← The Curbsiders Internal Medicine Podcast
The Curbsiders Internal Medicine Podcast
#529 A Case of Syncope with the Clinical Problem Solvers
00:57:43
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- [00:00]
Dr. Matthew Watto
Hey, before we get to the show, I wanted to remind you to check out our patreon@patreon.com curbsiders. If you haven't signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes, and a whole bunch of other cool stuff@patreon.com curbsiders
- [00:19]
Dr. Paul Nelson Williams
Paul,
- [00:19]
Dr. Matthew Watto
I'm writing a book on reverse psychology,
- [00:25]
Dr. Paul Nelson Williams
but I'm not going to want to read it.
- [00:26]
Dr. Matthew Watto
Please, please don't buy it, Paul.
- [00:27]
Dr. Paul Nelson Williams
There we go.
- [00:28]
Dr. Matthew Watto
Please don't buy my book.
- [00:29]
Dr. Paul Nelson Williams
Not bad, Paul.
- [00:31]
Dr. Matthew Watto
My geometry teacher is really upset that her pet parrot died yesterday.
- [00:43]
Dr. Paul Nelson Williams
There. I feel like there's gonna be a poly in there somewhere, but I'm not sure I'm gonna get there. All right, tell me Polygon. I love it. Thanks, Paul. Yeah.
- [00:56]
Dr. Robby Jiha
The Curbsiders podcast is for entertain and information purposes only, and the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from boss cash, like Moral hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We aren't responsible if you screw up. You should always do your own homework and let us know when we're working.
- [01:23]
Dr. Matthew Watto
Welcome back to the curbsiders. I'm Dr. Matthew Frank Waddo excited that my good friend Paul liked my pun. I'm here with the great Dr. Paul Nelson Williams, America's primary care physician. Paul, how you doing?
- [01:36]
Dr. Paul Nelson Williams
I'm good, Matt. How are you?
- [01:38]
Dr. Matthew Watto
I'm good, Paul. Because our good friends Reza and Robby back on the show. It's been way too long since we've had them on there. You might know them as the clinical problem solvers. They're going to go through a mystery case. I don't want to spoil it for you, the audience, so I'm not going to tell you what it's about, but it's a great case and you're going to learn a lot. But, Paul, what is it that we do on Curbsiders? Remind people. Why are they here? Why are they listening?
- [02:02]
Dr. Paul Nelson Williams
Sure. Happy to, Matt. As a reminder, we are the internal medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. Tonight's a little bit of a different kind of episode. As you mentioned, we have Robby and Reza here just to show us how they reason through a case. We'll give it to them in sort of small chunks and kind of listen to them as they kind of pull the threads apart and try to figure out diagnosis before we just give it to them. It is remarkable to watch them work and teach and kind of just listen as they process and reason through things. But before we get to that, I should also mention we are joined by a co host and one of the producers of this episode, Dr. Edison, Eddie Jang. Eddie, how are you?
- [02:38]
Dr. Edison Jang
I'm great.
- [02:40]
Dr. Paul Nelson Williams
I am glad to hear it. Why don't you tell us a little bit about first of all the producers and then also you can introduce one of our guests and I'll talk about the second.
- [02:49]
Dr. Matthew Watto
Yeah.
- [02:50]
Dr. Edison Jang
Special thanks to Youssef Siklawi and Matty Conte, part of the Clinical Problem Solvers team who wrote the cases. Then first guest is Robbie Jiha. He's an associate professor of medicine at UCSF based at the San Francisco VA Medical center and is the director of education for the emergency department. Clinically, he splits his time between the emergency room and the inpatient medicine teaching wards. Ravi is also the co founder of the Clinical Problem Solvers, a global multimodal medical education that hosts a weekly podcast, daily virtual case conferences, and a clinical reasoning training academy.
- [03:29]
Dr. Paul Nelson Williams
Thanks Eddie. And we are also joined by Dr. Reza Manesh. Reza Manesh is a hospitalist at the Greater Los Angeles Veterans Affairs Medical center and professor of medicine. Professor God bless and we knew him back when Matt at the UCLA School of Medicine. He is the director of Didactic teaching at the va. Reza co founded Clinical Problem Solvers with a mission to democratize the teaching of diagnostic reasoning. He aims to help others find joy in their healthcare training and careers. He authored Finding Joy in Medicine, a memoir highlighting his formula for joy in medicine. And so without further ado, let's get to it.
- [03:57]
Dr. Matthew Watto
A reminder that this and most episodes will be available for CME credit for all health professionals through VCU Health at curbsiders.vcuhealth.org you can also make it easier to claim credit@patreon.com curbsiders Reza and Robby so great to have you guys back on the show. Before we get into our what I'm calling a mystery case tonight, why don't we Reza, why don't we get a hobby or interest? Like what are you currently into outside of medicine? I know you spend a lot of time on medicine and for those of you who can't see this, you're listening. Reza changed his name in the recording studio to Curbsider's number one fan. So thank you for that, Reza. Pandering will get you Everywhere.
- [04:43]
Dr. Paul Nelson Williams
It may well be true. I think you've always been such a supporter.
- [04:46]
Dr. Robby Jiha
Yeah.
- [04:47]
Dr. Reza Manesh
Well, first of all, thank you for having us on the podcast again. We have to make it very clear there is no clinical problem solvers without the curbsiders. You guys were the reason that we exist. And I'm going to do something fun here. I'm going to actually let Robby answer the question that you asked me. And a lot of people confuse. Confuse us. And I don't know why I'm tempting you to confuse both of us. But once you hear Robby discuss medicine, you're going to want to be confused with Robby.
- [05:18]
Dr. Matthew Watto
Okay, Understood.
- [05:22]
Dr. Robby Jiha
I guess that that reveals what I do obsessively all the time. But I will tell you that if you ask Prof. Raz this very question a month ago, he would tell you nothing but a four letter word spelled G, O, L, F, golf, golf, golf, golf, golf. But as is true of Prof. Rez, he is apoplectically switched onto another hobby, which is crushing the book that we've been working on, which is medicine. Or not medicine, but yeah, used to be golf. Now Rez is absorbed in the world of trying to write a book, which is a. This is an interesting non medical hobby. I've contributed a small fraction, so I'm happy to say that. But yeah, that's what Rez has been up to recently.
- [05:54]
Dr. Reza Manesh
If I can make an interjection, if you've never played golf, please don't play it. It's just not worth it. It's financially, emotionally and physically taxing. Matt. You see, one day I was on the golf course and I was more stressed than before I started playing. And I asked myself, why am I doing? Couldn't answer it. And that's when I stopped playing golf.
- [06:22]
Dr. Paul Nelson Williams
There's a quote that I think is usually, I think, attributed to Mark Twain, though I'm not sure if that's accurate or not. But he said that golf is just a nice walk ruined, which I think is exactly correct.
- [06:34]
Dr. Robby Jiha
That's too good.
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Dr. Matthew Watto
Well, Reza, I hope you find book writing doesn't sound like that much fun to me either. But I hope you find a hobby someday that doesn't stress you out and that lets you enjoy a nice walk. Thank you, Robbie. How about you? What are you enjoying? Or do you want Reza to answer what your hobby is right now?
- [06:56]
Dr. Robby Jiha
I know you gotta return the favor.
- [06:58]
Dr. Reza Manesh
No, absolutely. Well, here's the thing with Robby. You can equate him to a robot. So I can predict what Robby is doing at Any time of the day. I'm not even joking. It starts out with a cup of coffee, a run in the Presidio with his dog Nar, who is his best friend, over me. I know that he won't, he won't
- [07:20]
Dr. Robby Jiha
admit to it, but I know today I will. Today.
- [07:23]
Dr. Reza Manesh
Then he comes back, he matt, I think you're going to love this. And Paul, you'll love this too. He makes his own acai. And he sources the acai. Whatever acai is, I still don't know what that is. But he sources it from like a famous company that produces the highest grade of acai. So he'll have some acai, then he'll go in the Jacuzzi where he'll think about cases and he'll text me something. Then he'll go to work, he'll come back home. And once he's home after work, it' with him, his dog Nar, and his fantastic wife Kara, who is a rheumatology fellow at ucsf. And there's nothing else? There's no hobby, there's no other interest, that is Robby for the past 10 years.
- [08:05]
Dr. Matthew Watto
Wow, that's impressive. Just for the audience. I don't think Paul and I could predict each other's day with near as much accuracy. So, Paul, I guess we're not as good of friends as we thought we were.
- [08:19]
Dr. Paul Nelson Williams
Frankly, I don't want you knowing what I'm up to. Matt, I think we're better off this way.
- [08:24]
Dr. Matthew Watto
I know Paul likes records these days. He does like to run. He has a cat named Oliver. That's most of what I know about him.
- [08:34]
Dr. Paul Nelson Williams
You're doing great, buddy. That's pretty much it. There's a job in there somewhere.
- [08:37]
Dr. Matthew Watto
Yeah, he has a job. He's very dedicated to his patients. All right, guys, well, that was entertaining, but let's get to the main event here. Eddie, would you read us the start of a case? We're going to give you the first aliquot here. And Eddie, you'll put that into the chat for them as well so they can see it and hear it. And we will get started here. You guys are going to show off your clinical reasoning skills.
- [09:04]
Dr. Edison Jang
Okay, so we have a 65 year old woman with history of two prior ischemic strokes with residual right sided deficits. She also has hypertension, hyperlipidemia, type 2 diabetes mellitus, rheumatoid arthritis, sarcoidosis presenting after a syncopal episode. She reports that while walking from her bedroom to her living room, she suddenly felt warm Then lost consciousness, awakening on the floor with her back near the wall. She denies chest pain, shortness of breath, palpitations or prodromal dizziness. She also denies recent illness, fever, chills, nausea, vomiting, diarrhea or abdominal pain.
- [09:45]
Dr. Paul Nelson Williams
All right, Reza, let's start with you. So it's every internist's favorite presenting chief concern, a patient with syncope. So just to recap, the 65 year old woman with a prior history of strokes, has high blood pressure, diabetes, RA sarcoid, comes in after a syncopable episode. Before you even start to ask questions, I guess. Where is your head? Out. How do you start to conceptualize this to kind of start guiding the conversation and the history taking?
- [10:10]
Dr. Reza Manesh
Yeah, that is a great question, Paul. And truth be told, Robbie and I, over the past several months have been obsessing about the most important step in solving a clinical problem, which is correctly identifying the problem. Because if you don't identify the right problem, there's no chance you'll arrive at the right diagnosis. And so when I hear the word syncope, I sort of take a step back and I convert that into a broader term, transient loss of consciousness. And the reason I do that is because I don't want to pigeonhole myself into syncope because it can be a syncope mimic manifesting as transient loss of consciousness. It's almost like that patient, and I learned this from Robbie, who comes in with hemoptysis, but in reality it could be hematemesis or it could be bleeding in the oral pharynx. So we translate that to blood per aurum. Now, if you ask the question, what are the causes of trans. Like the most common causes of transient loss of consciousness, it's really the S's. And this was created by Moses, which at one point was a medical student. I imagine he's like an attending doing some really cool stuff right now. But it's syncope, seizure, sugar being low, and a stroke that's strategic to the brainstem and the area that keeps us aware, the reticular activating system. Or you could have systemic embolic phenomenon. Now, any patient who has transient loss of consciousness, you should get a point of care, glucose. But the issue is, by the time they come to the ed, they usually have consciousness. And you guys had presented a case of hypoglycemia previously, so I imagine this is not low sugar just based on that, Matt. But it often comes. Is this syncope or is this seizure? And this is where understanding what happened prior to the event, which Andy shared with us, how long the event lasted and then what happened after the event that will allow you to make tremendous progress. So before I share a schema for syncope or a schema for seizure, and we know that this patient has a history of strokes, it's better to better understand the entire HPI and the, and the exam. So then we can more confidently, you know, share something that's actually relevant. Because why spend 10 minutes talking about syncope if it ends up being a stroke or a seizure?
- [12:47]
Dr. Matthew Watto
Love it. So, Robby, anything to add to that?
- [12:52]
Dr. Robby Jiha
No, I don't know. I think that's absolutely superb. And I think if you're meeting this person in real life and you're getting the history, there's going to be one key piece of information that's going to wash over you, which is how is she doing now? And I think we're going to be studying whether this is a transient event, no matter what the nature of it is, or if this is an event that still has the scar that happened to her. And so I'm really eager to figure out whatever happened to her, was it truly transient, is it truly syncopable, or does she have ongoing disease activity? I think that's going to be really key to try to make progress.
- [13:24]
Dr. Matthew Watto
Okay, guys, that does a really nice job of setting things up. So Eddie, let's, let's give them the next alcohol quad of information so that they can get some of that other history that Reza was requesting.
- [13:36]
Dr. Edison Jang
So 30 years prior, she had shortness of breath and was actually found to have mediastinal lymphadenopathy and underwent mediastinoscopy and biopsy. She was started on prednisone. She's been on intermittent low dose steroids, 5mg, which has since been discontinued. For her RA, she has had joint pains which was RF and CCP positive for that. She was starting hydroxychloroquine and has been on stable dose for 15 years. Other home meds, atorvastatin, 40 milligrams, dipagliflozin, 10 milligrams daily, metformin ER 500 and metoprolol, 50 milligrams daily. Exam is notable for right upper and lower extremity weakness with contracture. This is stable from prior and consistent with the prior strokes. There's no new focal neurological deficits. You guys get an EKG. Demonstrates sinus rhythm with QTC prolongation. QTC is around 570 milliseconds and probable left atrial enlargement. Cardiac biomarkers including troponin and BNP were within normal limits. And a TTE showed an EF of 40, 35%.
- [14:57]
Dr. Matthew Watto
So, Robbie, we'll let you start out this time. A lot of new information here. So you've got the history, you've got the medication list, the exam, and then the initial testing. And you know, you can comment on all that, including. Do you agree with the initial testing?
- [15:13]
Dr. Robby Jiha
Yeah, totally. You know, I can just share some reflections and then Profferett's gonna mop up after me if I leave a mess, which I almost always do. And I think, you know, I'm really worried about this person. And I think we haven't made much progress on whether she had syncope or another loss of consciousness. And I think that'll require zooming in on the history a little bit further. But what we do see is that she doesn't seem to have any scars. And I think I should be a little bit more clear what I mean by that. I think people who come in who are hypovolemic, for example, or have an ongoing dynamic issue, you still see evidence of what happened to them before. And when we examine her and lay hands on her, we see nothing. She's exactly how she appeared before the sinkable episode. So the question is, how does that inform us as to what happened? And I think quite simply tell us that lightning struck. And hopefully this is the most benign form of lightning, which is this is a vasovagal episode. And there's a reason to pull on that thread because she felt a prodrome of warmth. But unfortunately there's another kind of lightning that strikes and that's the lightning of the arrhythmogenic syncope. And we have two reasons to worry about that. The first is her QTC is abnormal in a rhythm sense. She has a prolonged qtc. And so immediately you're thinking, hold on, do I have to get my mag ready? And did she go into Torsad? That is a concerning piece of history in the foreground. Even more concerning piece of history in the background potentially is that she has sarcoid. And the truth is, when Eddie said the one liner earlier that she has RA and sarcoid, I was like, what are Maddy and Yousef up to? Who? I know who put this case together? How does she have both sarcoid and rheumatoid arthritis? But the truth is when you scrutinize the background, both of them seem to be legit diagnosis. She's got rf, ccp, positive ra. How do you doubt that? And she has mediastinal biopsy proven 30 years, stable sarcoid. And both of them seem legit. And so here the sarcoid is especially concern. The propensity of sarcoid to cause conduction system disease is very, very noteworthy. And one, and something that keeps cardiologists and patients up at night for sure. So I, you know, I'm really worried that something serious happened to her because she's left with no scar and lightning that strikes from an arrhythmia really presents like this. So I think that's concerning. There's a small element in the ER Dr. I mean, that's also really worried about her for two reasons. The first is she has RA and that affects the atlanto axial joint and so her C spine may be unstable. And then she's been on prednisone for a gosh, many, many years. And so the most alarming part of her story is of course the syncope. But not a close, not a distant second is the fact that she was found with her, with her back against the wall. So the question is, what is her neck and what is her. What's her. What is her osteoporotic back? So geez, for me, I was hoping to hear that she would be in a, in a sea caller on the exam. And the fact that she's not actually has me a little bit anxious to be honest with you. But yeah, yeah, there we go. We'll just slop it on in our own minds. But yeah, those are my thoughts. I think the history of sarcoid and the EKG and the fact that lightning seemed to have struck or had me really, really worried. And also as a side note, I'm worried about consequences of our bones, which I don't think we'll spend much time talking about. But yeah, that's what this aliquot does for me. What do you think?
- [18:09]
Dr. Reza Manesh
In Frofrez, I'm thinking how do we get to be as smart as you, Robby, I got nothing to add.
- [18:16]
Dr. Robby Jiha
It's acai, baby.
- [18:19]
Dr. Reza Manesh
I'm going to start sourcing that aside. So actually just a quick story which I think should be included. Robbie bought me an acai maker.
- [18:26]
Dr. Robby Jiha
Oh man.
- [18:27]
Dr. Reza Manesh
And I, I did, I, I didn't use it a single time. He, he also bought me one of these headset and I didn't use. I, I gifted it away to someone, but the ASAI maker, I ended up gifting it to my neighbor who has two kids and I. Matt, I know you have many kids and you'd appreciate this story, but they tried to make ice cream with that aside maker. And the first time they tried to make it, it caught on fire. So basically I almost killed
- [18:55]
Dr. Paul Nelson Williams
next to
- [18:55]
Dr. Reza Manesh
me because of Robby.
- [18:59]
Dr. Matthew Watto
That's what you get for re gifting Reza. You shouldn't exactly.
- [19:02]
Dr. Robby Jiha
Thank you, Matt.
- [19:07]
Dr. Matthew Watto
I didn't know you could make asai. I barely know what that is. You mentioned an oculus headset. If he bought you one, I'm imagining he might have one. Where does that fit into his routine? Because you didn't mention that. Are you. At what part of your day are you doing the. Yeah, Bring the heat, man.
- [19:24]
Dr. Robby Jiha
I love it.
- [19:25]
Dr. Paul Nelson Williams
Bring the heat.
- [19:26]
Dr. Reza Manesh
She bought it knowing that I do a lot of stuff that's outside of medicine, like play video games. And since I enjoyed that, he bought it for me. He himself does not have the kindness
- [19:36]
Dr. Robby Jiha
of my heart and guess where it goes.
- [19:39]
Dr. Matthew Watto
Just stop trying, Robbie. He doesn't want your gifts. He just wants your friendship and your company. I think that's what I'm.
- [19:45]
Dr. Reza Manesh
I just want his intelligence, nothing else.
- [19:47]
Dr. Matthew Watto
Reza seems like an experienced gift guy, Robbie. He just wants you to take him somewhere, you know, that's. Make some memories together.
- [19:54]
Dr. Robby Jiha
I think you're spot on.
- [19:59]
Dr. Matthew Watto
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- [21:37]
Dr. Reza Manesh
Yeah, and you know, Matt, remember we started with saying, is it syncope, seizure, low sugar, or a strategic stroke? The fact that the patient looks so well now, to Robby's point, has no scar, is making me prioritize the cause of transient loss of consciousness to be syncope. So I think syncope was the right term. And Steph Sherman taught us an easy way to remember the causes of syncope, which is the core causes. Core cor, which stands for cardiogenic, orthostatic, or vasovagal. And I'm not going to even talk about the orthostatic or vasovagal, but I just want to reiterate what Robbie said in the cardiogenic, which is the most frightening cause of syncope, is you can just break down the heart into something that has rhythm and then something that is a pump. And when you do that exercise, it becomes so easy. So for the rhythm, you look at this qtc. The problem with a lot of the electronic medical systems is that they either show an abnormal finding as red and then a normal one is black. But it doesn't really include the severity of the abnormal finding. Here, the QTC of 570, usually I don't even pay attention to the QTC, so that has me really worried about the conduction system. And I know that during COVID when we were giving hydroxychloroquine, we would always screen the qtc, whether that is data driven or not. But you review her meds, and there's a really cool app, and it's a free app that people can download up to you guys if you want to include it. I believe it's called cred meds, where you can put in the drug and it will tell you the data behind whether it prolongs the qtc. But for a patient like this, you want to go through each one of those medications and you want to verify and fact check the qtc. It's not an easy way. I still don't know how to accurately check a QTC myself, but this is something I would email to a cardiology friend and be like, hey, is this accurate? Like the QTC that's being reported on the. On the ekg. But then you wonder, okay, I'm going to check the electrolytes, the mag, the potassium, the calcium. And then if those are normal and she's not on many drugs that prolong the QTC this long, then I wonder, is there a genetic channelopathy or is there some kind of extrinsic process that's affecting the conduction system to Robby's point? And then as far as the heart, the actual structural causes of syncope, what matters most. And Tony Brew published this. And things we do for no reason. The reason we get an echo in syncope or the only reason that we should really consider an echo is if we're worried about reduced EF, because reduced EF can correlate with, you know, ventricular tachycardia, BFIB, etc. And we just saw Paul lift. Oliver and Paul. I love cats. So I have two cats. They are my. They're literally my world. But then causes like aortic stenosis, pe, pulmonary hypertension, hocum. So this is a patient where you want to. The patient has an echocardiogram that's very, very helpful. But you really want to emphasize and invest cognitive energy on that very prolonged qtc. Did she go into torsade? And she's someone. I would definitely put some kind of patch monitor. I don't want to say names. I don't know what will make it. But some kind of sticker to monitor her rhythm.
- [25:06]
Dr. Paul Nelson Williams
So a couple things. So I just want to clarify the core mnemonic. I just want to make sure I have this right. Is cardiac, orthostatic, and the R is for reflex. Because I. I think that you said that like vasovagal or vagal. And I just want to make sure. I was like, wait a second. I'm not good at mnemonics, but I feel like I missed a step here. So I did just want to double check my math and make sure that the R is for the reflex.
- [25:24]
Dr. Reza Manesh
His math is all. I'm just nervous. Robbie.
- [25:28]
Dr. Robby Jiha
Yes.
- [25:28]
Dr. Reza Manesh
Right. Reflex. We did a ski rapist of chest pain. Four plus two plus two, and he
- [25:32]
Dr. Robby Jiha
added it to nine.
- [25:33]
Dr. Paul Nelson Williams
Just so you know, there is complete aside. And have y' all seen the movie clue? This will be meaningful to, like, three of our listeners. It doesn't matter. There's a prolonged scene where they're trying to figure out how many bullets are left in the gun. And, like, it just goes on and on. We're like, one plus one plus two plus one. No, that's one plus two plus two plus one. And I think about that all the time in medicine. But I did want to ask a question. So, first of all, I appreciate you following the curbsiders pathway, which is basically, we just skip right to objective data and don't talk to the patient. But I would like to take a step back as you're sort of building your differential. Let's say we didn't have all this great objective data to start. I'd be curious if there are any clarifying questions you'd have after hearing the initial case and sort of what you'd ask the patient to kind of clarify some of the stuff that we're sort of trying to tease out with all the objective data that's starting to pour in. I don't know if that's a fair question to ask or not.
- [26:21]
Dr. Robby Jiha
I can take this preference.
- [26:22]
Dr. Paul Nelson Williams
I think that's it.
- [26:23]
Dr. Robby Jiha
That's actually, to be honest with you, we talk a lot about in medicine the idea that 90% of the answers in the history, and that's definitely not true. You need other supporting data. But I think that a history that's not taken well steers you in significantly the wrong way. And I think what I'm itching to know about her is to understand one simple fact, which is what is the time course of this disease process? And I think for most people listening to this case, there's this idea of an apoplectic event that happened to her, that she was just kind of chilling, minding her own business, been doing fantastically well with her medications, and boom, she's on the ground and their back's on the floor. Right? And the vast majority of time you have a mental model like that, it's often inaccurate that there's idea. There's this notion that things have been smoldering in the background. And it may be smoldering because we didn't bother to ask, or it may be smoldering to the point where she's gotten so used to this reduced quality of life that she doesn't even vocalize and realize that it's normal. So what am I really itching to know is how much can she walk and how much can she exert herself? It is exceptionally rare to go from 0 to 100 as she appears to be super, super rare. And so odds are we're missing a big chunk of the history. And odds are that she has had a decline in exercise tolerance to the point now where her EF is 45%. We have objective data to support that. So what am I itching to know? I'm really itching to zoom in on the time course here and truly understand. Did we go from 0 to 100, which is possible but unlikely, or she has she been declining for some time? And if, if the door opens to there has been a hidden cryptic decline either because of deficient history taking on our end or adaptation on her end, then I think where she goes with that, I think is definitely an open conversation that I wouldn't steer. But that's, that's the one element I really want to zoom in on.
- [28:03]
Dr. Matthew Watto
I think we can go to the next aliquot because we don't have the specifics of that. Let's just say that the treating clinician was not as curious. But I like that point, that if she's been doing great high exercise tolerance, all of a sudden, this just came out of nowhere. Or has she had a decline in functional status that's been going along and led up to this event?
- [28:25]
Dr. Robby Jiha
Can I just interject to say one quick thing because I think you might ask yourself a fear question. The whole point of this exercise, what's the point of clinical reasoning? And on the surface it seems be so we can get the right answer, so we can treat the patient in that order. So you get a dx then rx. But the truth is many of us institute empiric treatment well. Well, before we know what the diagnosis is, right. We give people nausea medications, fluids, so on and so forth. So the question that has to cross everyone's mind is do you empirically treat her for something right now, given what happened and how serious it was? And for me, I'm giving her 2 grams of mag right now. You have a history of syncope, you have a QTC of 516, you have many reasons for her to have an unhealthy heart and you don't want to wait for her to develop torsades, Right? So for me, she's crossed an impaired treat treatment threshold and the benefit of MAG for the possibility of QTC induced torsitis through the roof. So I think we're reasoning our way towards a diagnosis, but I think we've crossed a treatment threshold that's not targeted treatment, but definitely impaired treatment with mag, at least for me at a nervous ed based internist.
- [29:24]
Dr. Matthew Watto
Okay, Eddie, let's go to the next aliquot.
- [29:28]
Dr. Edison Jang
Okay, so an implantable loop recorder was placed for rhythm surveillance and the patient was discharged two weeks later. The patient represented after her implantable loop recorder Documented ventricular tachycardia. She was called to be readmitted to the hospital. Vitals were within normal limits and her exam was unchanged from two weeks prior. Labs including high sensitivity troponin were within normal limits.
- [29:55]
Dr. Matthew Watto
All right, Reza, what do you think?
- [30:00]
Dr. Reza Manesh
Well, I just want to say, Eddie, you're doing a great job of reading the case aliquots. Thank you for being with us. You know, we sort of stepped over the reduced ejection fraction. It's not severely reduced, but it is reduced at 45%. And Amit Goyal, who is a co founder of Cardio Nerds, created a hefref schema for our podcast for the clinical problem solvers. And I thought it was just really a powerful way of thinking about hfrap. And I think it's related to this case. And he in that schema says, look, the majority causes of HEF rep is due to ischemia, coronary ischemia, cad, then the other causes are hypertension, valvulopathy, toxins, and then arrhythmias. And then there's the idiopathic category. Now, I think what's really important here is that we have a rhythm that could be translated into ischemic most of the time, but it could also be non ischemic. So basically I'm thinking about the BT and the HF rep in parallel tracks. And what I really want to know is she has a lot of risk factors for coronary artery disease and I would love to examine her coronary vessels. And now we can do studies like coronary CTA where we don't actually have to take them to the cath lab. Yes, you can, can't do an intervention, but it can give you a lot of useful information. We would never, ever, in a patient who doesn't have a history of sarcoid, say that, wait, wait a minute. We need to first rule out cardiac sarcoid before doing, you know, a coronary cta. But in clinical reasoning, everything is about the host that you're taking care of. And because she does have a history of sarcoid long standing and to Robby's point, this has a tropism for the heart. You really want to, at Branch Point 1 is, see, is this a non ischemic cardiomyopathy? Which would then translate to a non ischemic ventricular tachycardia. And so I would be very curious, like at this stage, what does a coronary CTA show? And I suspect, I mean, it could be positive. She has a lot of risk factors But. But I'm not sure that would deter me from also doing additional investigation into the cardiac myocardium. And we can talk more about that later. But the power of a cardiac MRI with gadolinium. And I just have to share this because it took me a while to learn this, and when I learned it, like, the light bulb went off. When you give gadolinia and there's delayed enhancements in a coronary distribution, then that's consistent with CAD or ischemia. But if you give gadolinia and there's delayed enhancement in Apache distribution, then that makes coronary disease less likely and prioritizes more of Apache infiltrator process, like amyloid or sarcoid. But I would love to hear Robby add on there, too, for just the VTAC and, like, the way of thinking
- [33:11]
Dr. Robby Jiha
about it versus my command. That's such a beautiful platform to launch on. And, you know, prophet's up to me. I'm very frank with you. I'm just shocked here. I know, honestly, to be more frank with you, I feel the nerves. I haven't felt this nervous in a long time. We've been doing this for so long. But there's something so powerful about the platform, the sage you built, the number of people who are listening to us, that I'm feeling the jitters. But honestly, I have to tell you that I'm shocked at this finding. Who. How many times do you hear the word hey? The patient got an implantable lupocort, and it showed vt, and she casually came back to the hospital. You know, like, it's just such a. Such a dramatic finding. But I do think that there's teaching value in that, and it tells you a little bit about what this VT represents. But if we just go back to the original conversation we have about lightning striking, striking this patient and her having some form of electrical activity. And I just want to take a moment to reinforce that when you truly establish that somebody went from 0 to 100, as we seem to have done here, there's only two possibilities. You either have vasovagal syncope, or you have a malignant arrhythmia. And the case for vasovagal syncope in her was really weak because she didn't really have any reason to. So I think that these things line up. I believe this result because her story really matches to it. And so I think there's two parallel questions that I'm thinking about distal to the underlying cause, which Profrez just walked us through, which is what kind of VT is this. And I think you can liken ventricular tachycardia to seizures. And if you tell a neurologist that your patient is seizing, they immediately want to know is this a focal seizure or is this a diffuse generalized seizure? I find it helpful to think about ventricular tachycardia in the exact same way. Is this monomorphic vt, which is VT that's originating from one specific part of the heart, or is this polymorphic vt? With the idea being that the whole heart is quivering. The distinction between those two is fundamental both to the prognosis and to the underlying cause. Monomorphic VT means there's a scar somewhere in the heart and that scar is the problem and everything else is fine. Polymorphic VT means every single myocyte in the heart is causing and contributing to the disease process. To give you an example, we have two pieces of data. We have the history of ischemia or we have the risk factor for ischemia and we have the qtc. Which of those is more likely compatible with each diagnosis? So if she has ischemia, long standing ischemia creates a scar, creates a nitis from monomorphic vt, because there's one area of old infarct that's causing monomorphic vt. In stark contrast, if this is related to her qtc, it's not going to be monomorphic. Every single cell is affected by that prolonged qtc and so patients show up with polymorphic vt. So can we make an educated guess based on the information we know what kind of VT she has? And it's very likely to be monomorphic. It is almost impossible to walk into a hospital and be like, here is my implantable loop recorder. I had polymorphic vt. The idea being there that if when every single myocardial cell is quivering and unhappy, the amount of cardiac output that's generated by that heart is basically zero. It's incompatible with life. And so it's interesting, I think we'll have to figure out what kind of VT this is rather than guess. But I would leap to say this is probably monomorphic. And so her QTC might be a distractor. And so just like Profrez, I'm definitely not to commit to that, but I think I'm going back to visit the history of why she would have a scar. And I think ischemia, ischemia, ischemia number one, two and three. But she has number four and number four sarcoid. And I bet you that if you remove ischemia from the calculus, sarcoid is number One in this country in terms of induce, inducing VT in the world, Chaga's disease is increasingly common. I say that because I think I know you guys have a global audience, and so I think the calculus has to begin with, what kind of VT is this? And if it's monomorphic ischemia. Ischemia, Ischemia. And then. And then sarcoid. I'm glad we. We have an answer. More so I'm glad we have a journey to go on. Most importantly for. For her because, yeah, that was a scary, scary fall.
- [37:15]
Dr. Paul Nelson Williams
Just for the listeners at home who don't watch the video, Matt is so tickled right now. Like, he is just vibrating in his seat. I don't know if you can see that. Like, he's just listening to you guys talk. He's just. He's so excited about information.
- [37:25]
Dr. Matthew Watto
I'm enjoying it. I'm with you.
- [37:28]
Dr. Paul Nelson Williams
It's a nice reminder of how dumb I am. But this has been. This is a pleasure so far, just to hear you guys reason through this.
- [37:36]
Dr. Reza Manesh
Paul, what we need to do is get some acai, and then we too can feel very smart.
- [37:42]
Dr. Paul Nelson Williams
Well, first, increase my homeowner's insurance, and then I'll consider, I suppose. All right, Eddie.
- [37:51]
Dr. Robby Jiha
All right.
- [37:53]
Dr. Edison Jang
Left heart catheterization demonstrated minimal coronary irregularities without obstructive coronary artery disease. Given documented ventricular tachycardia. Reduce ejection fraction. An implantable cardioverter defibrillator was placed.
- [38:10]
Dr. Matthew Watto
So I'll go back to Robby for a second. So this kind of. You mentioned the coronary disease, and we don't know. We didn't get the information the way the case was written, if it was monomorphic or polymorphic vt. But where do you. Where do you go from here with this left heart cath? And, you know, the defibrillator was placed.
- [38:30]
Dr. Reza Manesh
Yeah.
- [38:30]
Dr. Robby Jiha
I'll keep this to two short sentences because I'd love to see what Profrez thinks. And I'll start the sentences. Now. The probability of ischemia is dramatically reduced because we don't see any epicardial coronary disease. But as your podcast has taught us over and over again, especially in women, the absence of epicardial coronary disease does not mean the absence of ischemia. Especially with my microbiome.
- [38:58]
Dr. Reza Manesh
Man, that's a long sentence. Sentence number one. Go for sentence number two. That's it.
- [39:05]
Dr. Matthew Watto
I'm done.
- [39:10]
Dr. Reza Manesh
What am I supposed to do, Robbie?
- [39:12]
Dr. Robby Jiha
Oh, that's.
- [39:13]
Dr. Matthew Watto
Anything. Well, just anything to add. Or we can go, you know, we can Go on to the next. Next aliquot, if you want.
- [39:20]
Dr. Reza Manesh
One thing I'll add is like. And again, this is like, something that took me a while to learn. But sarcoid is not a biopsy diagnosis. It's a diagnosis you arrive at after you rule out all those causes of granulomatous disease from fungal infections, mycobacterial infections, lymphoma, rheumatologic causes. So sarcoid is. You exclude everything else. And if the presentation is compatible, then they get that label. You know, Matt, when they taught us in med school, if it's non caseating, it means this. If it's case, that doesn't really pan out, to be honest, like, it might prioritize a bit, but anything can do anything. If the audience takes one thing away from this episode is that anything can do anything. But this patient's prednisone, remember, was discontinued. I think that's a very important point because Robbie built such a good emphasis on sarcoid being the number one cause outside of coronary ischemia. And if we framed it as a elderly woman on prednisone suppressive therapy for years, where the prednisone was just stopped, then maybe now that granulomatous process can start coming to the surface. And maybe in this particular patient, you don't need to do an endomyocardial biopsy to show granulomas. Maybe you just do that. Now the medicine team, Paul, has to call radiology. Like, hey, they have an icd. Is it compatible? Then they'll say, oh, go talk to the cardio. There's so much drama. Just get that MRI with GAD early, and then just start the steroids and.
- [40:58]
Dr. Matthew Watto
Yeah, all right. Anyways, I think we should go to the next. Let's get Reza his mri. Eddie, let's go to the next Aliquot. We're brought to you by Quince. And in the Wato household, Quince is a favorite brand, not just for me, but for my wife. She has a lot of quince clothing, and she even buys it as gifts for friends and family because she thinks it's that good. I love quints. Recently, especially for this summer, I've been wearing the organic cotton Coolmax chinos. These things are so lightweight. They're breathable. They feel great. In the summer in the Northeast, it's, like, hot. It's very humid. And these pants are really doing it for me. I have multiple pairs. I think you'll love it, too. I also love to wear the Quince Flowknit Performance Polos Those are another favorite of mine and I have a bunch of those in different colors. And what I love about quints is everything at quints is priced 50 to 80% less than similar brands. That's because they work directly with Ethical Factory and cut out the middlemen. So you're paying for quality, not brand markup. And Quince goes way beyond clothing. Custom upholstered sofas, ceramic cookware, premium bedding. It's the kind of brand you end up recommending to everyone for everything. And I told you, my wife and I, we recommend this to a lot of people and we're buying it as gifts for friends and family. Elevate your summer wardrobe. Go to quince.com curve for free shipping on your order and 365 day returns. Now available in Canada too. That's Q-U-I-N-C-E.com curb for free shipping and 365 day returns. Quince.com curb.
- [42:48]
Dr. Edison Jang
Cardiac MRI was limited but demonstrated mid myocardial late gadolinium enhancement involving basal and mid septal segments in the right ventricular insertion point, consistent with prior myocardial insults such as sarcoidosis. Full body FDG PET CT showed increased uptake in the basal septum and right ventricular free wall, suggesting an active inflammatory process.
- [43:11]
Dr. Reza Manesh
This is the power of that cardiac MRI with gad. And this shows you that it's not in the distribution of a coronary territory. The same way, you know how we look at an EKG for the left ventricle and we're like 2, 3, AVF is inferior, 1, blah, blah, blah is lateral. This is similar to that. So now I think we built a very strong case for sarcoid. I would love to know from Robbie, like in reality, I would be asking a rheumatologist if we can just start therapy for sarcoid. But I would just, you know, I'm not going to do it myself and I'm luckily in a center where I can talk to a rheumatologist. But this is a patient where I would, you know, advocate if possible to avoid any tissue diagnosis because we built a case so strongly for sarcoid and to just. Now I don't know what that therapy look like now that there's cardiac involvement, if it has to be a higher dose. But I think it's a very compelling story for cardiac sarcoidosis.
- [44:09]
Dr. Matthew Watto
What do you think, Robbie?
- [44:10]
Dr. Robby Jiha
I'm right there with you. You know, I think that when I'll tell you what I'M honestly doing when you're so far into a case, you kind of have to take a moment to make sure that you're solving the right thing. So, for me, we had apoplectic syncope. We found an arrhythmia, we found, we clarified that the arrhythmia is likely monomorphic vt. And I think that that ultimately crystallizes the problem to an arrhythmogenic cardiomyopathy. And I think it's a small learning point, but a learning point that's worth emphasizing, which is that the reason guidelines recommend an ICD in patients who have an EF of less than 35% that don't recover with GDMT is that the arrhythmic risk tends to occur in patients with markedly low efs. So let's acknowledge a small elephant in the room, which is that her EF is 45%, yet she's having serious events like this, which is why it's probably wise of us to recognize that disconnect that she's having such profound rhythm burdens despite her EF not being that low. And so if you try to understand what Proffera said from the beginning, we're trying to understand what the problem is. And I would say the problem is an arhythmogenic cardiomyopathy. And that's not to be confused with a genetic disease called arrhythmogenic right ventricular dysplasia, now termed arrhythmogenic cardiomyopathy. But that's actually the prototypical example of what it means to have a heart disease that tends to actually mess with your conduction system or your rhythm more so than your contractility. And so there's not many diseases that present as an arrhythmogenic cardiomyopathy. And the most important ones to know in the United States are four of them. Hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, the two genetic diseases, sarcoidosis and amyloidosis. And so here, when you have an active inflammatory process on MRI in a patient with a history of biopsy proven sarcoid 30 years ago, I think you've definitely reached your treatment threshold. If this were me, I would be begging and pleading. And as I said to Prof. Rez yesterday, all hail prednisone, and I think we need some. Now. I just want to throw out one small teaching point that I learned from my wife in the world of rheumatology, which is that Plaquenil, which she's on. Long term. Long term. High doses of plaquenil. She's on 200 bid. Can also cause an erythmogen cardiomyopathy. So I was. I was thinking of that in the back of my mind because that would have been an important consideration if her MRI were non inflammatory. But I think now that you're seeing inflammation, I think sarcoid is a. Is a really important cause.
- [46:44]
Dr. Paul Nelson Williams
I hate to be this guy, but I think you mean hydroxychloroquine, if I'm not very much mistaken.
- [46:48]
Dr. Robby Jiha
Yes. Oh, my gosh.
- [46:49]
Dr. Paul Nelson Williams
Thank you. Cannot believe we got a way to
- [46:51]
Dr. Matthew Watto
do it, but nevertheless, Paul, just searching for one possible thing to correct on the episode.
- [46:54]
Dr. Paul Nelson Williams
Listen, I'm just. I'm just looking for something to do here. I cannot justify my presence here any other way.
- [46:59]
Dr. Matthew Watto
For the audience, they have no notes. This is just off the. They had no idea what the case was going to be, what to prepare for. This is just like how they can just talk about pretty much anything you bring up, which is amazing.
- [47:12]
Dr. Paul Nelson Williams
But if you don't have the video, you should know their eyes turn black and roll up in their head before they actually answer these questions. It's quite amazing to see.
- [47:19]
Dr. Matthew Watto
That was a good one, Paul. Are you guys ready to reveal the diagnosis? Okay, Eddie, what's the. You want to read the. The final piece?
- [47:29]
Dr. Edison Jang
So the care team, including cardiology and rheumatology, were consulted and evaluated the patient. An endomyocardio biopsy was considered, but the patient opted to avoid any further procedures. The combination of documented vtac, persistent QT prolongation, mid myocardial late gadolinium enhancement and FDG uptake on the PET were suggestive of cardiac sarcoidosis as the unifying diagnosis. She started on corticosteroid steroids and has been following with outpatient rheumatology and cardiology. Final diagnosis, cardiac sarcoidosis complicated by ventricular tachycardia and non ischemic cardiomyopathy.
- [48:08]
Dr. Matthew Watto
Well done, guys.
- [48:09]
Dr. Paul Nelson Williams
Great stuff. Good luck to this patient's diabetes. But that was amazing and fun to watch.
- [48:16]
Dr. Matthew Watto
Well, come on. I mean, it's not funny. What you said was funny, Paul, but it is. Yes, Paul. She'll see America's primary care physician, Dr. Carl Nelson Williams to get that fixed. Well, guys, that's great. Any closing thoughts? I mean, you've made the diagnosis correctly. A lot of good teaching points along the way, and I love that you just. Robby, you really have an arrhythmogenic cardiomyopathy, like. Differential.
- [48:44]
Dr. Paul Nelson Williams
Differential. Yeah. Can I ask A process question. And I don't know if this will be fair to ask or if you'll actually have an answer, but I had a chance to read part of the book and one of the things I really appreciated about this was just being directive about pausing and reflecting, which I kind of see that you guys do. I'm just wondering, this is going to sound like a dumb question, but I'm asking it sincerely. How do you know when to do that? Are there any cues or things that happen in terms of as cases on Spool that you are sort of prompted where I should just take a moment here and kind of think about things because this is so fun to watch. It is such a joy to hear you guys reason through things. So I would just love to hear any hot tips that you have in terms of how you guys think and not just that, you know a lot of stuff.
- [49:27]
Dr. Reza Manesh
Well, thank you, Paul, Matt, Eddie, Yousef and Maddie for making this a special episode. Thank you, Ravi, for always dancing with me. I think, Paul, one of the reasons we wrote this book was because we wanted a book to read like a novel, but also teach clinical reasoning. And we want to emphasize knowledge is important. There's no substitute for like a fund of knowledge. But more importantly is knowing how to ask the right question. And so to give you an example, recently my cat, my cat Gino. My fiance and I have a cat, Gino, and, and. And his brother Sydney, they 13 years old. Gino developed edema under his left eyelid. And initially we thought that that just represents either an allergy because he has a history of allergy. Then a week went by, it persisted. And then we're like, okay, maybe it's infection. And then I was in the shower maybe two weeks ago and I just started crying. And it just goes to answer your question, not to make this episode sad, just something in me felt like there was something really sinister going on. And once we gave him antibiotics, it didn't improve. Then we paused, we reframed, and we took him to a hospital. And there a CT scan showed that unfortunately he has this huge mass that is starting in his sinus and growing inward every which way. Luckily, he got a biopsy. He's going to go for radiation therapy. And I actually texted Robby prematurely because he's doing fine now, that I wanted dedicate this book to Gino because he's. And unless you're a cat dad or a dog dad or dog mom, cat mom, you don't realize how important these animals are to you. I'm not Even answering Paul's question, I realize that it's just my heart and my mind is with Gino. But the pause and reflect, it's easy to do when you have a fund of knowledge and when something doesn't fit you sort of to say, hey, I'm not going to force this. Like yeah, for example, someone comes in with heart like new heart failure. You give them Lasix, they feel better. But you know, that's not a terminal diagnosis. Like something led to that. What led to that? Heart failure. So something that saves me. Paul is always asking why, why, why? Until I can't answer it anymore. That really helps. Like why? Why this? Why this? Why this, this? But anyways, I'm rambling. Robbie. What? What's your answer, by the way? Gino is. He's meowing like this cat is the devil. He would wake me up at 2 every day requesting greenies. And the other night he woke me up again and I couldn't be happier. And like I was like, oh, Gino Balla. Which means my sweet Gino, what can I get for you anyways? Pray for him. Anyone who's listening to this episode, 100%.
- [52:30]
Dr. Paul Nelson Williams
You're speaking to my heart.
- [52:31]
Dr. Robby Jiha
Yeah, I don't even know what to
- [52:33]
Dr. Reza Manesh
say, I'll tell you that.
- [52:35]
Dr. Robby Jiha
I'll answer your question in a sec. Paul. I just want to say that, yeah, I have a list of causes of arrhythmogenic cardiomyopathy. But the truth is I'm a mega medicine nerd who accomplished nothing without the support, mentorship and coaching of Prof. Like, the CP solvers wouldn't exist. I would just sit here in my deep dark dungeon as he, as he paints it, just drawing schemas all day long.
- [52:58]
Dr. Reza Manesh
Exactly.
- [52:59]
Dr. Robby Jiha
Exactly. So any impact that those small pieces of knowledge have is down to him in his love. Frankly. Yeah. I think you don't have to convince an MS.3 to pause and reflect. I think when I was in Ms. 3, that's all I did. I didn't know how to do anything else but sit there and think and reflect. I didn't know how to move the case forward. And I think what happens with time and experience is you think you know and you just sweep things under the rug. And I think as Profrez is teaching us with Gino's really sad story is that that when things aren't going the right way, you have to know when to step back and really analyze things. And I think those of us with experience are paradoxically the most likely people to keep moving because we think we know. And I think sometimes you just have to whip out that MS.3 humility and realize, wait, hold on. Am I just forcing this case through just because I'm busy or don't have time or. I don't know. And so when you don't have the option as an Ms. Three, you don't know anything else. And so I think it's a difficult cognitive thing to do. And I think fundamentally, when you know you're sweeping things under the rug and ignoring them, you should probably not do that.
- [54:00]
Dr. Matthew Watto
I like thinking of Robbie if he never met Reza. Just like Paul, you know, the Always Sunny episode where Charlie Day is in the mailroom and he's got, like, the string. Red string drawing. He's trying to. Smoking cigarettes, trying to figure things.
- [54:12]
Dr. Paul Nelson Williams
Robbie's looking for Pepe Silvia. Yeah.
- [54:14]
Dr. Matthew Watto
Yeah, that could.
- [54:16]
Dr. Robby Jiha
And the irony is I will not get that reference at all.
- [54:19]
Dr. Paul Nelson Williams
But that's the. This is also love, by the way.
- [54:23]
Dr. Matthew Watto
Yeah. All right, guys, fantastic stuff. Tell the audience where or when they can find the book, and then anything else you guys want to plug. And thank you so much for your time and your teaching. This has been great to learn from you guys again.
- [54:41]
Dr. Reza Manesh
Well, the book is Discipline of Diagnosis, and it was edited by Tessa. And if you ask, who is Tessa? She's a high school senior student who listens to our podcast, and she, like, gave us feedback. And my grandfather taught. Taught me that anyone, despite their years, may have something to offer. And Tessa's a better writer than me and Robbie will ever be in this lifetime. So huge shout out to Tessa. The book will be available on Amazon sometime in May, and hopefully you guys can include a link. We have a. An A chapter from the book on our RLR website. We can also include that where people can read it before purchasing. There is no guarantee that you will love the book, but we hope you enjoy it and we hope it makes you pause and reflect and better thinkers for your patients. And it's. I mean, it's. I'm so proud of this book. So, so proud. And it wouldn't be possible without Robby or Tessa. And. Yeah.
- [55:39]
Dr. Robby Jiha
And it comes with a free bowl of acai.
- [55:43]
Dr. Reza Manesh
Robbie will come to your house and make you a sly if you buy 10 or more coffees.
- [55:49]
Dr. Paul Nelson Williams
The CP Solver guarantee.
- [55:51]
Dr. Edison Jang
Yeah.
- [55:58]
Dr. Paul Nelson Williams
This has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole.
- [56:03]
Dr. Edison Jang
Yummy.
- [56:06]
Dr. Paul Nelson Williams
I. I was gonna thank you for preempting Matt saying holes. I'm not sure I like that better. Eddie. I gotta be honest. With you either way. Still hungry for more? Join our Patreon and get all of our episodes ad free plus twice monthly bonus episodes@patreon.com curbsiders. You can find our show notes at the curbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox. This includes our Curbsiders Digest, which recaps the latest practice changing articles, guidelines and news in internal medicine.
- [56:29]
Dr. Matthew Watto
And we're committed to high value practice changing knowledge and we want your feedback. So email us@askcurbsidersmail.com a reminder that this and most episodes are available for CME credit for all health professionals through VCU healthurbsiders.vcuhealth.org you can also sign up on Patreon to receive quarterly bundles@patreon.com curbsiders for quarterly CME bundles. A special thanks to our writers and producers for this episode episode Yousef Siklawi, Maddie Conti and Dr. Edison Jang and to our whole Curbsiders team. Our technical production is done by podpace. Elizabeth Proto does our social media. Jen Watto runs our Patreon. Chris the Chew Manchu moderates our discord. Stuart Brigham composed our theme music and with all that, until next time, I've been Dr. Matthew Frank Watto.
- [57:20]
Dr. Edison Jang
I've been Madison Jang and as always,
- [57:23]
Dr. Paul Nelson Williams
remember Dr. Paul Nelson Williams. Thank you and goodbye.
- [57:44]
Dr. Robby Jiha
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