Robbie

But if we translate it to gait unsteadiness, there's a little bit more uncertainty about whether we think he has a blood problem or whether he has an intrinsic neurological issue like a cerebellar TIA, right?

And so you should really, really, as you're trying to see this patient, you should be open to the idea that all you know is he doesn't feel right.

And the simple question you are asking is, does he have a brain problem?

or does he have a blood problem and that's all that you can really establish at this point in time i think what can help you make more gain more confidence as to whether it's a brain or blood is to not ask him how precisely he feels because the words as you saw progress illustrate can be difficult for anyone to articulate but to ask him if it's exertional discomfort or exertion independent discussion

So for me, I don't think you're going to get much return on investment by asking him to be precise about which one of those words he used, but rather to ask him, hey, when he got off the bike and started to walk, did he feel better?

And if he has exertional, funky feeling, then I think lightheadedness is much more apt.

So I'm curious, Prof, if he was able to relay that with more precision, in which case the EKG is way more important than it is if somebody is like, no, I just feel wobbly.

That's so powerful.

So that's why I would translate, okay, I think he has a perfusional problem.

And so immediately the way I think about perfusional problems, Prof. Rez, I think it's powerful that you gave us the data already, is we're asking, does he have a quantitative perfusion problem or a qualitative one?

Now, these are fancy words for capturing what is either the deficiency in the amount of blood that's going to his brain, which would be captured in the realm of either overt shock or milder versions of it like presyncope or syncope, or even milder versions like continuous orthostasis.

Qualitatively, when people feel lightheadedness from a blood problem without a deficiency in the amount, they might have an issue with the content of the blood.

And the most common example is anemia.

And thankfully, you already gave us a CBC that I didn't catch the exact number, but your cavalier rapid reading of it made me think it was under present, which is great.

But remember the awesome... I'm going to give one example to illustrate other differential diagnoses.

The main other differential diagnoses are things that poison the hemoglobin molecule, like carbon monoxide.

So carbon monoxide presents lightheadedness and whatnot.

So the question that we're after in this person is...

We're confident he has a perfusional problem to the brain because it's exertional.

And now the question is, does he have a deficiency in the amount getting to his brain?