Part 15: Episode 15: Giving Up

This update covers:

Gabriel Cunningham 3 - Blazing Darkness (part 2 of 2)



Gabe: Congestive liver failure... possible heart failure link.

RONI: Yes, Doctor. If left alone, his condition may become critical.

Gabe: He's gonna complain, but we can't send him home like this.

RONI: Yes, Doctor. I have obtained approval to continue diagnosis.

Diagnostic's chapters are usually broken into parts like this. It's the same chapter, but you do multiple diagnoses on the same patient.



Gabe: From the symptoms I found, I can tell you have congestive liver failure.

Tillman: Then make the damn diagnosis so I can get out of here!

Gabe: Unfortunately, I can't do that. I need to look into why you even have congestive liver failure in the first place. The primary cause of congestive liver failure is heart failure.

Tillman: Heart failure? Don't tell me...

Gabe: Oh, so you DO have an idea about this!

Tillman: Of course not! I have no idea whatsoever!

Everybody lies. Poorly.

Gabe: Alright, pal, let's get one thing straight. I'm a doctor. Even if a patient's a grumpy old man like yourself, I still have to save his life. So whether you like it or not, you're going to tell me everything I need to know to diagnose you.

Tillman: Damn... Suit yourself!

You can only start with more questioning this time. Actually, you might be able to use visual examination at this point, but there's nothing to find.



Tillman: Yes, two years ago I did, but that has nothing to do with this! *wheeze* Arguing with you is making me feel faint, you quack! If I really do get sick because of you, I'll sue your ass into the ground! This Country...! This country needs me! What's a little chest pain compared to the well being of the country? No youngster like you will stand in my way!

Two this time, both pretty easy. He said he felt faint:

Gabe: Feel faint, huh? Looks more like trouble breathing, and that's not even m fault, you old geezer! RONI, make a note of Mr. Tillman's shortness of breath.

RONI: Understood, Doctor. New Symptom: "Dyspnea"

He also off-handedly mentioned chest pain.

Gabe: Chest pain, huh? I almost missed that one. RONI, write that down, too. Seriously, it's like pulling teeth with this guy!

RONI: New symptom: "Chest Pain."

Gabe: My suspicions of heart failure are even stronger now. Ready to cooperate with the exam yet?

Tillman: Urggh... Alright, I'll cooperate with you. But if you don't find anything, you'll pay!

Gabe: Who threatens a doctor? Well, that's fine. Let's just continue. I have a feeling you're still hiding something.

This opens up the stethoscope and diagnostics options, as well as a new one: the EKG. First, we'll auscultate.



Auscultation Video
Viddler
Youtube

The lungs and heart both had problems. There were discontinuous crackling noises in the lungs...

Gabe: RONI, did you get that one?

RONI: New symptom: "Discontinuous Sounds."

...and extra heart rhythms. The normal "lub-dub" heartbeat consists of two noises, called S1 and S2. We're hearing two extra noises, S3 and S4. This is called a gallop rhythm.

Gabe: RONI, jot that down.

RONI: New symptom: "S3 and S4"

Next, we'll go back to the numbers. RONI will badger you to do this, reminding you that the patient's condition can change and so the numbers need to be re-checked.



Blood Pressure: These measure the blood pressure to blood vessel walls. Fluctuations can indicate various heart or arterial diseases. Normal range is 110 ~ 140. Measured value is 85.0

Gabe: Add that to his file.

RONI: New symptom: "Low Blood Pressure."

BNP: The Brain Natriuretic Peptide is a type of hormone secreted by the heart. It indicates heart failure. Normal range is 0 ~ 18. Measured range is 430.0.

Gabe: What the hell? The BNP level is abnormally high. That's worth recording.

RONI: New Symptom: "High BNP Level."

I'm not really sure why he's surprised. It fits with everything else we've found rather well. Anyway, now we can see the EKG. The Electrocardiogram (The ancronym is based on the German, which is why is uses a K) is a device that records the electrical activity of the heart. It's used to find abnormal heart rhythms. In this game, it works like the pictures, except that the lines move. You have to compare with the normal picture and find the differences.





There are two to spot. On the top line, there is a downward spike that shouldn't exist next to all the large upward spikes.

Gabe: The Q waves are too deep. This isn't the activity of a normal heart. RONI, write that down somewhere.

RONI: New Symptom: "Abnormal Q Waves."

On the bottom line, check near the left for a small negative dip that shouldn't be there. This doesn't occur in every beat, which makes it a little harder to spot.

Gabe: Odd. The T waves are showing negativity in this portion. How bizarre. RONI, add it to the list.

RONI: New symptom: "Negative T Waves."

Gabe: Well, looking at the symptoms up until now, there seems to be an abnormality in the myocardium. RONI, get us approval for an X-ray.

RONI: X-rays use radiation to make images! Beep boop!

Gabe: I know!

Alright I may have abridged that a little more than normal. And yet I didn't cut anything useful from RONI's explanation.

X-Ray_01
Patient:



Sample:



I doubt I need to point this one out.

Gabe: His heart's too large. There's definitely an abnormality after all. To look at the movement of the myocardium, an echocardiogram would be ideal. Hey, RONI, think he'll sit through an exam?

RONI: Doctor, I am required to remind you that a patient's consent is needed before examination.

Gabe: Well, we can always narrow the list of candidates down again if we need to, but let's try talking to him, just in case.

RONI: Understood. New Symptom: "Enlarged Heart."



Gabe: That means our next step is to proceed with an echocardiography.

Tillman: I refuse! How dare you treat me like some leper!

Gabe: Well, then let's talk about your past. What happened two years ago?

Tillman: Hmph!

Gabe: So, you aren't going to tell me about that either, huh? Nothin'? Well, then, I'm stumped. Guess I'll have to go get a hint from the information I've got.

We'll do that, then.



Symptoms List:
Enlarged Heart
Abnormal Q Waves
Negative T Waves
High BNP Level
Low Blood Pressure
S3 and S4
Discontinuous Sounds
Chest Pain
Dyspnea

In the image, it's kind of obvious that Aortic Dissection has way too few symptoms to explain all of this, and the same goes for Acute Pericarditis (besides, we think the problem is the myocardium, not the pericardium.) The middle one, then, is best: Dilated Cardiomyopathy.

Dilated Cardiomyopathy:
A condition in which the heart becomes enlarged, weakening the myocardium's movements. Initial stages present no subjective symptoms, but as the condition progresses, chest pains and dyspnea will begin to appear. S3 and S4 can be heard through ausculation of the heart sounds, and discontinuous sounds can be heard in respiration if there is pulmonary congestion. Abnormal Q waves and negative T waves will be present on an EKG, and an X-ray of the chest will confirm an enlarged heart. An analysis will detect high BNP level and low blood pressure. In order to make a complete diagnosis, an echocardiography must be done to determine the presence of an enlarged left ventricle. The exact cause of this disease is unknown, but current theories note a relevance to Viral myocarditis.

That's all of our symptoms. It's only missing the echocardiography.

Gabe: That's one serious disease.

RONI: Echocardiography is absolutely necessary to properly diagnose dilated cardiomyopathy.

Gabe: Yeah, but we'll need some strong evidence. Wait... "a relevancy to viral myocarditis?" Don't tell me THAT'S what happened two years ago! Let's go talk to him. This isn't funny anymore.



Gabe: Yeah, that's fine. I have a plan this time, too.

Tillman: What kind of scheme are you running here?

Gabe: I was just toying with idea of leaking some interesting facts to the press about a certain politician who had viral myocarditis two years ago and collapsed due to heart disease.

Tillman: You bastard! How the hell do you know about...!?

Gabe: So it WAS viral myocarditis, then. I needed confirmation.

Tillman: You bastard... How dare you!? Who do you think I am!? I'm not putting up with this any longer. I'm leaving!

Gabe: Hey...

Tillman: Shut the hell up! I will not hear another word out of you!



Gabe: Now you listen to me. It doesn't matter who you are or what kind of powers you have. I'm a doctor! And as long as you're sitting in front of me, you're nothing more than a patient! Now, shut up and let me do my job! RONI, send a request for echocardiography. We've got a date with the image analysis lab.

That was honestly a bit underwhelming, but hey.

RONI: Echocardiography is a technique of using ultrasonic waves to form an image of the heart. This examination is a safe and essential tool for observing heart irregularities and diseases.

Gabe: You know it was MY idea to run this exam.

Ultra Sound_01
Patient:



Sample:



Ultra Sound_02
Patient:



Sample:



Ultra Sound_01
Patient:



Sample:



Still pretty easy(there are some stupidly difficult ones later, I swear). The left ventrical is enlarged. Which in layman's terms translates to "the big circle in the middle of the third picture is different."

Gabe: Geeze, it's even worse than I imagined.

RONI: Understood, Doctor. New Symptom: "Enlarged Left Ventrical."

That's enough. All that's left to do is slot in the missing symptom.



Blazing Darkness: Ending


Next time: Nolan. Freakin'. North.

Medal Challenge

There was another medal available in this update that I didn't point out. As a fun activity to try at home, see if you can spot it!