest infection, maybe pneumonia. I haven't seen the x-ray, I don't know. Um the the infection itself shouldn't cause the chest pain that you're describing, though. And it may be there's two pathologies. People who get COPD also get coronary artery disease because it's usually assimilated as smoking. Um so it maybe these got two pathologies, and the being very unwell with what could be a community-quired pneumonia has set flared off um worsening or triggered an angina or worsening uh myocardial insufficiency. Um, is there a unifying diagnosis as causing both of these things? I still say COVID could cause, could could cause um so a couple of these things together. So I would like to see that COVID test result. But at this point, I'd be leaning towards let's get a chest x-ray, get his bloods. I'm thinking about antibiotics and uh and I want an ECG and I want to have another look at this chest pain, but I I've made one decision already.

SPEAKER_03 16:28

Okay. So what's really interesting is what I really like what you said was actually there might not be one diagnosis here. And I think as what we do as clinicians is we find a diagnosis and then we close down the diagnostic process. But actually, Hickam's dictum is patients can have as many diseases as they damn well please. So just because he may have COVID, it doesn't mean he hasn't got something else. But what we do is we undertake what we call premature closure and we prematurely close that diagnostic process because we've got a diagnosis and we've got however many other people to see. Is that something that you think that you've done or absolutely?

SPEAKER_01 17:13

I probably do it on a daily basis. I referred to as the anchoring heuristic as well, because you sort of drop anchor on a diagnosis and you do not shift that anchor for the rest of that patient's day. And I think some of the it happens a lot in acute medicine. And one of the good things is that um the process of being an acute admission into hospital is that you get several people coming to see you, and that's a good thing and a bad thing. When the patients, you know, by the time they come to acute medicine and we we take history again and they go, Plum and eck, I've told three people this already. Why are you taking into it? Now just read what they wrote. But at least we keep getting fresh pairs of eyes. And I think that does help with this premature closure because if you if you approach the case saying, okay, I've read the previous person's assessment, but I'm going to go in with an open mind, um, that can be really useful. But as you say time limited, it may be a case of we look at the patient's notes, we go, poly nephritis. Uh, okay, and we go, hello, I'm my name's Ben Lovell, I'm your doctor, I hear you've got poly nephritis. Now, how are you feeling today? Here's the antibiotics, and we don't have that open mind. And then that premature closure, that anchor persists from from team to team to team. And so we don't often re-challenge it because we don't have the the time and the bandwidth. And often the pro the first assessment is perfectly reasonable and it makes a lot of sense. It makes a lot of sense to us, it fits very neatly. So, why go looking for acute intermittent porphyria if someone has said pylone nephritis? It's it doesn't make much sense, you know. You don't think zebras if you hear hoofheeds.

SPEAKER_03 18:40

Absolutely.

SPEAKER_01 18:41

Yeah, so I think, and also it is how the history is presented to you. Because um I I like when I when I'm on the post-it round, I like the the clerking doctor to present to me um with the with the the patient's presentation first. The way we're taught at med school, presented complaint was this history presented complaint, and I don't prefer the assessment going, hi, I've got a patient for you, Dr. Lovell. It's a it's um it's uh a community choir pneumonia, as evidenced by this x-ray, this CRP, and this symptom. Because I just get a funny sense that I'm I I appreciate what you're saying, and you're trying to be time efficient, but I'm worried if you present to me the diagnosis and then there's the evidence why, I'm probably missing a couple of things that say why it isn't. Um, and 99 times out of 100, that's probably fine, but it does mean that down the road I will miss something. So I always like to go back to the go back to the E.T. Clarky, go back to the LA, the the ambulance performance you've got it, and just say, okay, so we have here everybody listening, is my team all gathered? Right, a 56-year-old man who calls an ambulance at 4 a.m. and they come to his house and they find, and then I read that, and then we go through the story together.

SPEAKER_02 19:50

Yeah.

SPEAKER_01 19:50

Um, and I've had um trainees before say to before going, Oh, but I prepped these notes. You don't trust my prep then. I'm like, it's not that. I want us all to discover this patient together in a narrative style because I just find that avoids the premature closure which you've mentioned, and it just means that um we all sort of develop a construction in our head about what's going on with that patient and it gives more opportunities for teaching. So they go, what's going on now? What do you think, this cool? What do you think? Okay, let's look at the next page, let's look at the blood tests now. And I just find that a more interesting ward round, personally.

SPEAKER_03 20:22

Yeah, absolutely. And it keeps you engaged and it keeps everybody else who's on the ward round engaged as well, doesn't it? Absolutely. Okay, so let's go back to our gentleman then who's in the side room. Who's got this cough, probably got a bit of COPD, and you go to examine him from the end of the bed. He looks, as I've said, he looks okay, but he does look a bit flushed and a bit miserable, really. So hands, nothing apart from a little bit of nicotine staining on his fingers. So you do question about how many cigarettes are you actually still smoking? Um, his pulse is 100 beats per minute. His blood pressure, he's 140 over 92. His oxygen saturations, he doesn't have any oxygen on at the moment, are 93% on room air. Okay, so you move to examine his face, and his face looks a little bit puffy. Um, he's a little bit dysneic from the end of the bed. There's no obvious signs of cyanosis. You have a look in his mouth. I always look in people's mouths for thrush because it's one of those things that we often miss and they complain of a sore throat when you look and it's coated in thrush. So always have a really good look in the mouth and look at the teeth as well. You go down to his chest and you have a listen to his heart. Heart sounds normal. So one of your differentials is cardiac failure. There is no third heart sound, there's no galloprism, there's no evidence of mitral regurge, aortic stenosis, any valvular disease. When you auscultate the chest at the back, you You can hear bilaterally a few coarse prepitations, but nothing else of note in the lungs. On percussion, it's a little bit dull at the bases, but nothing else of note. When you look into his abdomen and his tummy, he's got some dilated blood vessels around his abdomen, around his umbilicus, and it sort of he looks very flushed on his chest as well. You go down and you have a look at his legs, and there's a little bit of pitting edema bilaterally, tiny amounts, nothing that is really significant. I think something as well that we often don't look at, but can sometimes be helpful if we're thinking about cardiac failure is actually to look at um the genitalia of men, because sometimes you can get some testicular swelling as well if you've got cardiac failure. So, you know, don't forget that if you know that's something else you're thinking about.

SPEAKER_01 22:58

I wonder what a patient um uh with with testicular swelling when I was a urology uh F2. This is a hundred years ago, and they said gross testicular swelling, and I looked at him and he had pitting edema from the nipples down. He was just completely in fluid retention, and that's what's exactly what you said. Um I said, yeah, he's got testicles and this is not a urological problem, he needs to go to the medics for some lovely foods of mine. So it's a good point.

SPEAKER_03 23:26

Okay, so that's your examination findings. Any thoughts?

SPEAKER_01 23:30

So you're telling me this patient has got crackles on his chest bilaterally and pitting edema to his lower limbs. Uh okay, he's fluid overloaded. You're saying he's got dilated uh vessels on his um on his chest, on his abdomen, sorry. Are you talking about cappet medusae?

SPEAKER_03 23:47

Is he just it just looks very his vessels all just look a little bit engorged on his tummy and up on his chest and sort of all over. So on his fingers, there was no signs of clubbing um in the nails. He didn't have any signs of um pitting or onacolitis in his nails, and there was no signs of spider Nevi either.

SPEAKER_00 24:14

Okay.

SPEAKER_03 24:15

He denied heavy alcohol usage.

SPEAKER_01 24:18

Yeah. Um, okay, and his face is puffy. Do you mean edematis?

SPEAKER_03 24:23

It's difficult to say. I did say to him, does your face feel puffier than normal? And he said, Oh, my wife said it looks like I've put a bit of weight on his face. Um, and he hadn't been taking steroids or anything like that for the COPD that may have caused it. He just said his face look feels puffy.

SPEAKER_01 24:40

Hands were swollen as well. No. Just you can get pitting edema and facial and periorbital edema with hyperalbum anemic states. So yeah, good thought. I just wondering if he's if he's nephrotic. Um uh and that that's why he's collecting fluid. How do I tie that back in with everything else? Chest pain um and his productive cough. I mean, he could, he could, would he could have like an infection which is precipitating acute neurone nephritis and nephrotic syndrome. Um, so when I get to his bloods, I'll be keeping an eye out for his albumin now, as well as his CRP and everything else. And his chest sticks, right?

SPEAKER_03 25:19

Okay, so blood-wise, his full blood count, his hemoglobin is 100. His white cell count is 12 with a mild neutrophilia. His platelet count is elevated at 686. His CRP is slightly elevated at 72. His albumin is on the lower side and it's 24.

SPEAKER_01 25:45

Oh, it is. Oh, okay.

SPEAKER_03 25:47

The rest of his liver function is okay. So his ALT, AST, bilirubin are all normal. It's just a slightly low albumin.

SPEAKER_01 25:56

What about his renal function?

SPEAKER_03 25:58

Renal function's normal. Okay. So his urea is normal, his creptinine is normal, potassium and sodium are all normal.

SPEAKER_01 26:08

Okay, and do I get a chest x-ray?

SPEAKER_03 26:11

You do get a chest x-ray. And what are you going to be looking for on this chest x-ray?

SPEAKER_01 26:14

Well, you said he's got crackles both sides. So I'm looking for any signs of fluid overload or any uh consolidation which would explain his cough, his productive cough and sort of.

SPEAKER_03 26:23

Yeah, absolutely. So we do a chest x-ray. And it's certainly something that I did see a lot of in uh with COVID was those bilateral crackles that when you then did the chest x-ray, you had it was it's very typical, wasn't it, of COVID really? It's like nothing else you've ever seen apart from probably cardiac failure. So you do the chest x-ray, and there is a small plear effusion on the left-hand side, but nothing really else of note. When you look at a chest x-ray and it's put in front of you, how do you approach that chest x-ray?

SPEAKER_01 27:04

Okay, so yeah, you didn't say how do I teach chest x-ray analysis, which is very different to what I do.

SPEAKER_03 27:10

So, what do you do when you look at an x-ray?

SPEAKER_01 27:13

Okay, in all honesty, I look at the image on the screen, I mentally and instantly compare it to my internal library of all the chest x-rays I've ever seen, and I look for pattern recognition and what leaps out of me. This is not how I teach it, by the way. But I think I've seen enough thousands of X chest x-rays now that I can zone in usually on what is abnormal without missing too much stuff. Obviously, I teach it very differently. You look at the alumni, you look at the heart, you look at the width of the auto, you look at the customic angles, you look at the, and I think I still do that, but I just do it very, very fast. Um, and uh yeah, I so I screen it like that. So I I switched, I switched at some point in my career from analysis, what I suppose you'd call hypothetical deductive reasoning by looking for any kind of findings to pattern recognition and looking and comparing it to my internal template of normal chest x-rays, which I think is I think that's an experiential thing.

SPEAKER_03 28:10

Yeah, and it's it's certainly something that happens, it's the same with ECGs as well, isn't it? Um, and it's it's going back to that how we think type one thinking, type two thinking, thinking fast and slow. So we I'm sure certainly as we become more senior in our career, we definitely follow that type one thinking, pattern recognition, very rapid thinking, because actually we don't have the time, but also we've got the knowledge. What are the risks of that with X-rays?

SPEAKER_01 28:39

Missing. Missing things, or fixating on the one abnormality and missing the other, you know, looking at the the consolidation and missing the fractured glenohumeral joint or or something like that. So um, and I know that radiologists do go through a template and they fill it out and they don't miss stuff. They're probably reeling in horror at what I've just said. But I feel like I'm in a safe space, Amy, and I can be honest with you. Yeah, yeah.

SPEAKER_03 29:03

I mean, it's it's really it's really important to actually verbalize what we do. And on the same, you know, I'm looking at the x-ray. I always check the name just to make sure I've got the right x-ray. Um, and then you focus in on that abnormality that you can see, and what you're expecting to see from the history in your examination is probably a plural fusion or a consolidation on you. So that's what you're looking for, and that's certainly what we found on the chest x-ray. But and this is where the brilliance of trainees comes in, because they look at things very differently, because they do follow that systematic approach of an analysing an x-ray. Okay, let's look at A, let's look at the airway, B, let's look at the lungs, let's look at the breath fields, C, let's look at the cardia, the cardiac border, D, look at the diaphragm and E everything else. So they looked at the whole and they said, Um, Dr. Burbridge, what's that? What's what that? Quite wide and mediastinum. I just didn't see it. Because I wasn't looking for it. And they said, Look, if you just look, look in that right, look in the right apex there, that doesn't write. So you've got this wide and mediastinum, and you've got this shadow in the right apex, subtle, that I did not see, I did not pick up on it. But my fantastic trainee said, Look at that. Okay. So I've now got this 65-year-old man with a wide and mediastinum. He's got something possibly in the right apex of the lung, I'm not entirely sure. He's short of breath, he's got a cough, he's got some chest pain, he's not been eating very much. He's a smoker and he looks flushed.

SPEAKER_01 30:47

Sounds malignant, doesn't it?

SPEAKER_03 30:50

Okay.

SPEAKER_01 30:51

Okay. So widen mediastinum. So you're you're you're double-clicking on a file in my brain called um aortic dissection. So in that file, I have bilateral blood pressures, please. Okay, screening for is his chest pain going through to his back and his shoulder blades?

SPEAKER_03 31:13

No, it's not, and the blood pressures equal on both sides, and that was my thought.

SPEAKER_01 31:19

Okay. Um, and then you're talking about a lutancy at the at the apex and a smoker. So we're looking for for tumor now. So he does need cross-sectional imaging. Um do I do I want to go for the CTA orthogram or do I want to just do a CP chest um at this point? I don't know. A widened media signum in and of itself in a was it like a departmental PA or was it an AP sort of chest x-ray job in A and E?

SPEAKER_03 31:49

It was just a chest, it was just an A and E one that was done like quite quickly. It wasn't a departmental PA film, it was an AP film.

SPEAKER_01 31:58

Because that can sometimes change perspectives on certain structures and make things look a different shape than they actually are. And um I ideally I'd send into the CT scanner and say, if you could manage an a gated A orthogram and just get a cross-sectional imaging of the lung at the same time, that would be great. Um if they said look, it's one or other, then I would be probably more leaned to lean towards getting the the CT chest and and hoping that they could see something on the autocon, but maybe they could get both actually. He's down in the scanner, it's probably worth doing both.

SPEAKER_03 32:30

Okay, so you've got you want to look for that dissecting aorticaneurism with a wide immediastinum, but also you're worried about that's possible lucency in the in the right apex.

SPEAKER_00 32:42

Yeah.

SPEAKER_03 32:42

Um, if I'm gonna give you, I've got 15 pounds now. You've got 15 pounds to spend on one blood test. What blood test would you like to do with your 15 pounds that you haven't done? That you you know, you've you've mentioned malignancy, a long malignancy.

SPEAKER_01 32:58

Okay, digging deep now by one blood test.

SPEAKER_03 33:03

I don't know how much it costs, but you've got 15 pounds. I'm sure it'll cover it.

SPEAKER_01 33:06

I think a D dime was 12 quid, so you're not too often.

SPEAKER_03 33:09

You're not doing a D dime test.

SPEAKER_01 33:11

I'm not doing a D dime, but that's the only one I know money, I know the actual price of. Um one blood test to rule them all. Um, I don't know, Amy. I feel like I'm missing something here. I don't know what what one blessed blood test I would like really that would change my management. A CRP, I've already decided I'm giving him antibiotics, so that's not going to change my management. I've got a whole list of blood tests down here and things that I would add on. Um I mean, upper to upper lucency TB, but I don't, he doesn't, he's been he said he's been unwell for a couple of weeks and losing a bit of weight. I mean, pulmonary TB could present like that. Um, but I'd get that more in an acid fast stain of a sputum rather than from a blood test. Um, what else, what else, what else, what else, what else? BNP might be useful, elevator to lean towards heart failure, but again, I don't know if that would ultimately change my management here. And I've got my albumin already. Um, and I want to get my urine dip and my uh my protein cratene ratio on your urine, but um no, I don't have a single blood test of 15 pounds.

SPEAKER_03 34:20

Okay, I've just made the price up, but you never know. Okay, so you want to do calcium.

SPEAKER_01 34:25

Oh, okay.

SPEAKER_03 34:26

Okay, so because he's got this something in the lung, is this a lung malignancy? Could he be hypercalcemic?

SPEAKER_01 34:32

So you're looking for either primary um he's got a parathyroid-producing uh lung tumor, or or he's metastasized to bone and he's breaking down bone. So I guess he's got two reasons to be hypercalcemic. And you say that he has been losing weight. Has he been sort of polydipsic and uh not really constipated or the groans and stones business?

SPEAKER_03 34:54

He has been constipated, actually.

SPEAKER_01 34:56

Okay, hypercalcemia could be. Yeah.

SPEAKER_03 35:00

So you've got a 65-year-old man losing weight, a poor appetite, a flushed face and some dilated veins. A possible tumour in the right apex. What do we really need to rule out now in this man?

SPEAKER_01 35:27

Well, I think malignancy is the short answer.

SPEAKER_03 35:29

Absolutely. But what could the malignancy be causing?

SPEAKER_01 35:32

Oh, a neuroendocrine tumour, I I guess it could be causing. Um, we've talked about well, yeah, you say flushed face, you know, and I okay, so flushed face, that is one of the key things I'm trying to get you to think about a diagnosis. You're gonna have to cut me out my misery.

SPEAKER_03 35:52

Okay, superior veno carval obstruction.

SPEAKER_01 35:55

Okay, so did he um oh and did he have engorged facial veins and engorged uh neck veins?

SPEAKER_03 36:03

Not really, he was just very flushed, okay, like plethoric. So, and it was a very difficult diagnosis because it didn't fit my pattern of superior veno carval obstruction.

SPEAKER_01 36:19

I've seen once before, yeah. And and they had very dilated veins on one upper quadrant of the chest as well, uh, I remember, and down one arm.

SPEAKER_03 36:28

Yeah, and it was we when it was I don't know how the diagnosis was made. It's just I to be honest, it was I guess it was you're ruling in and ruling out things. So we knew there was a wider mediastinum, and you are exactly right, that is what we did. We did a CT aortagram and a CT chest because that wider mediastinum, and actually the wider mediastinum it wasn't a ruptured um aorta, it was they picked up CPU veno carval obstruction, secondary to an extrinsic obstruction by a lung malignancy, and that's why he had been losing weight. The plethora was there because he had got some engorged veins, and it was just wow, that didn't even enter my differential diagnosis.

SPEAKER_01 37:21

And the diagnosis was made on CT scanning, it was. Yeah, it was I mean, I don't think we should beat ourselves up here because we ordered the test that revealed the diagnosis, you know.

SPEAKER_03 37:31

Yeah, exactly. I think there's so many learning points there in the fact that I didn't even see the mediastinum and the abnormality in the right apex because I was so focused on looking at the basis of the x-ray to fit the diagnosis I'd already made.

SPEAKER_02 37:48

Yeah.

SPEAKER_03 37:50

So, and it's about okay, I really need to take a step back and really question that's where my trainee was like, okay, what else is going on on that x-ray? And that was a really, really good learning point for me to really not rush to that diagnosis, which is exactly what I did. But also when I was setting the scene before, it was chaos. And a diagnosis like this is nuanced. So when it's noisy and loud and you're hot and hungry and need the toilet or whatever, how can we work better to make these difficult diagnoses? Is there anything we can do?

SPEAKER_01 38:31

Yeah, I guess making sure that you're in the right frame of mind before you start a ward round and everybody else's as well. And then breaking. I mean, do you remember those ward rounds that went on for hours? Um I remember there there's a few consultants who just like to keep going until they'd finished, ignoring any break or meal times. And I'd have to carry around a little um packet of biscuits in my pocket, and then three hours into the ward down, I'd say, I'm just gonna pop to the loo, and I have to go to the toilet and stuff these biscuits and stop myself going. I go ready now. Um you know, I'm just making sure you break regularly. And I would argue that rounding from 8 a.m. till lunchtime is still too much of a walk round, and that's for yourself as well as for your team. Um, because what's going on in my head often is keep pushing through, oh just get it done, just get it done and get it and get it done. But that's not the way forward. And for the other members of the team, they they don't often feel they can say, look, can we stop and have a break, please? Um, I'm extremely thirsty, I'm extremely um hungry. Uh I get hungry at about 11 o'clock, and then I I find it difficult to push through to lunchtime. Um, and also I know, I know that the trainees are starting to get a bit nervous when you if you've done a mega ward round because you've just created so much work.

SPEAKER_02 39:49

Yes.

SPEAKER_01 39:49

When am I going to get started on these tasks that I've been given if we are not being released from the ward round yet? So I think if you have got a big ward round, you have to break in the middle for 20-30 minutes to give everybody comfort breaks, um, to make sure everybody's uh got empty bladders and full stomachs.

SPEAKER_00 40:07

Yeah.

SPEAKER_01 40:07

Um and the time critical stuff, which you know, Mr. Mrs. Consultant, you probably should be helping with as well. Um, just gets the get the ball rolling for the day. Um, even if you just pick up the phone and say, hey, listen, I'll do this referral, I'll make these phone calls if you um rather than saying, let's have a 30-minute break now, guys. You crack on with job back in 30 minutes, and then we'll pick up things again, and you going off for a lie down or what have you.

SPEAKER_03 40:34

Never lie down at work.

SPEAKER_01 40:36

Just sit and stare for 20 minutes, which I enjoy. Sit and stare. But um, I think I really think I I only speak for my world of acute medicine, which I I I don't think that that uh we should just be leaving and dumping all of these these tasks on members of the we can do a couple of them in two minutes, which might take them 15.

SPEAKER_03 40:56

I mean, I get to 10 o'clock, half 10, and I have to get coffee. Yeah, it's like it's I don't know, it's like um Pavlov's dog, it's like a time comes and I have to coffee time and I get coffee for myself and the rest of the team. And then um that takes us away from the ward. It gives you the little bit of break for 10 minutes while you get in the coffee, and then you have you know five minutes and it makes the world of difference. Yeah, just by taking that time out. Um, it really does make a massive difference. So I'm just gonna run through a little bit of the sit on the superior vena cava.

SPEAKER_01 41:29

Please do. Um we didn't refresh it, so please do.

SPEAKER_03 41:33

Well, I did as well. I mean, it was, but it's one of those cases now. I'm like, everybody's got superior vena cava obstruction. Well, clearly they haven't, but that's what I'm thinking of. So the superior vena cava is a union of the left and the right brachiocophalic veins, which empties into the right atrium. And it doesn't have a valve, the superior vena cava. It's very thin walled, it hasn't got much pressure. It's about seven centimetres in length and about two centimetres in diameter. Um it empty as it empties into the right atrium, it's emptying all of the blood from the top half of the body into that right atrium. And the blood is then transmitted upwards into the right internal jugular vein, the JVP, the jugular venous pressure. So when you visualize the right internal jugular vein, what you're actually visualising is the pressure within the right atrium, which is the JVP, which is one of those things that I will probably never really be able to properly understand or properly assess. It doesn't matter how many times I try and read about it, I do think the JVP is a quite challenging sign for me to really properly pick up on. It's it's probably easy when it is abnormal, when it's really full and they're overloaded, but it is one of those subtle signs. Absolutely. So the superior vena cava takes the blood from the head, the neck, the upper limbs, and the thoracic structures here. And it's actually surrounded by the trachea, the right bronchus, the aorta, the pulmonary arteries and the lymph nodes. So if you've got a problem with the SVC, either extrinsic compression from the trachea, the bronchus, the aorta, or intrinsic, these can cause obstruction. Extrinsic, the common is cause is going to be malignancy. And it's usually lung malignancy or lymphoma. Rarely might be a thymoma, but tends to be your lung malignancy. Internal or intrinsic problems in the CPU vena cava, we're actually starting to see more of now because of indwelling catheters, cardiac resynchronization therapy or central venous catheters. And they may cause a thrombus within the SVC. Which then causes an obstruction. And any obstruction, either extrinsic or intrinsic, will prevent good flow into the right atrium. Therefore, you get all these dilated veins. SVC obstruction normally comes on over time. And because it comes over time, what happens is your body develops collateral vessels. And it's these collateral vessels that develops a collateral circulation using the azygous vein or the internal mammary vein. And you get these dilated veins on your chest, and you get the plethora in the face and the engorged neck veins that we talked about. Now, the most common lung malignancy that causes this is the non-small cell lung malignancy, which also causes often a hypercalcemia, which is another reason why you probably want to check those calcium levels. So, treatment of superior veno carval obstruction. It's an oncological emergency if it's due to a malignancy. If it's due to an internal thrombus, I want to get advice from the radiologists and the hematologic physicians. There are no real guidelines for the management of SVC obstruction in the world. I couldn't find one. Do you know of one, Ben?

SPEAKER_01 45:16

Because I could really couldn't find anything that I know they do emergency radiotherapy when it's obstruction and high-dose steroids.

SPEAKER_03 45:26

Yep.

SPEAKER_01 45:27

And I guess if it's a clotch, you'll be speaking to interventional radiology about catheter-directed thrombolysis. Do I know of an actual paper guideline? I've not seen one in any hospital I've worked in, no.

SPEAKER_03 45:37

No, and I couldn't find one either. I mean, I went all over the internet, I did huge numbers of searches, and I couldn't actually find a guideline that tells you how to manage SVCO. Maybe local guidelines, but I certainly couldn't find there wasn't a nice guideline or there wasn't any societal guidelines looking at this. So there's an area of research out there, Ben, that needs to do in.

SPEAKER_01 46:02

Well, if any of the listeners know of it, you know, please do take either of us and just drop them in because I'd be really interested to see them as well.

SPEAKER_03 46:08

Yeah, absolutely. Um, because I did look and it was just something that I couldn't find. So management-wise, um looking around a little bit, exactly like you said, if it's a malignant one, you often and you first of all, if it's an acute airway obstruction being caused by the SVCO, obviously they will need urgent intervention with airway support. However, most cases aren't actually that urgent. So then you need to think about you don't want to give any medication or do anything that's going to interfere with the diagnosis because you're going to need to get some tissue to try and identify what the malignancy is. You often do use high dose doers, which is dexamethasone. You're going to obviously need to speak to the acute oncology service and try and formulate that tissue diagnosis before you then go on to chemotherapy, radiotherapy, or stenting, which can also be done. Now, if it's a benign cause, such as a thrombosis, you're exactly right, you're going to talk to the hematologists or the radiologists. Infection as well can sometimes cause it when you've got your enlarged lymph nodes compressing sarcoid, TB, syphilis, which in fact syphilitic SVC obstruction was the very, very first ever diagnosed SVCO or identified by William Hunter many, many years ago was a syphilitic aortic aneurysm causing SVCO. So the treatment is, as we said, steroids, or it might be antibiotics or treat the infection. But again, you really do need to get really specialized advice on something like this. So what we did for our gentleman is I spoke to the oncology team and said, I've got a gentleman who's probably got a primary lung malignancy, he's a smoker, he's got superior veno carval obstruction that we've identified on CT. And also clinically, what would you like me to do? So we gave him some dexamethasone, we gave him some oxygen because he was slightly hypoxic, and we they took him to the ward. And then eventually, a few days later, he did have radiotherapy. That was felt that that was needed.

SPEAKER_01 48:24

Did you say he had COVID in the end?

SPEAKER_03 48:26

Or that's interesting. He didn't have COVID. And I think that's what's really important about this case is you know, we went in there, it was, you know, I don't know what wave we were in, but he I was told he had COVID. I went in there with that he must have COVID because everybody's got COVID. Then I thought it was heart failure, then I thought it was pneumonia. I was all over the place, to be honest. Um, because of many reasons. Um, and actually it turned out to be none of those. So I certainly learned a less lots of lessons.

SPEAKER_01 48:59

COVID ward to see a COVID patient, then of course you're going to be thinking COVID at the front of your brain.

SPEAKER_03 49:05

So exactly.

SPEAKER_01 49:06

Yeah, it's it's it's a nice uh lesson to to say just because you're going to the COVID ward, you can still see some pretty diverse general medicine there. And as well.

SPEAKER_03 49:16

And the problem is, is should we be calling the COVID ward the COVID ward? Because by calling it the COVID ward, you're going into it thinking everybody's got COVID. Because you've got that cognitive bias of being told you're anchoring onto that diagnosis of COVID, which then stops you looking for other diagnoses. And I think again, thinking back to how we uh work, how we ergonomically work and human factors, you know, should we really be thinking about, you know, this really questions should we be calling the endocrine ward the endocrine ward? Because does that automatically lend us to think the patient's got an endocrine problem? Again, stop us looking for other conditions.

SPEAKER_01 50:00

Oh, we we don't have an endocrine ward, so we don't have that problem. Oh, but I guess, but you're right, we we working on an acute medicine unit, what's in the names? Remember when we they used to be called AAUs, they still are in some places, or and they were called the medical admissions unit. And the reason why we didn't like that so much, because we said, well, look, we're not just an admission service, we're practicing general medicine here, so and we're called acute medicine, so maybe we should be the acute medicine unit. And I think there is a if we think about it, there's a different flavor to acute admissions unit, to acute medicine unit. Um, and so I think there is a lot in a name um about what what something does. You know, I I know that um medicine geriatrics are are are now pushing against words that have been stigmatized, like elderly. And I wouldn't be surprised if the word frail becomes stigmatized over time and that gets rebranded as something else because you know words have different meanings and they change a lot. Um, and I do think that words and what we call things are very powerful. Um, and like I said at the beginning, if you call that patient in embed seven, the the pileonephritis case, that is she is a pile nephritis case, and you don't pick up the kidney abscess or something, or you don't pick up the acute uh um PE because uh you know we're looking at the other thing. So I think labels are important, I think words and names are important because I think they guide our thinking, consciously or subconsciously.

SPEAKER_03 51:22

Yeah, certainly. I think we really need to think about that because I did um quite a few years of rheumatology training. So because of that, I think I still I think I overdiagnosed rheumatology conditions because that's what I learned, and that's in my in my mind, and I think you know, I'm I'm more conscious of that now. And again, it's another one of those biases, isn't it, that really affects our decision making. So it's an interesting case. You know, the gentleman was absolutely fine, um, was treated appropriately and discharged, but I learned a huge amount from that case, and I have as well now. Yeah, it was just um yeah, really made me go back to basics. And I think that's what we all need to do is when we're not sure, when things don't fit a pattern, go back to basics.

SPEAKER_01 52:09

Yeah, um uh about being reflexive. So I tell you something that I do, um, which is a trick I picked up when I was an IT ITU trainee, and uh um, and you know how ITUs love their A to L, A to M assessment, which is brilliant, isn't it? When I'm with a really tricky case and I'm trying to make sense of it, I still do that.

SPEAKER_00 52:30

Yeah.

SPEAKER_01 52:30

Um and I say, Oh, I I feel like I'm missed. This is so complex. They've got three things going on, and uh what about this weird result here? How does this fit in here? And I say, okay, A, patent, B, sats of this, and I go all the way through and I go A, B, C, D, uh, D, E for electrolytes, F for fluid, G for gut, H for hematology, I for infection. And then at the end of it, it takes time, it takes a good 20 minutes or more. But at the end of it, I say, okay, now I I guess I've got a global picture of this patient in my head now, and I can move forward. So that is a time where I do move away from pattern recognition um and sort of quickly cross-referencing sort of subconsciously with previous cases and illness exemplars I've met in my career, to actually going back to the good old-fashioned hypothetical deductive reasoning approach that you're taught in medical school, where you you draw up hypotheses and you test them. Um, and that's what I guess what you mean by going back to basics, that's my sort of example for it, saying I've got to go, I've got to reapproach this now with a completely open mind, and I'm gonna approach it like a novice and try and build up and construct a working understanding of this patient from the basics. Because my my rapid, my blink thinking is not getting me anywhere. Yeah, this doesn't this doesn't absolutely resonate with something I've seen before.

SPEAKER_03 53:46

It's we're going back into our slow thinking, aren't we? Our type two thinking. Yeah, absolutely. Thank you so much, Ben, for taking the time to record this podcast with me today. I think there's been some good learning points for everybody.

SPEAKER_02 53:59

Thank you very much. Thanks for having me again.

SPEAKER_03 54:02

Thank you so much to all our listeners. And please, if any of you out there know of a SBCO obstruction guideline or pathway, please let us know because it'd be really interesting to look at it and review for our own learning and education. So thank you all for listening to the Home of Medicine. And if you want to get in touch, you can tweet me at Amy Burrbridge or you can email me at Amy at eFimacademy.org. Goodbye.

SPEAKER_02 54:29

Bye.

SPEAKER_03 54:30

You've been listening to the Home of Medicine Podcast, a podcast brought to you by the eFim Academy in association with the European Federation of Internal Medicine, a leading organization in internal medicine. Thanks for listening.