"It feels like I have Bruised Lungs Doctor" - Managing Clinical Uncertainty

Amie and Ben discuss a case of a 33-year-old woman attending SDEC with a sensation of "bruised lungs" and night sweats. 

Can Ben figure out what is going on? 

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

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

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

Transcript

Host [Dr. Ben Lovell]: Hello and welcome to the Home of Medicine Podcast with me, Dr. Ben Lovell, and my ever-faithful co-host.

Amie [Dr. Amie Burbridge]: Hi, it's Dr. Amie Burbridge here. I am a consultant in acute medicine, and I have some really exciting news: I started a new job this week! I am working at Lincoln Medical School, where I will be heavily involved in professionalism and developing the clinical reasoning curriculum. It couldn't be more perfect for me, and I'm incredibly happy to be starting this new chapter of my career.

Host [Dr. Ben Lovell]: What is your official new job title?

Amie [Dr. Amie Burbridge]: My title is Associate Clinical Professor and Director of Professional Development.

Host [Dr. Ben Lovell]: Clapping hands! Absolutely fantastic. Writing an undergraduate curriculum in clinical reasoning for medical students is trailblazing stuff.

Amie [Dr. Amie Burbridge]: It is truly my dream job. But I will still be maintaining my clinical work, which means the podcast will absolutely continue. I have a case for you today.

I was called in to see a 33-year-old female as a second opinion. This was actually the individual's third presentation to our Same Day Emergency Care (SDEC) unit. She had returned for a planned follow-up appointment after a resident doctor knocked on my door and expressed uncertainty regarding how to safely progress her management. I decided it was best to go back to basic principles, sit down with the patient and her partner, and re-take the history from the beginning.

She recounted a two-and-a-half-week history of feeling generally unwell. She experienced intermittent shortness of breath without distinct triggers or relieving factors, and she used a fascinating phrase: "It feels like my lungs are bruised." She couldn't expand further, but noted a dull, diffuse ache across her upper thorax.

Crucially, she was coughing up phlegm containing bright red blood. The hemoptysis was intermittent and not thoroughly mixed with the sputum; she described it as an occasional pooling that felt as though it originated in her throat or mouth rather than a deep, productive cough. She also reported a constant need to clear her throat, a two-kilogram weight loss over the past fortnight, and marked night sweats. She noted she was completely flawed and exhausted by the illness. Finally, she had experienced a single episode of diarrhea, but no emesis. What are your initial thoughts on this framework?

Host [Dr. Ben Lovell]: The primary features are intermittent dyspnea, distinct thoracic pain, phlegm accompanied by acute hemoptysis, and constitutional symptoms like weight loss and night sweats. A simple, two-week history of respiratory symptoms and thoracic pain could easily point toward an acute chest infection or a focal pneumonia. However, coughing up bright red blood stands apart from the typical rusty sputum seen in a standard community-acquired pneumonia, which suggests something more complex.

When you combine a brief history of progressive fatigue, night sweats, and objective weight loss in a young woman, it forces you to consider an occult malignancy. Specifically, a hematological malignancy like lymphoma or leukemia fits this script well. Significant lymphadenopathy compressing the trachea or the carina can trigger a persistent cough reflex, and local vascular irritation can cause intermittent hemoptysis.

While a primary care clinician might immediately think of a pulmonary embolism given the triad of dyspnea, thoracic discomfort, and hemoptysis, true hemoptysis is generally rare in a PE unless it is a massive or submassive event causing structural infarction of the bronchopulmonary circulation. Those patients tend to be profoundly unwell. My primary focus here is separating a persistent lung infection from an atypical hematological process.

Evaluating Previous Therapies and Objective Signs

Amie [Dr. Amie Burbridge]: As I mentioned, this was her third presentation to SDEC. On her first visit, she was prescribed a standard course of Amoxicillin, and on her second, she received Doxycycline. Neither antibiotic course altered her symptoms. Furthermore, a chest radiograph performed during her second assessment was documented as entirely normal.

Host [Dr. Ben Lovell]: Documented as normal by whom? I am incredibly particular about imaging; if a colleague tells me a film is clear, I always insist on reviewing the raw images myself to ensure a subtle abnormality hasn't been overlooked.

Amie [Dr. Amie Burbridge]: I reviewed the film myself and agreed it was clear. I didn't deploy a point-of-care ultrasound probe on this occasion, despite my usual habits!

I proceeded to a formal physical examination. Her baseline medical history was entirely clear, she took no routine medications, and she had no known drug allergies. Her objective vital signs were reassuringly stable:

• Respiratory Rate: 14 breaths/min
• Oxygen Saturations: 99% on room air
• Heart Rate: 76 bpm (regular)
• Temperature: 36.0°C
• Blood Pressure: 114/75 mmHg

On system review, her cardiovascular exam was normal. On lung auscultation, I noted a subtle hint of noisy expiratory breathing isolated to the left side, though it was non-specific. Her abdomen and calves were soft and non-tender, and there was zero peripheral edema.

Given the history of night sweats and weight loss, I carefully palpated her cervical, axillary, and inguinal regions, but found no palpable lymphadenopathy. Finally, I performed an oral and pharyngeal examination. Her mouth was free of oral candidiasis, but the posterior pharynx was noticeably erythematous and raw, displaying signs of superficial pharyngeal ulceration. Does that pivot your differential axis?

Host [Dr. Ben Lovell]: Finding posterior pharyngeal ulceration changes things. My single most important question is: how long have these mucosal ulcers been present, and do they match the two-week timeline of her systemic malaise?

Amie [Dr. Amie Burbridge]: They matched the timeline perfectly. To answer further, she was sexually active in a long-term marriage, had no history of foreign travel, reported normal regular menstruation, and denied any associated vaginal discharge or symptoms suggestive of a sexually transmitted infection.

Her primary blood results revealed:

• Hemoglobin: 141 g/L 
• White Cell Count: 6.0 x 10^9 / L (Neutrophils: 4.0, Lymphocytes: 1.2)
• Platelets: 424 x 10^9 / L
  
  
  
• C-Reactive Protein (CRP): < 4 mg/L (normal)
• Renal Function (U+Es): Completely within normal limits

Host [Dr. Ben Lovell]: Because her entire baseline cell count and inflammatory markers are completely normal, a primary hematological malignancy or a typical acute bacterial infection becomes highly improbable. Pharyngeal ulceration shifts my focus toward a rheumatological or systemic autoimmune process.

We have to consider conditions like:

• Behçet’s Disease: Though typically associated with recurrent aphthous or genital lesions, it is statistically rare in a Caucasian demographic.
• Systemic Lupus Erythematosus (SLE): Can present with mucosal ulcers and constitutional malaise.
• Granulomatosis with Polyangiitis (GPA): An autoimmune vasculitis that can cause upper airway ulceration and posterior epistaxis, which can mimic deep hemoptysis when blood trickles down the throat.

We also need to rule out acute HIV seroconversion, which frequently presents with an atypical sore throat, mucosal ulceration, and night sweats. If we suspected a covert malignancy despite the normal blood counts, we would need to check an LDH or beta-2 microglobulin before considering a PET scan, but the evidence doesn't support that escalation yet. I would want to circle back and ask about transient cutaneous rashes, a history of miscarriages, or prior deep vein thromboses, and order an autoimmune serology screen including ANA, ANCA, and complement levels.

Amie [Dr. Amie Burbridge]: Her history was negative for alopecia, miscarriages, or thromboses. She did mention a vague, non-pruritic, non-painful erythematous rash across her upper back that had self-resolved before her admission, but there were no skin lesions visible on my assessment.

Interestingly, a comprehensive autoimmune serology panel had already been processed: her ANA was negative, ANCA was negative, and her ESR was entirely negligible. Every single diagnostic test was completely normal. What would your next step be?

Host [Dr. Ben Lovell]: If every targeted investigation, inflammatory marker, and autoimmune screen is normal, the only remaining option to rule out a occult structural process would be cross-sectional imaging via a CT scan of the thorax, abdomen, and pelvis.

However, given the short duration of a highly systemic but stable presentation, this could easily represent a self-limiting viral illness, such as a severe viral respiratory tract infection that has completely exhausted her. Without objective, compelling evidence of organic pathology, I would find it incredibly difficult to justify a cross-sectional CT scan to a radiology team. At this point, I would opt for close clinical observation rather than immediate imaging.

The SDEC Stalemate: Managing Uncertainty and Hierarchy

Amie [Dr. Amie Burbridge]: I am glad you said that, because that was my exact reasoning. After reviewing the entire timeline with the patient, her partner, and the resident doctor, I concluded that there was no evidence of a life-threatening or malignant process. I explained that she had likely suffered a severe viral infection—such as an atypical presentation of COVID-19—that had completely flawed her, and that her intermittent hemoptysis was driven by localized irritation from the pharyngeal ulceration.

I advised discontinuing any further antibiotic therapies, reassured them that her normal bloods and stable observations were highly positive signs, and proposed a clear "watch-and-wait" approach with a plan to review via her GP in seven days if things failed to settle. The consultation felt complete.

However, when I stepped out of the room, the resident doctor stopped me and said, "I disagree with you. I believe this patient has an occult malignancy and requires an urgent CT of her thorax, abdomen, and pelvis."

We went back and forth for a long time discussing whether to scan or not. It was a thoroughly professional, highly valuable debate, but it genuinely challenged my clinical decision-making. It forced me to reflect on why we as physicians feel a transactional obligation to stamp a definitive diagnosis on every presentation, even when a self-limiting non-diagnostic outcome is the most appropriate conclusion.

Host [Dr. Ben Lovell]: It comes down to fear: the fear of missing a critical diagnosis, the fear of inadvertently harming a patient, and the baseline anxiety surrounding a potential formal complaint or legal issue if a rare condition unfolds later. Sitting with clinical risk and navigating uncertainty is incredibly uncomfortable.

When we tell a patient "I don't know," we are asking them to share that burden of risk with us. Some patients accept that senior reassurance, but others struggle without a concrete answer. It is far easier to write a prescription for a chest infection and send a patient home than it is to navigate the delicate human factors of an open-ended, non-diagnostic conclusion.

Amie [Dr. Amie Burbridge]: Compounding the issue, the resident doctor had already explicitly mentioned the word "cancer" to the patient prior to my second opinion. Once that word enters a consultation, the psychological landscape shifts completely.

How do you manage a situation where a colleague has introduced a severe diagnosis, and you have to walk in as a senior clinician and pivot away from it without undermining your team?

Host [Dr. Ben Lovell]: It is an incredibly delicate line. You must never dismiss a colleague or throw them under the bus by calling their reasoning nonsense. I would address the patient directly and frame my role clearly:

"I understand it is jarring to hear a different perspective now. I am the attending consultant on call today, and my junior team brought me in specifically to provide a senior, second opinion because your case is complex and unusual. I have reviewed your normal blood work, your clear imaging, and your stable vitals. If I had any residual suspicion of an underlying malignancy, I would not hesitate to order further scans. My senior view is that this is safe to monitor, and I am entirely comfortable holding that responsibility."

Amie [Dr. Amie Burbridge]: We reached a complete stalemate. The patient felt physically better that day but remained highly anxious because she was rarely ill, and the resident doctor remained firmly convinced a scan was necessary. I strongly believed a CT was an over-investigation.

Ultimately, I chose to prioritize the trainee's autonomy and learning curve. I told the resident, "I understand your clinical rationale, and while my approach differs, I want you to have the autonomy to manage this uncertainty. If you truly believe a CT is the safest course for this patient, proceed with the scan." We ordered the CT thorax, abdomen, and pelvis.

Host [Dr. Ben Lovell]: And what did the scan show?

Amie [Dr. Amie Burbridge]: It was completely normal.

The purpose of sharing this case isn't to show that my initial instincts were right. There are absolutely times where I have resisted an investigation, only for a scan to uncover a major surprise that completely humbled me. The core issue is how we balance our medical training—which conditions us to find a clear diagnosis—with the reality that a huge portion of acute and primary care medicine consists of non-specific, self-limiting viral presentations where a definitive label simply doesn't exist.

Human Factors: Graded Assertions and Team Culture

Host [Dr. Ben Lovell]: This underscores why I deeply respect general practitioners. They manage immense volumes of clinical risk every day without instant access to same-day labs or advanced cross-sectional imaging, relying purely on clinical history, examination, and communication skills.

As hospital consultants, making a deliberate time investment in our patients—listening thoroughly and examining them methodically—is vital. Even if we don't provide a concrete diagnosis, the patient leaves knowing we engaged our clinical reasoning fully and treated their concerns seriously, rather than offering a flippant, five-minute assessment. It builds essential trust.

Amie [Dr. Amie Burbridge]: I was proud of the resident doctor for professionally standing their ground. I want to actively encourage trainees to challenge senior decision-making in a professional manner. Having my own thought process questioned made me stop and deliberate deeply, which is incredibly valuable for a consultant.

Host [Dr. Ben Lovell]: Junior colleagues have saved me from major diagnostic errors countless times simply by noticing a trend or suggesting an alternative perspective I had entirely missed.

However, challenging a senior up a hierarchical gradient can be incredibly intimidating for a trainee if the culture doesn't feel psychologically safe. In human factors training, we teach specific communication tools called graded assertions to help bridge this gap safely.

The framework I use most frequently is the CUS (or CUSS) acronym, which provides a stepwise approach to escalating a safety concern:

• C – Concerned: The trainee initiates the conversation softly: "I'm a bit concerned we might be overlooking a hidden process here." This signals a thought without undermining anyone's dignity.
• U – Unsure: If the concern isn't recognised, the escalation rises: "I'm unsure or uncertain that it's entirely safe to discharge this patient today given their history." This encourages the senior to pause and re-evaluate.
• S – Safety: The third tier introduces objective risk language: "I feel this is a genuine patient safety issue if we send them home without further clarity." This clearly catches a consultant's attention.
• S – Stop: The final, nuclear option: "We need to completely stop and review this situation from square one." This requires significant bravery but is vital in high-stakes environments.

Another highly effective tool is the PACE framework, which tracks a similar pathway:

• P – Probe: Asking a focused question, often phrased politely as a learning query: "Just for my own learning, why are we opting against a CT scan in this context?"
  
  
  
• A – Alert: Highlighting a specific clinical risk: "I want to alert you that the patient has documented weight loss and night sweats."
  
  
  
• C – Challenge: A direct, professional variance: "Do you mind if I gently challenge that plan? I feel a CT scan is clinically warranted here."
  
  
  
• E – Emergency: Shifting the situation to an acute safety event requiring immediate intervention.

When I was a junior doctor, the culture was very different; we were often terrified of our consultants and simply followed orders to avoid being reprimanded on a ward round. As senior leaders, we have an absolute responsibility to actively build an approachable, open culture where junior team members feel safe speaking up.

Amie [Dr. Amie Burbridge]: This is exactly what I want to embed from day one as I develop the clinical reasoning curriculum at Lincoln Medical School. We need to teach medical students early on that uncertainty is a normal part of medicine, and give them the confidence and frameworks to raise concerns safely, knowing they will be listened to and respected.

What is your final takeaway from this case, Ben?

Host [Dr. Ben Lovell]: My main takeaway is that it is entirely appropriate to advocate for your patient and gently challenge a plan, even if you choose to frame it as a learning query. The medical hierarchy is designed so that the consultant at the top ultimately holds the legal risk and responsibility, which is why we have the final say. But as a trainee, if you have articulated your concerns clearly and professionally, you have fulfilled your duty as a patient advocate.

Amie [Dr. Amie Burbridge]: Beautifully said. Advocating for your patient, your own learning, and your clinical reasoning is vital. Sometimes, recognising that a non-diagnostic conclusion is the right path is just as important as making a definitive diagnosis.

Thank you, Ben, and a huge thank you to our listeners! Please remember to rate, review, and subscribe on your preferred platform. Keep an eye out for our upcoming dedicated website, homeofmedicine.com. Thank you, everyone, and goodbye!

Host [Dr. Ben Lovell]: Thank you, Amie. Goodbye!

Clinical Concepts & PathologiesSame Day Emergency Care (SDEC): An emergency ambulatory care pathway enabling rapid assessment, diagnostic workup, and treatment without overnight hospital admission.

• Hemoptysis: The coughing up of blood or blood-stained sputum from the respiratory tract.
• Constitutional Symptoms: Systemic symptoms that affect the whole body, such as unexplained weight loss, night sweats, and generalized malaise.
• Lymphadenopathy: An abnormal enlargement of the lymph nodes, frequently investigated as a sign of localized infection, autoimmune activation, or malignancy.
• Behçet’s Disease: A rare, chronic autoimmune vasculitis characterized by recurrent oral and genital ulcerations, ocular inflammation, and systemic lesions.
• Granulomatosis with Polyangiitis (GPA): An autoimmune systemic vasculitis of small-to-medium vessels, typically involving the upper respiratory tract, lungs, and kidneys.
• Human Factors: An interdisciplinary field in healthcare focusing on optimizing human performance, team communication, and systems to maximize patient safety.
• Graded Assertions: Structured communication frameworks designed to help team members systematically escalate patient safety concerns across a hierarchical gradient.

Diagnostic Frameworks & Imaging

• Chest Radiograph (CXR): A baseline projectional radiograph of the chest used to evaluate the lungs, heart, and thoracic bones.
• CT Thorax, Abdomen, and Pelvis (CT TAP): Cross-sectional computed tomography utilizing advanced X-ray imaging to screen for structural abnormalities, occult malignancies, or deep inflammatory processes.
• Autoimmune / Vasculitis Screen: A specialized panel of laboratory serology (including ANA and ANCA markers) used to evaluate for systemic connective tissue diseases or vascular inflammation.
• CUS / CUSS Framework: A graded assertion safety communication tool focusing on the escalation states: Concerned, Unsure, Safety, and Stop.
• PACE Framework: A human factors communication strategy mapping out an escalation pathway via Probe, Alert, Challenge, and Emergency.

This episode follows the evaluation of a 33-year-old female presenting to same-day emergency care for the third time with a constellation of vague thoracic discomfort, localized ulceration, and constitutional symptoms. Rather than focusing on an elusive pathognomonic finding, the hosts explore the diagnostic tension that arises when multiple imaging sets and laboratory investigations return entirely normal. The clinical core shifts into an essential masterclass on human factors, navigating stalemates between senior and resident physicians, and managing the psychological burden of risk tolerance.

How should a clinician systematically evaluate progressive hemoptysis combined with constitutional symptoms when a chest radiograph is normal? When a plain chest X-ray fails to demonstrate localized consolidation or focal masses, the clinician must broaden the differential diagnosis to include upper airway pathology, occult hematological conditions, or multi-system autoimmune disorders. A normal frontline image requires close clinical monitoring or an escalation to cross-sectional computed tomography if weight loss and night sweats objectively persist.

What behavioral communication frameworks allow junior clinicians to safely challenge a senior diagnostic plan? Junior physicians can utilize graded assertion models like PACE (Probe, Alert, Challenge, Emergency) or CUS (Concerned, Unsure, Safety, Stop) to systematically escalate a patient safety concern across a hierarchical gradient. These standardized human factors tools lower psychological barriers, allowing trainees to advocate for patient diagnostics without creating immediate interpersonal conflict.

How do defensive medicine and a low tolerance for uncertainty influence diagnostic over-investigation? A low tolerance for clinical uncertainty often drives a fear of missing a rare diagnosis or facing a future professional complaint, pushing clinicians to order unnecessary cross-sectional imaging. Managing this cognitive bias requires senior physicians to engage deliberate clinical reasoning, accept calculated risk, and focus heavily on structured "watch-and-wait" safety netting.

Chapter Markers & Timestamps

• – Introduction & Academic Milestone: Dr. Amie Burbridge shares her appointment as Associate Clinical Professor and Director of Professional Development at Lincoln Medical School.
• – The Case of the "Bruised Lungs": Presentation of a 33-year-old female returning to SDEC for the third time with chest pain, phlegm, and bright red blood.
• – Differentiating Acute Infections from Occult Malignancy: Dr. Ben Lovell breaks down how to map constitutional symptoms (night sweats and weight loss) in young adults.
• – Frontline Treatments & Imaging Realities: Reviewing the patient's failed outpatient antibiotic regimens and her initial normal chest radiograph.
• – A Systematic Physical Examination: Tracking lymphadenopathy, checking structural fluid status, and evaluating localized mucosal changes.
• – The Clue in the Posterior Pharynx: Discovering superficial pharyngeal ulceration and mapping out rheumatological and infectious differentials.
• – Breaking Down the Autoimmune Screen: Analyzing entirely normal full blood counts, inflammatory markers, and negative serology.
• – The SDEC Stalemate: The clinical confrontation between Dr. Burbridge's "watch-and-wait" viral plan and a resident's request for urgent cross-sectional imaging.
• – The Psychology of Defensive Medicine: An in-depth analysis of the fear of missing a diagnosis and the discomfort of sitting with clinical risk.
• – Balancing Trainee Autonomy against Over-Investigation: Navigating senior responsibility when a resident physician strongly advocates for a CT scan.
• – Cross-Sectional Imaging Consensus: The final outcome of the thoracic, abdominal, and pelvic CT scan.
• – Human Factors: The CUS Framework: A deep dive into graded assertions, detailing how to utilize "Concerned, Unsure, Safety, and Stop" in a hierarchy.
• – Deconstructing PACE: Utilizing "Probe, Alert, Challenge, and Emergency" to advocate for a patient's care plan.
• – Summary & Wrap-up: Reclaiming the validity of non-diagnostic conclusions and promoting psychological safety in medical curricula.