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Chapter 1: What is the main topic of abrupt lightheadedness?
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Welcome back, Clinical Problem Solvers!
Woo!
How was that?
I give it a 6 out of 10.
You know what? Mediocre is the way to go. Don't overshoot. Don't undershoot. Honestly, 6 out of 10. 6 out of 10 is perfect. You know what's not mediocre, Proffers?
What's that?
The discipline of diagnosis. It's not mediocre. You know, so many people... have, uh, talked to me specifically about the pharyngitis chapter, which has me both very proud of your decision to lead with that, but also very skeptical of the people who keep talking to me about it, because I think that that's probably maybe all that they've read.
Um, but, but they all seem to be riveted by, um, story and, um, Yeah. Yeah. I really, really hope that all of you listening to this, um, if you haven't, um, if you haven't gotten the book yet, at least think about it, because if you're listening to this, um, what that will offer you is this on steroids, concentrated, personalized, and some, so, uh, yeah, uh, a mere $9.99 on Kindle and, um,
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Chapter 2: How does the discipline of diagnosis play a role in medical practice?
So that's worth $27. Oh dude. I swear I would pay hundreds of dollars. I mean, I can, luckily I'm in that position, but I would pay hundreds of dollars for that approach.
Oh my gosh. Oh, now I know how to get rich. Just charge profits for this.
Well, listen, I just want to show some gratitude towards, the RLR family, towards any CP Solver member, but especially towards you, man. It's been like a tough moment in my life and you've been there. And, you know, in those moments, you just become closer to the people you really love. And so I'm really grateful to you, man.
Like I just, I felt my pain you carried and you were just there to check in, to listen, to provide me, you know, kind words. So thank you.
I was unsure if you were going to go that route or not, but I feel so stupid because you are nothing but authentic and real.
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Chapter 3: What case study illustrates the complexities of lightheadedness?
And yeah, I think folks are probably really intrigued as to what you're referring to. So I'll let you decide how much you want to elaborate on, but I know it's a, yeah, it's difficult.
I actually, you know, part of me wanted to just put this in our library of podcasts. So later when we're demented, we go back and, And I feel this RLR series is way more than just cases. Yeah, definitely. And it's even more than just the community we built. It's literally our library and our timestamps for various moments in our lives.
Some sad, some great, some, you know, every emotion you can think of, but You know, and I think if you've never had a pet, you won't know this, and it's not your fault because I remember when my friend's pet passed, he like went into a depression for a year. And I was like, well, how could that be? It's just the pet. Fast forward, now I'm a cat dad.
And one of our cats, unfortunately, like in itself could be a really a clinical case that I present to Robbie. He had some eyelid swelling. We thought it was allergies. Then we had a vet visit him. And we thought it was maybe conjunctivitis, periorbital abscess. But ultimately, he was diagnosed with osteosarcoma of the sinus. And about a month after, he passed away.
And it was probably the hardest thing I've gone through in my life. Because this pet, Gino... he literally would sit on my lap every night for dinner. And that's the only time he would sit on my lap because he always prioritizes Liz appropriately. Because Liz had him for 13 years. So I would take advantage. my dinner with the plate in the air and Gino on my lap.
Really?
I swear to God, to make sure he's not disturbed. And then the bastard, as soon as my dinner with Ed and Liz with the blanket on her lap, he would like dash over to her. Oh, man. And really, I don't want to talk about this too long, but there's just two things I took away from this, and I wanted to share it with the audience. Number one, something that gave me so much peace
during these difficult moments was the fact I treated him with unconditional love. And I was thinking to myself, one day we're all going to leave. Maybe some people will leave before us. Maybe we die first. But I think the thing I want to carry with me for each of my interactions with anyone is that I did no harm.
And I was like the best brother I could be, the best friend I could be, the best son I could be. And realizing life is short. And knowing that you were just a good person towards others gives so much, you know, comfort. And then the second thing, what Liz and I started doing is showing, saying grace before dinner and like not taking things for granted.
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Chapter 4: What diagnostic tests are essential for evaluating lightheadedness?
Oh, man. I think these horrible moments are horrible. But life is beautiful. It really is. And, you know, the fact that a human being and a cat got to make the most beautiful, epic memories is unreal. And I'm not going to talk much because I know it's triggering and, of course, naturally, but... When you think what's on the other side of what you're mourning, it's unreal. It's so beautiful.
And what I love about this space is the relationship that's fostered over here and why you decided to go on record to have memory for us is demented. And all these people who are listening to this, we're all building a bond with them directly or indirectly. And I think that's the most beautiful part of life.
And that's the only part that matters is to build those bonds with people because at the end of the day, it doesn't matter what purse or shirt or class of airline you fly.
we're gonna save that story for another time yeah i know i know what a story yeah well shut me up and keep going robby i have a case for you that i i really like i mean it i think you have to be the person who discusses this because i think you can relate most to the providers caring for this patient and it's a case that i think Everyone listening needs to be well aware.
And I can't wait to see how you dissect this using your emergency department skills. And I want you to be totally authentic as you always are. So here's the story. A 65-year-old man, he loves to ride his bike around the VA campus. And as he's riding his bike, He feels a bit lightheaded to the point where he has to actually get off his bike and walk a little bit.
And he thinks he just needs to go home, take a nap, and just sleep it off. So he goes home, takes a nap, he sleeps it off, feels better, and then starts going for a walk later in the day. But again, like feeling a little unsteady, lightheadedness, no loss of consciousness. In that context, he comes to the emergency department. He comes to the ED. He shares a story that I just shared with you.
No chest pain, no shortness of breath, no palpitations, none of that. And his blood pressure is 125 over 80. Has a history of hypertension, but it's unclear if he's been taking his meds or not. Heart rate is normal. Gets an EKG. And I'll actually show you the EKG. I have one from prior and one from now.
And maybe what I'll do is I'll show you that EKG and let you know that his CBC just showed mild anemia with an MCV of 84. Creatinine is 1.5. Usually it's 1.2, but he doesn't really drink much fluid throughout the day. He only eats ramen occasionally. And we have this EKG and then I'll pause to see what your thoughts are, what you would want next. And how do you decide like,
Does he need further workup?
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Chapter 5: How do EKG findings relate to potential heart issues?
Can he be discharged? Like, how do you navigate that space of lightheadedness? And again, his past medical history is just hypertension, hyperlipidemia, and he had a traumatic brain injury five years prior, but no true sequela of that. Can I show you the EKG or do you want to talk for, show you the EKG?
Whatever you think is best for our friend here.
Why don't you actually talk first?
Yeah, yeah, I have many thoughts.
I want you to go into the EKG with a hypothesis.
Yeah, yeah, yeah, I have so many thoughts. You have to be very careful with this story, Prof. Rez, because let's just be honest, okay? It was so interesting watching you tell the story. You first said lightheadedness, and then you said unsteady. which are very different by the book because lightheadedness triggers the idea of orthostasis.
Unsteadiness triggers the idea that there's a gait problem, right? And so even you as a seasoned presenter oscillate between those words. Can you imagine what it's like to be a patient trying to describe how you actually feel? So let's just be honest about what we know. We know this person feels weird. That's all we know.
And if we translate it to lightheadedness, we're coming to a conclusion about what we think why he feels weird is because he's not perfusing his brain. 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?
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Chapter 6: What are the differential diagnoses for lightheadedness?
And now the question is, does he have a deficiency in the amount getting to his brain? Or does he have a normal amount, but the blood going there is a simple economy class, and what he really needs is business class quality blood going to his brain. We'll see. But those are the hypotheses I have for Rothbard.
That's I that's so powerful because it's almost like you're you know, you taught me once with fatigue. Ask the question, is it exertional or not? If exertional, your cardiopulmonary blood system and the same thing with sort of unsteady lightheadedness. So you've now categorized this as like a perfusion issue. And so I'm curious, like going into this EKG, what are you going to be screening for?
Yeah. You know, when you're asking yourself that. If I'm worried that somebody's not getting enough blood to their brain, how does their cardiac electrical activity help me do that? And so what you're looking for is any problems with the rhythm that contribute enough to cause somebody's blood pressure to drop.
but you're also using the fact that they don't have palpitations as a skew for what the EKG is. So I think the way that this EKG would be diagnostic is if it shows a pathological bradycardia, if it shows sinus pauses or advanced AV block. Apart from that, what the EKG can serve for is a proxy for structural disease.
So the EKG may show, Q waves may show prolonged QTC, in which case you don't see the actual problem itself, but you can see that this heart is unhealthy, which can help you generate hypotheses based on what you're seeing.
So I think causality would be a pathological bradycardia, but a clue would be anything that tells you what structural issues are happening in the heart, like LVH or right axis deviation, so on and so forth.
How can we get you to say causality more often? All right. So, Robbie, I'm going to show you the EKG. The first EKG is, like, one from years ago. And the second one is from this admission.
Yeah. And I'm going to send it to the ER. I never read EKGs in detail in the ER. I just, like, literally I'll share my reflex impression and then we'll see.
Be as authentic as possible.
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Chapter 7: How does the conversation shift towards the management of pulmonary embolism?
Yeah. I'm thinking, okay, this is a Wellens, and I'll talk through my differential diagnosis for Wellens. So for me, I immediately look at this, and I'm like, oh my gosh, this is a Wellensoid pattern, because he has... T-wave inversions in V2 and V3. But what I'm going to do is share a quick differential diagnosis for this EKG. And there are essentially three things that can do this.
The most important is that a patient has acute coronary syndrome. And this EKG is as a result of spontaneous thrombolysis. The other possibility is that this patient has a pulmonary embolism, and the clues to the presence of a pulmonary embolism are a Wellens-like pattern, but with associated similar changes in the inferior leads, which unfortunately for him, he has.
So he has a T-wave inversions in lead III and lead AVF, which have me a little bit worried about that possibility of P.E., The third differential diagnosis that causes is Takotsubo's. And there are some other changes in AVR that are at place. But honestly, when I see this, I think, okay, I can park the bus at Welland. So when I see this, the patient's not going to be discharged.
And I think admitting the patient is key. And the decision that's left for me in the ER is do I get a CTPE, yes or no? And for me, the only thing that would stop me from getting a CTPE in this patient is if his troponin were disproportionately elevated, meaning that since his vital signs are not abnormal, if he has a PE, his troponin should be underwhelming.
But if his troponin is markedly high, I would be happy with the diagnosis of ACS and treat him as such. So, Professor, I'm talking a lot, so maybe we can have a dialogue or whatnot, but I think I see this and I worry that an abrupt onset lightheadedness syndrome with this EKG change really has, for me, PEACS in that order, with the troponin being a realistic tiebreaker between the two.
I'm also not, I've also been trained to think anytime that I think something potentially in the brain, and these changes not to overlook the possibility of cerebral T waves. So I would want to do a really, really good neuro exam Uh, and, uh, and review to see he's not on anticoagulant, which I don't think he has to make sure this is not the brain. So that's my, that's my checklist.
So Robbie, before you saw the EKG, um, actually you didn't even mention a single diagnosis. I'm just more curious to ask you what's PE in an ACS and brain. Was that all like in the back or were you still trying to define the problem? like perfusion versus unsteady. I'm just curious, did the EKG put that specific diagnosis of PE, ACS, et cetera, into your mind?
Yeah, Prof. Rez, I think all that was in my mind was, as I said, exactly what I said to you, there's not enough blood getting to his brain. Now, I don't do this in the ER because we move too quickly, but if I were to sit to that, it's not the only thing I know. I also know that he abruptly stopped getting blood to his brain.
So if you ask yourself, like most people who have lightheadedness, what's the average story of lightheadedness? We see this all the time, Prof Rez. Hey doc, last three or four days, not feeling great, this, that. And then you either get a story of diarrhea, diuretics, or you see that pesky Entrestor or ACE inhibitor and you're like, oh, okay, no problem. So he's not that. And if we break down
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Chapter 8: What lessons can be learned from this case about patient care?
But see, it's about defining the problem and getting the label right of the problem. This easily could have gone into like, he has a subdural because he fell off his bike, and he has more continuous sense of uneasiness.
Okay. So what ends up happening is he gets a troponin. The first one is 46 high sensitivity. Normal is less than 20 in our lab. The second one is 41. He feels great. Like his blood pressure is normal, feels good. Um, You know how you always say the eating, the walking, the talking. He meets all three of Robbie's criteria for discharge. I know, but Robbie wouldn't discharge.
You already made that very clear. So he gets discharged. This is just what happened. He gets discharged. And when I read the note, it was that, you know, his vitals are normal. The trope wasn't too elevated. And it was sort of like precinct hippie. Maybe there's some dehydration. He has a little bit of an AKI.
As he gets discharged to walk towards his home, he's like walking under a bridge and then has a full on syncopal episode witnessed by a bystander. They call EMS. He's like vomiting in the ambulance. He's awake, like little out of it. it's brought back to the emergency department. Like it was like a few hours after his discharge, maybe even 30 minutes after his discharge.
And, um, he's brought back. His blood pressure is 160 over 90 and his high sensitive troponin now is 79 and a probium PSN and it's 6,000 and they get a chest x-ray now. Okay. They get a chest x-ray and, um, Let me show you the chest x-ray for you to... Actually, before reading the chest x-ray, maybe you could share some thoughts, and then I'll show you the chest x-ray.
Yeah, you know, Parfraz, I think that the fact that he syncopized, I think just as a marker of... You know, the truth is we don't know he syncopized, but I think the fact that he came right back to it in the context of exertional lightheadedness, how does that be the wisest problem representation? Yeah. The fact that he's vomiting after is just, I think, a marker.
I don't create any specificity to it, but I think whenever you're seriously sick, some people get very sympathetic and some people get very vagal. And you said he was hypertensive afterwards, which I think is just probably more autonomic than anything else in his body trying to recover.
So if I, you know, going back to the original differential diagnosis, which of those two, ACS or PE, I'm also tracking the possibility he might have something in his brain, Prof. Rez, but if he has ACS or PE, which one is more likely to present with syncope?
It's definitely a pulmonary embolism, though there are instances where ACS can present with syncope, but it would require a second-order mechanism, like it would require ACS-induced VT or ACS-induced... ACS purely presents... with a continuous syndrome that gets worse and worse and worse and worse rather than PE, which has some cool mechanisms that can present with a syncopal event. Beautiful.
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