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?

Links & Resources

• RCPE Education: rcpe.ac.uk/education

Connect With Us

• Email: a.burbridge@nhs.net
• YouTube: Home of Medicine Channel

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 a new episode of Home of Medicine Podcast in association with RTP Edinburgh. My name is Dr. Ben Lovell, and I am a consultant in Acute Medicine working in London. And here is my wonderful co-host.

SPEAKER_01 0:25

Hi, I'm Dr. Amy Burbridge.

SPEAKER_03 0:28

Right, Amy, it's my turn to present a case to you. 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. So, this is a 34-year-old man. Um, reason for presentation, generally unwell for six weeks. Uh and to be more specific, uh intermittent fevers, fatigue, loss of energy, loss of appetite. He says he had the flu six weeks ago and just never shook it off. And he's felt rubbish with it ever since. And the reason for presentation today is that the last two days, he started to feel more breathless and generally just awful. And he's had enough. There you go. That's the presenting complaint. Anything particular that you're thinking there.

SPEAKER_01 1:27

Okay, so 35-year-old male, normally fit and well, but has been unwell for six weeks. Fever, fatigue, low energy, low appetite, and he's had the flu. And he's now breathless and short of breath. Okay, so I'm gonna be thinking, is it a post-infective syndrome? Is this post-viral infection? Post viral syndrome. Is this a respiratory condition? 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? Shortness of breath, breathless recent infection, could this be a PE? Chronic infection or chronically unwelling, is he anemic? Um is he iron deficient? Is that why he's short of breath? Is that why he's breathless? Is that why he's tired? Is this an anemia? Um, whenever I see these sort of six-week histories, I think, could this be malignancy? So is there something else going on here? Is there a lymphoma, a leukemia, a malignancy elsewhere? 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? Could this be vasculitis? Could this be um, I mean, it's unlikely, but it could be. So those are the sort of things that are going through my head at the moment.

SPEAKER_03 3:02

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. Do you know what would be really interesting? 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. Um, that'd be quite cinematic and interesting, I think. Uh anyway, back to the story. I no, I think that's I think that's really good. I thought PE, I thought um flu. He said six weeks ago he had the flu, never got better. But what happened? 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. Um, but we need more information, I think. Rest of the history, past medical history, nil. It's a fit and well 34-year-old, doesn't take any regular medication, has no allergies socially. 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. And then coming to examination, he's febrile, uh, 38.1 degrees. Um, his heart rate's 105 sinus. Blood pressure's 116 over 68, spiritual rate's 18, and is sat 97% on air. Um, that was his booking in observations. So he is febrile. He says he's had intermittent fevers for six weeks, and he's febrile at the moment, which is interesting. There is inflammation afoot. Whether it's also infection is yet to be seen. But there is an inflammatory response going on here to something. So then we play the game of hunt the infection. Um his chest is clear to examination. 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. No rashes anywhere. Um, and all other neurological examination was normal, essentially. Um does that put you anywhere useful now, or has that ruled out some things or ruled in some other things? Has he lost any weight? He feels like he has lost a bit of weight, but he cannot quantify it. But he says certainly he's been off his food.

SPEAKER_01 5:39

And any night sweats?

SPEAKER_03 5:41

He has actually had some night sweats. He feels quite hot overnight. What are you thinking about?

SPEAKER_01 5:46

I was thinking of these symptoms for lymphoma.

SPEAKER_03 5:49

Mm-mm.

SPEAKER_01 5:50

Um was going through my mind. Um has he noticed any lumps and bumps?

SPEAKER_03 5:56

He has not noticed any lumps and bumps.

SPEAKER_01 5:59

Any itchy skin?

SPEAKER_03 6:01

No.

SPEAKER_01 6:02

Okay. Is he sexually active?

SPEAKER_03 6:05

I didn't have that information at per point of presentation. But you know that's something. So when you went to post take the patient, this is something you'd be asking. Okay. Anything else? Yes.

SPEAKER_01 6:15

Um, any recent travel?

SPEAKER_03 6:17

Oh, okay. So we'll go and ask that at our post-key ward round. Yep. Anything else we need to ask on the post take?

SPEAKER_01 6:25

Um any recreational drugs?

SPEAKER_03 6:29

Rec drugs. Okay. And what are you thinking about in in uh sexually active recent travel recreational drugs? What are you screening for?

SPEAKER_01 6:37

Um HOV.

SPEAKER_03 6:38

Okay.

SPEAKER_01 6:39

That's important. Uh could this be HOV zero conversion? Some of the symptoms that you described could be that. Um travel, has he been abroad recently? Has he been exposed to TB? Lives in a fatcha? Um, has he been anywhere where he could be exposed to um I'm just trying to think actually. Any the travel six weeks and recreational drugs? You know, is he taking um amphetamines that could be causing the weight loss, the fever, the tachycardia? So I know they're a bit of a stretch, but you know, it could potentially be there.

SPEAKER_03 7:15

So why why is it a stretch?

SPEAKER_01 7:18

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.

SPEAKER_03 7:24

Why is it not gonna happen? And so I'm not sure what you mean.

SPEAKER_01 7:28

Well, because I I um I I do think sewing debt sometimes. I'm like, yeah, is he really gonna have TB? Is he really gonna be on amphetamines that's caused these symptoms? No, sometimes do I need to strip it back to basics and roll out common?

SPEAKER_03 7:43

All right, um, so I went to post-take the chap and he didn't look very well. But you don't when you got the flu. But he looked, he looked he looked over it, as the kids say. He looked tired, fed up, a slight glistening sheen to his skin. He looked sallow, he looked pale. Um he um, what else to say? Yeah, it was a smiley tachycardic, he was no longer februar because he'd had paracetamol in the ED. Um, and I did ask whether he was sexually active. He says, not in the preceding six months. Uh I asked about recent travel, and that was a no. Um, admittedly, I did not ask if he took recreational drugs. Um, apologies. And I re-listened to the chest, and yet it was clear. I mean, when we see people with infection, I feel like this is numbers out top of my head. I don't have a data, but I feel like we look for chest and urine quite quite commonly as the big ones. And his chest was clear. And there was a chest x-ray for me to look at, which was clear as you like. Um, and uh he denied any dysturia. UTI is very uncommon in a 34-year-old man, but he denied any sort of signs and symptoms of that as well. And I really pressed on his tummy, any secret abdominal abscesses I need to know about, but there was nothing there really. And his skin was all completely normal to examination as well. Uh gosh, do I send him home or do I bring him in?

SPEAKER_01 9:03

Ooh, I wouldn't send him home. Because I mean I'd like to do some blood tests.

SPEAKER_03 9:10

Oh, okay, okay. Okay. CR CRP96. Okay. HB112. Platelets 213, white cells 14, 1.4, neutrophils for 12. His urea and electrolytes were completely normal.

SPEAKER_01 9:30

Lymphocyte count?

SPEAKER_03 9:32

Lymphocyte count was 1.1. It was normal. 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.

SPEAKER_01 9:46

LFTs?

SPEAKER_03 9:48

LFTs were normal.

unknown 9:49

Okay.

SPEAKER_03 9:50

Coag was normal.

SPEAKER_01 9:51

VBG?

SPEAKER_03 9:53

VBG showed a normal lactate of less than two.

SPEAKER_01 9:56

And glucose was normal.

SPEAKER_03 9:58

Yes.

SPEAKER_01 9:59

ECG was normal.

SPEAKER_03 10:01

A mild sinus tachycardia, but nothing else on it.

SPEAKER_01 10:05

HIV test?

SPEAKER_03 10:06

HIV test, which we do a standard actually on patients on the tape. Yeah. So uh it came back negative.

SPEAKER_02 10:12

Okay. Blood cultures?

SPEAKER_03 10:17

What's up? We're done and sent, but not available on day of presentation.

SPEAKER_01 10:22

Okay. And did you send a urine culture as well?

SPEAKER_03 10:25

I didn't actually, because there was nothing on the initial screen that made me want to look for you. Yeah, back to urea.

SPEAKER_01 10:31

So you did so, but it's still short of breath, isn't he? But it's 97% on air.

SPEAKER_03 10:37

Yeah, respiratory rate's 18.

SPEAKER_01 10:39

Oh, would you do uh would you do POCUS of the lungs?

SPEAKER_03 10:43

I wouldn't because I don't know how. But somebody else might do it. And what are you looking for?

SPEAKER_01 10:49

So I I I I mean I've kept whittering on about this because it's my newfound skill. 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. So actually, sometimes it can be very helpful where chest x-ray hasn't been. So that might be an option.

SPEAKER_03 11:19

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.

SPEAKER_01 11:29

Absolutely. Ah dear, what would I do? So he's got a slightly high white cell count. He's got a neutrophilia, his hemoglobin is on the lower side of normal. Um, basically blood corteus, livers normal, chest extreme. I would look at his lungs. Would I admit, would I send him home? Would you do a D-dimer? Would you do a CTPA? 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. So I don't think you're gonna do a D-dimer anyway. And also it's got inflammatory process going on, so it's probably not relevant. Would you do a CTPA? Is tachycardic recently unwell? I might, you know.

SPEAKER_03 12:17

That's a reasonable shout, actually.

SPEAKER_01 12:21

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. 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. And where what's the middle ground? What's the compromise? What should I be doing and what shouldn't I be doing?

SPEAKER_03 13:00

I'm I'm deliberately being very quiet, so I'm letting you think it out.

SPEAKER_01 13:06

I feel like I'm in a therapy session where you just end up talking. They're staring at me. Do you know what? Okay. I'm gonna give some antibiotics. I'm gonna give some oral antibiotics. And I'm gonna do poker to the lungs. And at the moment I'm not going to do a CTPA, but I'm certainly considering it. Okay.

SPEAKER_03 13:37

So what oral antibiotic are you giving?

SPEAKER_01 13:40

Uh amoxicellin, 500 milligrams TDS. Okay. If he's not allergic to anything, which she said he wasn't. I guess he did have an atypical infection. I'm gonna go with ammoxicellin.

SPEAKER_03 13:54

Okay. 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. 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. So I said, let's bring him in, give him something broad spectrum. I went for IV uh kef, which is our broad spectrum, which is our antibiotic for infection of unknown source. Um, and I say, let's sit on him overnight, take lots of blood cultures, and let's see what will be will be. Um and I brought him in and I saw him again the next morning. And interestingly, the next day, his CRP had gone up to 150. He was persistently febrile, um, but otherwise, he looked similar to as I saw him before. 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. You know, I went to our morning MDT. Ever wants to know what's the estimated discharge day for all your patients? I'm like, for him, just just say two days because I don't I don't know yet. I've not made the diagnosis. We're still treating him with vitamin T, which is time. And we'll we will see what happens. And I think it was close of play that we got the phone call from Micro. And they said that all three of his blood culture bottles have grown the same bug. Staph aureus.

SPEAKER_01 15:22

Do you know? I mean, you were gonna say staph aureus.

SPEAKER_03 15:25

Did you? Huh?

SPEAKER_01 15:27

Because I've been thinking endocarditis.

SPEAKER_03 15:29

Why?

SPEAKER_01 15:31

Because it came into my head about one minute ago.

SPEAKER_03 15:35

And I've been doing that's great, but uh why? What's the reason? People have been listening, going, why did why did it come into your head? Why did your consciousness produce endocarditis? It must have had some data.

SPEAKER_01 15:45

Because, okay, so I was thinking, this sounds vasculitic. Endocarditis is a vasculitic process. 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. It just thought, mmm, this could be endocarditis, infective endocarditis.

SPEAKER_03 16:08

And staph aureus, what do you make of that as a potential causative organism for staph aureus? For endocarditis.

SPEAKER_01 16:15

It's not common, is it actually? It's more common in drug users.

SPEAKER_03 16:19

Mmm.

SPEAKER_01 16:20

So it could still not be endocarditis. But now I'd start to look for endocarditis. I'd want to do an echo. I'd want to look at his heart. But he said there was no heart murmur, but it doesn't necessarily mean.

SPEAKER_03 16:31

I didn't say that. I did not say that. I said nothing about his heart sounds. What? 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.

SPEAKER_01 16:48

Okay, so this could be endocolitis. He could have a murmur. Let's listen to his heart.

SPEAKER_03 16:52

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. And um we did manage to arrange an echo, and the echo showed vegetation on the tricuspid vowel with moderate associated TR.

SPEAKER_01 17:29

Was he a drug user, an intravenous drug user?

SPEAKER_03 17:32

I hadn't asked him, had I.

SPEAKER_01 17:36

No, you didn't ask about recreational drugs travel or sexual activity.

SPEAKER_03 17:41

I I went back and asked about sexual activity and travel. I didn't ask about recreational drugs, because this is a fit and well 34-year-old, highly educated graphic designer. 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. And I was trying to sort of pick up why it's unlikely this man might take recreational drugs. Um and I was wondering if if you were thinking the same thing. I was subconsciously thinking.

SPEAKER_01 18:06

I probably was.

SPEAKER_03 18:07

But let's let's get down to it. So he gets diagnosed with tricuspid valve endocarditis. He gets placed on our standard endocarditis um regime, which was, I think, amoxicillin, flucloxicillin, and gentomycin. Um he has a myrma, he has a vegetation on transthoracic echo. And then on questioning, this man does inject heroin off and on, and has done so for many months. 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. This man couldn't be an intravenous drug user. 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. Um, probably I don't need to ask about does he inject opiates um on a regular basis? And there was the hole. The other Swiss cheese hole was the lack of murmur detection um at the point of Clarking. 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. 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. Um, but I didn't, because I clearly have a bias, an archetype. 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. Therefore, I did not pursue it. You wanted to ask about recreational drugs. Um, so clearly you suspect everybody, anybody's potential to be a drug use a drug user. But it it did not fit my own representative bias for this particular patient. And that's something that I've been thinking about a lot ever since then.

SPEAKER_01 20:15

Hmm, that's did you go into his drug use a little bit more with him?

SPEAKER_03 20:22

I did a little bit. It was something him and his flatmates were doing um off and on. They didn't can consider themselves to be drug addicts because they didn't do it regularly. It was just when they wanted to party. Wow. Yeah.

SPEAKER_01 20:41

So inject heroin. Well, okay. That's that's new for me. Oh, okay, uh, thank you. 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. But I don't know.

SPEAKER_03 21:03

But I think I mean there are um functional addicts out there who who can hide it, who do take on the daily. And I guess there are people who socially shoot up. But it was something I wasn't very familiar with. Gosh.

SPEAKER_01 21:17

Wow. And recovery from the infection, how did he get on? What was his valve like?

SPEAKER_03 21:24

It was not in a good state. And this gentleman eventually got referred to our tertiary cardiothoracics unit for a valve replacement because the terracuspid valve was partially destroyed.

SPEAKER_00 21:34

Gosh.

SPEAKER_03 21:35

Yeah, so he had surgery and made a good recovery as far as as far as I can make out. 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. But I think it was a good learning case. 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. Not deliberately, I just wasn't told about it. So my brain. Clicked over it. 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. And I think that's important. That's not true. I just didn't tell you about his heart examination. And it's interesting how by not getting that information, our brain sort of synthesizes it as that this the sign wasn't present. Part of our jobs as consultants on the post-tate ward round is to listen incredibly carefully, spot gaps, and just say, sorry, murmurs? Anything on heart examination? 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. Because if we don't, then maybe our subconscious could fill in the gaps for us. And we assume if it ain't mentioned, it's because it wasn't there. But we need to hear that it's not there. Do you know what I mean? This is the art of post-taking. I never got taught how to post take a patient. I've sort of had to sort of invent my own way of doing it, as all as all acute consultants do. But this was a learning point for me about how I conduct my post take ordinance.

SPEAKER_01 22:57

And I certainly do them very different, I think, to you. Um, I think I need to learn from you actually, Ben, because I don't think my post-taking wardrounds are particularly good. Um I'm so slow. I've talked about this before. I I have to take the history and re-examine everything and everyone. Um and it's but it paralyzes me. Like I'm just uh yeah, I'm overwhelmed by post-taking now. Maybe I've been doing it for such a long time that I'm just I need a break from the post take. I don't know. In acute medicine, that's what we do, isn't it? Day in, day out. We are post-take. That's that's exactly what we do. And I think it's really difficult cognitively every day to see new patients. 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. We are the decision maker, and that can be really difficult sometimes.

SPEAKER_03 24:01

It also requires a large amount of trust. You say you're very slow, I'm very, very fast. And that's not because I'm that's not better, but that's uh I I take a lot on faith. Um, and I say, so so you're telling me you detected X and Y. This is the blood, this is the X-ray, and you're convinced this is the diagnosis. Okay, now my job is to go and double check. Hello, Mr. Smith. Nice to meet you. I'm Ben Lovell, I'm the consultant. I've been hearing all about you from insert a resident doctor's name here. I'm so sorry you've come into the hospital. I understand you've had a nasty cough and we've diagnosed you with pneumonia. How are you feeling today? Um, and you've been unwell for two days and you've been coughing, and then you had a fever, and here you are. And and I rely on the patient to jump in and say, no, no, no, not two days, or no, that's not right. 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. And do I miss stuff? Or look at the case we're doing today. 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. But I find that I can't, I can't re-examine from scratch, not totally. I can't take scratch, not when there's so much to do. And this is the method I slowly developed over eight years of being a consultant, which I find works for me most of the time. Um, and that involves me sometimes going to the patient saying, Hello, nice to meet you. I'm so sorry you've had to come into the hospital. It looks as though you're A and well, but we don't know what's going on yet. Have you got any ideas what could be going on? And being quite open about that sort of thing. Um, and I change it from patient to patient, but that's how I move quickly through the post-it wardrobe. And and for me, that won't sue a lot of people, but for me it works.

SPEAKER_01 25:48

I think you would really dislike my wardrobe. So I'm like, okay, then say then, Mrs. Smith, sit down, maybe hold a hand and say, tell me why you've come to hospital.

SPEAKER_02 25:58

You're the fourth person who asked me. Sometimes, yeah. So read the notes.

SPEAKER_01 26:03

And then I'll ask them, Well, what sort of work did you used to do? Well, I did, oh, that's lovely. Do you have any pets? I can see the resident doctors going, Oh God, she doesn't need to know about their pet rabbit.

SPEAKER_03 26:15

Um It's when they stop typing, it's when you're you're talking to a patient and you can hear this tippy tippy tippy tappy behind you because they're writing down on their computer what you're saying. And it's when they stop typing, you think they're not writing this down because they think it's not you think I've got off on a on a type of.

SPEAKER_01 26:31

It's got even worse. I've banned computers on my wardrobe.

SPEAKER_03 26:35

Why?

SPEAKER_01 26:36

Because I find it really distracting for my excessive history taking.

SPEAKER_03 26:40

So did your resident have to remember everything and then go out and write it all down again?

SPEAKER_01 26:46

Now I have to do all my own notes.

SPEAKER_03 26:49

Oh wow.

SPEAKER_01 26:50

Yeah, I know I've got, I think I've got, I think I need some I need to come and see how you work, Ben, because I have to type everything. Oh no.

SPEAKER_03 26:58

Gosh.

SPEAKER_01 26:58

Yeah, they're not going to be able to do it.

SPEAKER_03 27:00

I do check what they've written, but I I can't, I don't know. I I can't be going to write. Otherwise, what are they doing? Are they they're just watching and learning?

SPEAKER_01 27:07

No, I get them to examine the patients. I get them to talk to the patients. Um, but yeah, it's painful. I need I need to change. Uh this is crazy. Um, maybe I'll just come and do like a an elective with you 20 years after iconic through it.

SPEAKER_03 27:20

I'll leave that with you. I I I go back to the cases. It's not the best case for me to promote the Ben Love Orb system because it is the case where um I really could have done with a bit of Amy Burr bridging and examining the patient from from scratch.

SPEAKER_00 27:33

Maybe, maybe. Yeah. Somewhere in the middle, maybe.

SPEAKER_03 27:37

There's a happy medium somewhere. We we talk about bias, and I thought, well, here's an interesting bias. How often do we stereotype and in what we think is even a positive way, as opposed to a negative way, and having sort of prejudices against people, but it still doesn't turn out right. It still doesn't work if the patient doesn't match your mental archetype for what this condition looks like. And boy, did this man not match the picture I had in my brain of an IVDU.

SPEAKER_01 28:04

Wow.

SPEAKER_03 28:05

There you go. That's humanity for you.

SPEAKER_01 28:07

Thank you. It was a really interesting conversation about the case, but also about how we do posttakes and how we think, how we feel.

SPEAKER_03 28:17

Yeah. Fascinating. And I think there is a balance to be struck between taking everything at face value and just saying, sorry, go back a bit. What was that last thing you said? I didn't catch about murmurs or not. You didn't mention it. Oh, okay. We need to talk about it. Um, and I thought that was it. This is a good illustration of that. Great. Well, thank you for listening to me, drone on. Uh, and thank you, everyone who listens as well. Wherever you're listening to us on any app, if you could click a few buttons on your phone and leave us a quick rating or a bit of feedback or a review, that'd be super because that does something clever to algorithms and means we're more likely to be found when someone's searching for their next medical podcast they want to listen to. And of course, you can recommend us the old fashioned way by just telling people face to face hey, have you heard the Home of Medicine podcast? And we hope you enjoy listening and guessing along with us when we do these cases. Thanks so much for listening again, and it's goodbye from us.

SPEAKER_00 29:11

Goodbye.