{"version":"1.0.0","segments":[{"startTime":0.391,"endTime":3.248,"body":"♪ (music) ♪"},{"startTime":3.248,"endTime":5.653,"body":"(Cathy ) Hi, welcome"},{"startTime":3.248,"endTime":5.653,"body":"to \u003ci\u003eHarrison's Podclass,\u003c/i\u003e"},{"startTime":5.653,"endTime":8.723,"body":"where we discuss important concepts"},{"startTime":5.653,"endTime":8.723,"body":"in internal medicine."},{"startTime":8.723,"endTime":10.989,"body":"- I'm Cathy Handy."},{"startTime":8.723,"endTime":10.989,"body":"- (Charlie) And I'm Charlie Wiener,"},{"startTime":10.989,"endTime":13.932,"body":"and we're coming to you"},{"startTime":10.989,"endTime":13.932,"body":"from the Johns Hopkins School of Medicine."},{"speaker":"(Cathy) Welcome to Episode 29","startTime":15.908,"endTime":20.013,"body":"An 84-Year-Old with Severe Headaches."},{"speaker":"(Charlie) Here's the question","startTime":21.338,"endTime":24.606,"body":"an 84-year-old woman is seen"},{"speaker":"(Charlie) Here's the question","startTime":21.338,"endTime":24.606,"body":"by her primary care physician"},{"speaker":"(Charlie) Here's the question","startTime":24.606,"endTime":26.826,"body":"for evaluation of severe headaches."},{"speaker":"(Charlie) Here's the question","startTime":26.826,"endTime":30.112,"body":"She noted these several weeks ago,"},{"speaker":"(Charlie) Here's the question","startTime":26.826,"endTime":30.112,"body":"and they have been getting worse."},{"speaker":"(Charlie) Here's the question","startTime":30.112,"endTime":32.321,"body":"She's having at least"},{"speaker":"(Charlie) Here's the question","startTime":30.112,"endTime":32.321,"body":"one episode each day,"},{"speaker":"(Charlie) Here's the question","startTime":32.321,"endTime":34.388,"body":"with no obvious provocation."},{"speaker":"(Charlie) Here's the question","startTime":34.388,"endTime":36.477,"body":"Although she has not had"},{"speaker":"(Charlie) Here's the question","startTime":34.388,"endTime":36.477,"body":"any visual aura,"},{"speaker":"(Charlie) Here's the question","startTime":36.477,"endTime":39.636,"body":"she is concerned that she's been having"},{"speaker":"(Charlie) Here's the question","startTime":36.477,"endTime":39.636,"body":"intermittent loss of vision"},{"speaker":"(Charlie) Here's the question","startTime":39.636,"endTime":42.684,"body":"in her left eye,"},{"speaker":"(Charlie) Here's the question","startTime":39.636,"endTime":42.684,"body":"just for the last few days."},{"speaker":"(Charlie) Here's the question","startTime":42.684,"endTime":44.561,"body":"She denies new weakness"},{"speaker":"(Charlie) Here's the question","startTime":42.684,"endTime":44.561,"body":"or numbness,"},{"speaker":"(Charlie) Here's the question","startTime":44.561,"endTime":46.891,"body":"but she does report jaw pain with eating."},{"speaker":"(Charlie) Here's the question","startTime":46.891,"endTime":49.296,"body":"Her past medical history"},{"speaker":"(Charlie) Here's the question","startTime":46.891,"endTime":49.296,"body":"includes coronary artery disease"},{"speaker":"(Charlie) Here's the question","startTime":49.296,"endTime":52.052,"body":"requiring a bypass graft, ten years ago,"},{"speaker":"(Charlie) Here's the question","startTime":52.052,"endTime":56.258,"body":"diabetes mellitus, hyperlipidemia,"},{"speaker":"(Charlie) Here's the question","startTime":52.052,"endTime":56.258,"body":"and mild depression."},{"speaker":"(Charlie) Here's the question","startTime":56.258,"endTime":60.756,"body":"Her full review of systems is notable"},{"speaker":"(Charlie) Here's the question","startTime":56.258,"endTime":60.756,"body":"for night sweats and mild low-back pain,"},{"speaker":"(Charlie) Here's the question","startTime":60.756,"endTime":62.467,"body":"particularly prominent in the morning,"},{"speaker":"(Charlie) Here's the question","startTime":62.467,"endTime":66.216,"body":"and these have occurred"},{"speaker":"(Charlie) Here's the question","startTime":62.467,"endTime":66.216,"body":"around the same times as these headaches."},{"speaker":"(Charlie) Here's the question","startTime":66.216,"endTime":69.529,"body":"(Cathy) In Episode 11, we talk about"},{"speaker":"(Charlie) Here's the question","startTime":66.216,"endTime":69.529,"body":"the differential diagnosis of headaches"},{"speaker":"(Charlie) Here's the question","startTime":69.529,"endTime":70.867,"body":"and when to be concerned,"},{"speaker":"(Charlie) Here's the question","startTime":70.867,"endTime":73.784,"body":"and this patient is presenting"},{"speaker":"(Charlie) Here's the question","startTime":70.867,"endTime":73.784,"body":"with some worrisome findings."},{"speaker":"(Charlie) Here's the question","startTime":73.784,"endTime":75.802,"body":"So, the findings"},{"speaker":"(Charlie) Here's the question","startTime":73.784,"endTime":75.802,"body":"that are of note here are:"},{"speaker":"(Charlie) Here's the question","startTime":75.802,"endTime":77.902,"body":"the worsening over the course of weeks;"},{"speaker":"(Charlie) Here's the question","startTime":77.902,"endTime":81.926,"body":"neurologic symptoms-- he or she describes"},{"speaker":"(Charlie) Here's the question","startTime":77.902,"endTime":81.926,"body":"intermittent loss of vision"},{"speaker":"(Charlie) Here's the question","startTime":81.926,"endTime":83.613,"body":"and jaw pain with eating."},{"speaker":"(Charlie) Here's the question","startTime":83.613,"endTime":86.717,"body":"And that constellation of symptoms"},{"speaker":"(Charlie) Here's the question","startTime":83.613,"endTime":86.717,"body":"in someone who's 84 years old"},{"speaker":"(Charlie) Here's the question","startTime":86.717,"endTime":88.513,"body":"must make you think"},{"speaker":"(Charlie) Here's the question","startTime":86.717,"endTime":88.513,"body":"of giant cell arteritis,"},{"speaker":"(Charlie) Here's the question","startTime":88.513,"endTime":91.362,"body":"which I think is a do-not-miss diagnosis."},{"speaker":"(Charlie) Here's the question","startTime":91.362,"endTime":93.507,"body":"(Charlie) What do you mean"},{"speaker":"(Charlie) Here's the question","startTime":91.362,"endTime":93.507,"body":"by a do-not-miss diagnosis?"},{"speaker":"(Charlie) Here's the question","startTime":93.507,"endTime":94.984,"body":"(Cathy) By that I mean a diagnosis"},{"speaker":"(Charlie) Here's the question","startTime":94.984,"endTime":96.91,"body":"where a treatment"},{"speaker":"(Charlie) Here's the question","startTime":94.984,"endTime":96.91,"body":"can be started empirically,"},{"speaker":"(Charlie) Here's the question","startTime":96.91,"endTime":100.037,"body":"because if you don't there could be"},{"speaker":"(Charlie) Here's the question","startTime":96.91,"endTime":100.037,"body":"serious, irreversible consequences"},{"speaker":"(Charlie) Here's the question","startTime":100.037,"endTime":101.26,"body":"for the patient."},{"speaker":"(Charlie) Here's the question","startTime":101.26,"endTime":103.865,"body":"(Charlie) Okay."},{"speaker":"(Charlie) Here's the question","startTime":101.26,"endTime":103.865,"body":"So, what is giant cell arteritis?"},{"speaker":"(Charlie) Here's the question","startTime":103.865,"endTime":106.467,"body":"(Cathy) It's inflammation of"},{"speaker":"(Charlie) Here's the question","startTime":103.865,"endTime":106.467,"body":"the medium- and large-sized arteries,"},{"speaker":"(Charlie) Here's the question","startTime":106.467,"endTime":109.989,"body":"and characteristically involves one"},{"speaker":"(Charlie) Here's the question","startTime":106.467,"endTime":109.989,"body":"or more branches of the carotid artery,"},{"speaker":"(Charlie) Here's the question","startTime":109.989,"endTime":112.077,"body":"particularly the temporal artery."},{"speaker":"(Charlie) Here's the question","startTime":112.077,"endTime":115.26,"body":"With involvement of the ophthalmic artery,"},{"speaker":"(Charlie) Here's the question","startTime":112.077,"endTime":115.26,"body":"it can lead to blindness."},{"speaker":"(Charlie) Here's the question","startTime":115.26,"endTime":117.276,"body":"An empiric treatment"},{"speaker":"(Charlie) Here's the question","startTime":115.26,"endTime":117.276,"body":"with glucocorticoids, though,"},{"speaker":"(Charlie) Here's the question","startTime":117.276,"endTime":120.563,"body":"is effective in preventing"},{"speaker":"(Charlie) Here's the question","startTime":117.276,"endTime":120.563,"body":"this complication if it's caught early."},{"speaker":"(Charlie) Here's the question","startTime":120.563,"endTime":123.203,"body":"(Charlie) Do the other symptoms"},{"speaker":"(Charlie) Here's the question","startTime":120.563,"endTime":123.203,"body":"described in this case help you at all"},{"speaker":"(Charlie) Here's the question","startTime":123.203,"endTime":125.643,"body":"with the diagnosis of GCA?"},{"speaker":"(Charlie) Here's the question","startTime":125.643,"endTime":128.203,"body":"(Cathy) The night sweats and back pain"},{"speaker":"(Charlie) Here's the question","startTime":125.643,"endTime":128.203,"body":"that are worse in the morning"},{"speaker":"(Charlie) Here's the question","startTime":128.203,"endTime":130.326,"body":"make me think that this is rheumatologic,"},{"speaker":"(Charlie) Here's the question","startTime":130.326,"endTime":133.153,"body":"and the back pain may be"},{"speaker":"(Charlie) Here's the question","startTime":130.326,"endTime":133.153,"body":"polymyalgia rheumatica."},{"speaker":"(Charlie) Here's the question","startTime":133.153,"endTime":137.075,"body":"This can be seen in 40-50% of patients"},{"speaker":"(Charlie) Here's the question","startTime":133.153,"endTime":137.075,"body":"with giant cell arteritis,"},{"speaker":"(Charlie) Here's the question","startTime":137.075,"endTime":140.065,"body":"and about 10-20% of patients"},{"speaker":"(Charlie) Here's the question","startTime":137.075,"endTime":140.065,"body":"who initially present"},{"speaker":"(Charlie) Here's the question","startTime":140.065,"endTime":143.028,"body":"with features of isolated"},{"speaker":"(Charlie) Here's the question","startTime":140.065,"endTime":143.028,"body":"polymyalgia rheumatica"},{"speaker":"(Charlie) Here's the question","startTime":143.028,"endTime":145.739,"body":"can go on later to develop"},{"speaker":"(Charlie) Here's the question","startTime":143.028,"endTime":145.739,"body":"giant cell arteritis."},{"speaker":"(Charlie) Here's the question","startTime":145.739,"endTime":150.505,"body":"So, this constellation of symptoms"},{"speaker":"(Charlie) Here's the question","startTime":145.739,"endTime":150.505,"body":"really points me in the direction of GCA."},{"speaker":"(Charlie) Okay, so the question asks","startTime":152.093,"endTime":155.564,"body":"which of the following is"},{"speaker":"(Charlie) Okay, so the question asks","startTime":152.093,"endTime":155.564,"body":"the next most appropriate step?"},{"speaker":"(Charlie) Okay, so the question asks","startTime":155.564,"endTime":160.4,"body":"Option A says, aspirin,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":155.564,"endTime":160.4,"body":"975 mg orally every day;"},{"speaker":"(Charlie) Okay, so the question asks","startTime":160.4,"endTime":164.657,"body":"option B says, measurement"},{"speaker":"(Charlie) Okay, so the question asks","startTime":160.4,"endTime":164.657,"body":"of the erythrocyte sedimentation rate;"},{"speaker":"(Charlie) Okay, so the question asks","startTime":164.657,"endTime":169.235,"body":"option C says, immediate initiation"},{"speaker":"(Charlie) Okay, so the question asks","startTime":164.657,"endTime":169.235,"body":"of glucocorticoid therapy;"},{"speaker":"(Charlie) Okay, so the question asks","startTime":169.235,"endTime":173.113,"body":"option D says, referral"},{"speaker":"(Charlie) Okay, so the question asks","startTime":169.235,"endTime":173.113,"body":"for a temporal artery biopsy;"},{"speaker":"(Charlie) Okay, so the question asks","startTime":173.113,"endTime":177.344,"body":"and option E says, referral"},{"speaker":"(Charlie) Okay, so the question asks","startTime":173.113,"endTime":177.344,"body":"for an ultrasound of the temporal artery."},{"speaker":"(Charlie) Okay, so the question asks","startTime":177.344,"endTime":180.307,"body":"(Cathy) I would go with immediate"},{"speaker":"(Charlie) Okay, so the question asks","startTime":177.344,"endTime":180.307,"body":"initiation of glucocorticoids."},{"speaker":"(Charlie) Okay, so the question asks","startTime":180.307,"endTime":185.019,"body":"So, I mentioned before about steroids"},{"speaker":"(Charlie) Okay, so the question asks","startTime":180.307,"endTime":185.019,"body":"as an option for treatment,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":185.019,"endTime":187.145,"body":"but the other reason"},{"speaker":"(Charlie) Okay, so the question asks","startTime":185.019,"endTime":187.145,"body":"starting steroids may be helpful"},{"speaker":"(Charlie) Okay, so the question asks","startTime":187.145,"endTime":189.281,"body":"is because if you see a dramatic response"},{"speaker":"(Charlie) Okay, so the question asks","startTime":189.281,"endTime":192.242,"body":"it lends further support"},{"speaker":"(Charlie) Okay, so the question asks","startTime":189.281,"endTime":192.242,"body":"to the diagnosis, as well."},{"speaker":"(Charlie) Okay, so the question asks","startTime":192.242,"endTime":194.448,"body":"(Charlie) Would the other options"},{"speaker":"(Charlie) Okay, so the question asks","startTime":192.242,"endTime":194.448,"body":"be helpful at all?"},{"speaker":"(Charlie) Okay, so the question asks","startTime":194.448,"endTime":197.878,"body":"(Cathy) So, option A asks about aspirin,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":194.448,"endTime":197.878,"body":"and that may help with pain"},{"speaker":"(Charlie) Okay, so the question asks","startTime":197.878,"endTime":200.441,"body":"but it's really not therapeutic"},{"speaker":"(Charlie) Okay, so the question asks","startTime":197.878,"endTime":200.441,"body":"or diagnostic,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":200.441,"endTime":203.154,"body":"so that I would say is not helpful."},{"speaker":"(Charlie) Okay, so the question asks","startTime":203.154,"endTime":206.843,"body":"Option B mentions ESR,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":203.154,"endTime":206.843,"body":"and that's almost universally elevated,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":206.843,"endTime":209.157,"body":"but it's not specific for the diagnosis."},{"speaker":"(Charlie) Okay, so the question asks","startTime":209.157,"endTime":210.768,"body":"And the same is true for CRP,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":210.768,"endTime":213.781,"body":"so neither of those"},{"speaker":"(Charlie) Okay, so the question asks","startTime":210.768,"endTime":213.781,"body":"would be particularly helpful."},{"speaker":"(Charlie) Okay, so the question asks","startTime":213.781,"endTime":216.24,"body":"Option D mentions"},{"speaker":"(Charlie) Okay, so the question asks","startTime":213.781,"endTime":216.24,"body":"the temporal artery biopsy,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":216.24,"endTime":218.761,"body":"and that can definitely be part"},{"speaker":"(Charlie) Okay, so the question asks","startTime":216.24,"endTime":218.761,"body":"of the diagnostic workup,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":218.761,"endTime":221.906,"body":"but it shouldn't delay"},{"speaker":"(Charlie) Okay, so the question asks","startTime":218.761,"endTime":221.906,"body":"the treatment with steroids,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":221.906,"endTime":223.887,"body":"given the threat of visual loss."},{"speaker":"(Charlie) Okay, so the question asks","startTime":223.887,"endTime":226.33,"body":"Option E mentions"},{"speaker":"(Charlie) Okay, so the question asks","startTime":223.887,"endTime":226.33,"body":"temporal artery ultrasound,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":226.33,"endTime":229.403,"body":"and that could also be suggestive,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":226.33,"endTime":229.403,"body":"but it's not diagnostic."},{"speaker":"(Charlie) Okay, so the question asks","startTime":229.403,"endTime":231.093,"body":"(Charlie) So, what would you start?"},{"speaker":"(Charlie) Okay, so the question asks","startTime":231.093,"endTime":233.106,"body":"(Cathy) So, the primary therapy"},{"speaker":"(Charlie) Okay, so the question asks","startTime":231.093,"endTime":233.106,"body":"is prednisone"},{"speaker":"(Charlie) Okay, so the question asks","startTime":233.106,"endTime":237.729,"body":"at 40-60 mg daily for one month"},{"speaker":"(Charlie) Okay, so the question asks","startTime":233.106,"endTime":237.729,"body":"with gradual tapering after that."},{"speaker":"(Charlie) Okay, so the question asks","startTime":237.729,"endTime":239.801,"body":"You should do this in conjunction"},{"speaker":"(Charlie) Okay, so the question asks","startTime":237.729,"endTime":239.801,"body":"with rheumatology,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":239.801,"endTime":242.727,"body":"and if someone's going to be"},{"speaker":"(Charlie) Okay, so the question asks","startTime":239.801,"endTime":242.727,"body":"on steroids for a long period of time,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":242.727,"endTime":245.124,"body":"remember appropriate prophylaxis."},{"speaker":"(Charlie) Okay, so the question asks","startTime":245.124,"endTime":249.526,"body":"So, that includes PCP prophylaxis,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":245.124,"endTime":249.526,"body":"and calcium and vitamin D supplementation."},{"speaker":"(Charlie) Okay, so the question asks","startTime":249.526,"endTime":252.247,"body":"And in this patient,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":249.526,"endTime":252.247,"body":"she also has a history of diabetes,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":252.247,"endTime":256.466,"body":"so, you'll need to monitor her glucoses"},{"speaker":"(Charlie) Okay, so the question asks","startTime":252.247,"endTime":256.466,"body":"closely while she's on steroids."},{"speaker":"(Charlie) Okay, so the question asks","startTime":256.466,"endTime":258.845,"body":"(Charlie) Okay,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":256.466,"endTime":258.845,"body":"so the teaching point in this case--"},{"speaker":"(Charlie) Okay, so the question asks","startTime":258.845,"endTime":262.042,"body":"that in an elderly patient"},{"speaker":"(Charlie) Okay, so the question asks","startTime":258.845,"endTime":262.042,"body":"with new-onset headaches,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":262.042,"endTime":266.957,"body":"systemic findings, and visual symptoms,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":262.042,"endTime":266.957,"body":"suspect giant cell arteritis,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":266.957,"endTime":271.251,"body":"and immediate steroids may prevent"},{"speaker":"(Charlie) Okay, so the question asks","startTime":266.957,"endTime":271.251,"body":"complications such as blindness."},{"speaker":"(Charlie) Okay, so the question asks","startTime":271.251,"endTime":272.487,"body":"(Cathy) And to read more,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":272.487,"endTime":275.408,"body":"you can check out \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"(Charlie) Okay, so the question asks","startTime":272.487,"endTime":275.408,"body":"on Vasculitis Syndromes"},{"speaker":"(Charlie) Okay, so the question asks","startTime":275.408,"endTime":278.561,"body":"within the section"},{"speaker":"(Charlie) Okay, so the question asks","startTime":275.408,"endTime":278.561,"body":"on Rheumatology and Immunology."},{"speaker":"(Charlie) Okay, so the question asks","startTime":278.561,"endTime":282.285,"body":"♪ (music) ♪"}]}