{"version":"1.0.0","segments":[{"startTime":0.617,"endTime":3.281,"body":"♪ (music) ♪"},{"startTime":3.281,"endTime":5.604,"body":"(Cathy) Hi, welcome to \u003ci\u003eHarrison's Podclass\u003c/i\u003e"},{"startTime":5.604,"endTime":8.601,"body":"where we discuss important concepts"},{"startTime":5.604,"endTime":8.601,"body":"in internal medicine."},{"startTime":8.601,"endTime":10.906,"body":"- I'm Cathy Handy."},{"startTime":8.601,"endTime":10.906,"body":"- (Charlie) And I'm Charlie Wiener,"},{"startTime":10.906,"endTime":14.007,"body":"and we're coming to you from"},{"startTime":10.906,"endTime":14.007,"body":"the Johns Hopkins School of Medicine."},{"startTime":14.007,"endTime":15.339,"body":"♪ (music) ♪"},{"startTime":15.822,"endTime":17.731,"body":"(Cathy) Welcome to Episode 41."},{"startTime":17.731,"endTime":21.126,"body":"Today's episode is about"},{"startTime":17.731,"endTime":21.126,"body":"a 56-year-old with frostbite."},{"startTime":21.126,"endTime":24.875,"body":"(Charlie) Okay. So, a 56-year-old man"},{"startTime":21.126,"endTime":24.875,"body":"is admitted to the surgical service"},{"startTime":24.875,"endTime":26.381,"body":"one day ago for care"},{"startTime":26.381,"endTime":30.013,"body":"due to exposure injury and frostbite"},{"startTime":26.381,"endTime":30.013,"body":"in his distal extremities."},{"startTime":30.013,"endTime":33.594,"body":"He also is being treated for some"},{"startTime":30.013,"endTime":33.594,"body":"possible early bacterial infection."},{"startTime":33.594,"endTime":35.366,"body":"(Cathy) Oh, that sounds painful."},{"startTime":35.366,"endTime":39.349,"body":"Sometimes you can also get frostbite"},{"startTime":35.366,"endTime":39.349,"body":"to affect other exposed areas,"},{"startTime":39.349,"endTime":42.307,"body":"so you'll commonly see it"},{"startTime":39.349,"endTime":42.307,"body":"in the ears, nose, and chin,"},{"startTime":42.307,"endTime":44.169,"body":"but it's fortunate at least"},{"startTime":42.307,"endTime":44.169,"body":"for this person"},{"startTime":44.169,"endTime":46.483,"body":"that this is limited to the extremities."},{"startTime":46.483,"endTime":49.039,"body":"(Charlie) It is."},{"startTime":46.483,"endTime":49.039,"body":"Complicating his presentation"},{"startTime":49.039,"endTime":51.562,"body":"is that he has a long-standing history"},{"startTime":49.039,"endTime":51.562,"body":"of alcoholism,"},{"startTime":51.562,"endTime":54.694,"body":"drinking about one liter"},{"startTime":51.562,"endTime":54.694,"body":"of vodka on a daily basis."},{"startTime":54.694,"endTime":57.276,"body":"(Cathy) Well, that is definitely"},{"startTime":54.694,"endTime":57.276,"body":"more than is healthy for him."},{"startTime":57.276,"endTime":59.166,"body":"We know that more than three drinks a day"},{"startTime":59.166,"endTime":61.96,"body":"significantly increases the risk"},{"startTime":59.166,"endTime":61.96,"body":"of overall mortality,"},{"startTime":61.96,"endTime":63.356,"body":"and that's for many reasons,"},{"startTime":63.356,"endTime":65.331,"body":"so it's not limited to just"},{"startTime":63.356,"endTime":65.331,"body":"liver disease,"},{"startTime":65.331,"endTime":68.022,"body":"but also cancer and vascular disease."},{"startTime":68.022,"endTime":71.639,"body":"Overall, it's estimated that chronic,"},{"startTime":68.022,"endTime":71.639,"body":"excessive alcohol use disorders"},{"startTime":71.639,"endTime":74.304,"body":"decrease the lifespan by about ten years."},{"startTime":74.304,"endTime":77.621,"body":"But since we're in the acute setting,"},{"startTime":74.304,"endTime":77.621,"body":"in a hospitalization,"},{"startTime":77.621,"endTime":80.609,"body":"you want to know too, if he has"},{"startTime":77.621,"endTime":80.609,"body":"any history of alcohol withdrawal,"},{"startTime":80.609,"endTime":82.685,"body":"and also when he had his last drink."},{"startTime":82.685,"endTime":85.265,"body":"If he only stopped drinking,"},{"startTime":82.685,"endTime":85.265,"body":"for example, on admission,"},{"startTime":85.265,"endTime":87.603,"body":"than he could be at risk"},{"startTime":85.265,"endTime":87.603,"body":"for acute alcohol withdrawal"},{"startTime":87.603,"endTime":89.455,"body":"during the hospitalization."},{"startTime":89.46,"endTime":91.121,"body":"(Charlie) Well, let me update you."},{"startTime":91.121,"endTime":93.571,"body":"So, we don't have much past history"},{"startTime":91.121,"endTime":93.571,"body":"on this gentleman."},{"startTime":93.571,"endTime":96.882,"body":"Since admission, he's been treated"},{"startTime":93.571,"endTime":96.882,"body":"with IV fluids, antibiotics,"},{"startTime":96.882,"endTime":100.506,"body":"and he's been medicated since admission"},{"startTime":96.882,"endTime":100.506,"body":"for prevention of alcohol withdrawal"},{"startTime":100.506,"endTime":102.574,"body":"via a symptom-triggered approach,"},{"startTime":102.574,"endTime":105.339,"body":"and he last received lorazepam"},{"startTime":102.574,"endTime":105.339,"body":"two milligrams orally,"},{"startTime":105.339,"endTime":106.829,"body":"about two hours ago."},{"startTime":106.829,"endTime":109.902,"body":"However, you get called"},{"startTime":106.829,"endTime":109.902,"body":"because things are a bit different now"},{"startTime":109.902,"endTime":111.855,"body":"than when he first came into the hospital."},{"startTime":111.855,"endTime":114.378,"body":"The nurses tell you"},{"startTime":111.855,"endTime":114.378,"body":"that he's expressing a belief"},{"startTime":114.378,"endTime":117.408,"body":"that his wounds were the result"},{"startTime":114.378,"endTime":117.408,"body":"of burns that were inflicted upon him"},{"startTime":117.408,"endTime":118.991,"body":"by torturers in the government,"},{"startTime":118.991,"endTime":122.316,"body":"because he knows too much"},{"startTime":118.991,"endTime":122.316,"body":"about government surveillance plans."},{"startTime":122.316,"endTime":125.734,"body":"The surgical team reports it is"},{"startTime":122.316,"endTime":125.734,"body":"difficult to keep the patient in bed,"},{"startTime":125.734,"endTime":128.629,"body":"and he seems unsteady"},{"startTime":125.734,"endTime":128.629,"body":"on his feet at times."},{"startTime":128.629,"endTime":130.185,"body":"When he was out of bed,"},{"startTime":130.185,"endTime":134.335,"body":"he was disoriented,"},{"startTime":130.185,"endTime":134.335,"body":"tremulous, and hypertensive."},{"startTime":134.338,"endTime":136.327,"body":"He was actively confused."},{"startTime":136.327,"endTime":140.672,"body":"The delusional thoughts did not respond"},{"startTime":136.327,"endTime":140.672,"body":"to treatment with additional lorazepam"},{"startTime":140.672,"endTime":143.204,"body":"which was given intravenously"},{"startTime":140.672,"endTime":143.204,"body":"in this case."},{"startTime":143.204,"endTime":146.704,"body":"(Cathy) So, it sounds like some of this"},{"startTime":143.204,"endTime":146.704,"body":"may have been responsive to lorazepam,"},{"startTime":146.704,"endTime":149.161,"body":"but the delusional thoughts persist."},{"startTime":149.161,"endTime":151.254,"body":"What's the rest of his exam now?"},{"startTime":151.254,"endTime":153.114,"body":"(Charlie) Okay, well you"},{"startTime":151.254,"endTime":153.114,"body":"go see the patient--"},{"startTime":153.114,"endTime":155.437,"body":"he's sleeping quietly at this time."},{"speaker":"His vital signs are","startTime":155.437,"endTime":160.348,"body":"blood pressure 110/82, heart rate of 94,"},{"speaker":"His vital signs are","startTime":160.348,"endTime":164.083,"body":"respiratory rate of 16,"},{"speaker":"His vital signs are","startTime":160.348,"endTime":164.083,"body":"a temperature of 37°"},{"speaker":"His vital signs are","startTime":164.083,"endTime":167.198,"body":"and a room air saturation of 97%."},{"speaker":"His vital signs are","startTime":167.198,"endTime":170.502,"body":"He awakens easily"},{"speaker":"His vital signs are","startTime":167.198,"endTime":170.502,"body":"and has minimal resting tremor."},{"speaker":"His vital signs are","startTime":170.502,"endTime":174.029,"body":"On neurologic exam,"},{"speaker":"His vital signs are","startTime":170.502,"endTime":174.029,"body":"he exhibits past pointing,"},{"speaker":"His vital signs are","startTime":174.029,"endTime":177.11,"body":"difficulty with rapid"},{"speaker":"His vital signs are","startTime":174.029,"endTime":177.11,"body":"alternating movements,"},{"speaker":"His vital signs are","startTime":177.11,"endTime":180.18,"body":"horizontal nystagmus in both directions,"},{"speaker":"His vital signs are","startTime":180.18,"endTime":183.727,"body":"decreased sensation to light touch"},{"speaker":"His vital signs are","startTime":180.18,"endTime":183.727,"body":"and pinprick in the lower extremities"},{"speaker":"His vital signs are","startTime":183.727,"endTime":185.266,"body":"below the mid tibia."},{"speaker":"His vital signs are","startTime":185.266,"endTime":189.796,"body":"You get him up to walk and find"},{"speaker":"His vital signs are","startTime":185.266,"endTime":189.796,"body":"that his gait is wide-based and ataxic."},{"speaker":"His vital signs are","startTime":189.796,"endTime":192.8,"body":"He no longer expresses"},{"speaker":"His vital signs are","startTime":189.796,"endTime":192.8,"body":"the prior delusional beliefs,"},{"speaker":"His vital signs are","startTime":192.8,"endTime":195.881,"body":"but he's disoriented"},{"speaker":"His vital signs are","startTime":192.8,"endTime":195.881,"body":"and thinks he is in jail."},{"speaker":"His vital signs are","startTime":195.881,"endTime":198.222,"body":"He states that he was brought to the gulag"},{"speaker":"His vital signs are","startTime":198.222,"endTime":200.94,"body":"so that the government"},{"speaker":"His vital signs are","startTime":198.222,"endTime":200.94,"body":"could experiment on him."},{"speaker":"His vital signs are","startTime":200.94,"endTime":205.801,"body":"Currently, he has D5 half-normal saline"},{"speaker":"His vital signs are","startTime":200.94,"endTime":205.801,"body":"infusing at a 100 milliliters per hour,"},{"speaker":"His vital signs are","startTime":205.801,"endTime":208.267,"body":"and he's also receiving"},{"speaker":"His vital signs are","startTime":205.801,"endTime":208.267,"body":"nafcillin 2 grams IV"},{"speaker":"His vital signs are","startTime":208.267,"endTime":210.557,"body":"every four hours for cellulitis."},{"speaker":"The question asks","startTime":212.086,"endTime":215.75,"body":"\"What do you think is the cause"},{"speaker":"The question asks","startTime":212.086,"endTime":215.75,"body":"of this patient's altered mental status?\""},{"speaker":"And the options are","startTime":217.435,"endTime":219.813,"body":"A. hypoglycemia;"},{"speaker":"And the options are","startTime":219.813,"endTime":222.63,"body":"B. hyponatremia;"},{"speaker":"And the options are","startTime":222.63,"endTime":225.313,"body":"C. niacin deficiency;"},{"speaker":"And the options are","startTime":225.313,"endTime":227.557,"body":"D. thiamine deficiency;"},{"speaker":"And the options are","startTime":227.557,"endTime":230.485,"body":"or E. undertreated alcohol withdrawal."},{"speaker":"And the options are","startTime":230.485,"endTime":233.168,"body":"(Cathy) Okay. Well, we have"},{"speaker":"And the options are","startTime":230.485,"endTime":233.168,"body":"a lot of information here."},{"speaker":"And the options are","startTime":233.168,"endTime":237.286,"body":"The main points that I took away"},{"speaker":"And the options are","startTime":233.168,"endTime":237.286,"body":"are that he has normal vital signs,"},{"speaker":"And the options are","startTime":237.286,"endTime":241.339,"body":"he's disoriented, and he has"},{"speaker":"And the options are","startTime":237.286,"endTime":241.339,"body":"an abnormal neurologic exam"},{"speaker":"And the options are","startTime":241.339,"endTime":245.026,"body":"with prominent, mostly cerebellar"},{"speaker":"And the options are","startTime":241.339,"endTime":245.026,"body":"and sensory findings."},{"speaker":"And the options are","startTime":245.026,"endTime":248.394,"body":"When thinking about severe manifestations"},{"speaker":"And the options are","startTime":245.026,"endTime":248.394,"body":"of alcohol withdrawal,"},{"speaker":"And the options are","startTime":248.394,"endTime":252.84,"body":"vital sign instability with hypertension"},{"speaker":"And the options are","startTime":248.394,"endTime":252.84,"body":"and tachycardia are usually seen."},{"speaker":"And the options are","startTime":252.84,"endTime":254.871,"body":"But it doesn't sound like he has that now,"},{"speaker":"And the options are","startTime":254.871,"endTime":258.384,"body":"so we can rule out option E--"},{"speaker":"And the options are","startTime":254.871,"endTime":258.384,"body":"undertreated alcohol withdrawal--"},{"speaker":"And the options are","startTime":258.384,"endTime":260.591,"body":"as a cause of his current symptoms."},{"speaker":"And the options are","startTime":260.591,"endTime":262.911,"body":"The other point that you mentioned"},{"speaker":"And the options are","startTime":260.591,"endTime":262.911,"body":"that caught my attention,"},{"speaker":"And the options are","startTime":262.911,"endTime":265.46,"body":"is that he's receiving"},{"speaker":"And the options are","startTime":262.911,"endTime":265.46,"body":"D5 half-normal saline,"},{"speaker":"And the options are","startTime":265.46,"endTime":269.46,"body":"and you never mentioned giving thiamine"},{"speaker":"And the options are","startTime":265.46,"endTime":269.46,"body":"at all during this hospitalization."},{"speaker":"And the options are","startTime":269.463,"endTime":271.091,"body":"(Charlie) What's notable about that?"},{"speaker":"And the options are","startTime":271.091,"endTime":273.705,"body":"(Cathy) Well, alcohol interferes"},{"speaker":"And the options are","startTime":271.091,"endTime":273.705,"body":"with the absorption of vitamins"},{"speaker":"And the options are","startTime":273.705,"endTime":277.005,"body":"in the small intestine and it decreases"},{"speaker":"And the options are","startTime":273.705,"endTime":277.005,"body":"their storage in the liver."},{"speaker":"And the options are","startTime":277.005,"endTime":279.142,"body":"So, patients can have"},{"speaker":"And the options are","startTime":277.005,"endTime":279.142,"body":"multiple deficiencies--"},{"speaker":"And the options are","startTime":279.142,"endTime":282.558,"body":"usually what we see"},{"speaker":"And the options are","startTime":279.142,"endTime":282.558,"body":"is folate, pyridoxine, or vitamin B6,"},{"speaker":"And the options are","startTime":282.558,"endTime":285.806,"body":"thiamine, which is B1,"},{"speaker":"And the options are","startTime":282.558,"endTime":285.806,"body":"and also nicotinic acid."},{"speaker":"And the options are","startTime":285.806,"endTime":288.99,"body":"Glucose infusions can precipitate"},{"speaker":"And the options are","startTime":285.806,"endTime":288.99,"body":"acute Wernicke syndrome,"},{"speaker":"And the options are","startTime":288.99,"endTime":292.611,"body":"which is due to the acute precipitation"},{"speaker":"And the options are","startTime":288.99,"endTime":292.611,"body":"of thiamine deficiency,"},{"speaker":"And the options are","startTime":292.611,"endTime":295.777,"body":"so thiamine should always"},{"speaker":"And the options are","startTime":292.611,"endTime":295.777,"body":"be administered before or concurrently"},{"speaker":"And the options are","startTime":295.777,"endTime":299.268,"body":"to alcoholic patients"},{"speaker":"And the options are","startTime":295.777,"endTime":299.268,"body":"who require glucose infusions."},{"speaker":"And the options are","startTime":299.268,"endTime":302.892,"body":"Acute Wernicke syndrome is on the spectrum"},{"speaker":"And the options are","startTime":299.268,"endTime":302.892,"body":"of Wernicke-Korsakoff disease"},{"speaker":"And the options are","startTime":302.892,"endTime":306.18,"body":"which may progress to amnesia"},{"speaker":"And the options are","startTime":302.892,"endTime":306.18,"body":"and other loss of executive function."},{"speaker":"And the options are","startTime":306.18,"endTime":310.279,"body":"(Charlie) Why does glucose precipitate"},{"speaker":"And the options are","startTime":306.18,"endTime":310.279,"body":"the acute thiamine toxicity in the brain?"},{"speaker":"And the options are","startTime":310.279,"endTime":313.673,"body":"(Cathy) Thiamine is a cofactor"},{"speaker":"And the options are","startTime":310.279,"endTime":313.673,"body":"for glucose metabolism in the brain."},{"speaker":"And the options are","startTime":313.673,"endTime":317.43,"body":"The sudden glucose load that can happen"},{"speaker":"And the options are","startTime":313.673,"endTime":317.43,"body":"when you give a D5 infusion"},{"speaker":"And the options are","startTime":317.43,"endTime":320.081,"body":"can cause worsening"},{"speaker":"And the options are","startTime":317.43,"endTime":320.081,"body":"of the chronic thiamine depletion,"},{"speaker":"And the options are","startTime":320.081,"endTime":323.572,"body":"thus provoking the neurologic"},{"speaker":"And the options are","startTime":320.081,"endTime":323.572,"body":"manifestations of acute deficiency"},{"speaker":"And the options are","startTime":323.572,"endTime":325.417,"body":"or the Wernicke syndrome."},{"speaker":"And the options are","startTime":325.417,"endTime":328.232,"body":"In this country, alcoholism"},{"speaker":"And the options are","startTime":325.417,"endTime":328.232,"body":"is one of the most common causes"},{"speaker":"And the options are","startTime":328.232,"endTime":329.497,"body":"of thiamine deficiency,"},{"speaker":"And the options are","startTime":329.497,"endTime":334.617,"body":"and this patient has the classic triad"},{"speaker":"And the options are","startTime":329.497,"endTime":334.617,"body":"of ophthalmoplegia, ataxia, and confusion."},{"speaker":"And the options are","startTime":334.617,"endTime":338.407,"body":"(Charlie) Great, so the answer"},{"speaker":"And the options are","startTime":334.617,"endTime":338.407,"body":"in this case is D -- thiamine deficiency."},{"speaker":"And the options are","startTime":338.407,"endTime":340.296,"body":"(Cathy) Yes, that's the right answer."},{"speaker":"And the options are","startTime":340.296,"endTime":342.524,"body":"(Charlie) Niacin deficiency was option C,"},{"speaker":"And the options are","startTime":342.524,"endTime":344.574,"body":"and you mentioned niacin"},{"speaker":"And the options are","startTime":342.524,"endTime":344.574,"body":"is one of the vitamins"},{"speaker":"And the options are","startTime":344.574,"endTime":347.156,"body":"that may be deficient"},{"speaker":"And the options are","startTime":344.574,"endTime":347.156,"body":"in chronic alcoholism."},{"speaker":"And the options are","startTime":347.156,"endTime":349.961,"body":"Are you concerned that"},{"speaker":"And the options are","startTime":347.156,"endTime":349.961,"body":"that's contributing to this case?"},{"speaker":"And the options are","startTime":349.961,"endTime":353.581,"body":"(Cathy) Niacin deficiency causes pellagra"},{"speaker":"And the options are","startTime":349.961,"endTime":353.581,"body":"which characteristically presents"},{"speaker":"And the options are","startTime":353.581,"endTime":356.469,"body":"with dermatitis, diarrhea, and dementia."},{"speaker":"And the options are","startTime":356.469,"endTime":359.806,"body":"The presentation he presented with here"},{"speaker":"And the options are","startTime":356.469,"endTime":359.806,"body":"would not be consistent with that,"},{"speaker":"And the options are","startTime":359.806,"endTime":362.287,"body":"although, later in his course"},{"speaker":"And the options are","startTime":359.806,"endTime":362.287,"body":"he certainly should be started"},{"speaker":"And the options are","startTime":362.287,"endTime":365.065,"body":"on vitamin supplementation"},{"speaker":"And the options are","startTime":362.287,"endTime":365.065,"body":"that includes niacin."},{"speaker":"And the options are","startTime":365.065,"endTime":367.313,"body":"(Charlie) How would you treat"},{"speaker":"And the options are","startTime":365.065,"endTime":367.313,"body":"this patient immediately?"},{"speaker":"And the options are","startTime":367.313,"endTime":369.505,"body":"(Cathy) So first, you want"},{"speaker":"And the options are","startTime":367.313,"endTime":369.505,"body":"to stop the IV glucose"},{"speaker":"And the options are","startTime":369.505,"endTime":373.515,"body":"and start him on IV or IM thiamine"},{"speaker":"And the options are","startTime":369.505,"endTime":373.515,"body":"until there's no further improvement"},{"speaker":"And the options are","startTime":373.515,"endTime":375.01,"body":"in the acute symptoms."},{"speaker":"And the options are","startTime":375.01,"endTime":376.83,"body":"And then long term, oral thiamine"},{"speaker":"And the options are","startTime":376.83,"endTime":379.39,"body":"should be continued"},{"speaker":"And the options are","startTime":376.83,"endTime":379.39,"body":"until recovery is complete."},{"speaker":"And the options are","startTime":379.39,"endTime":382.874,"body":"(Charlie) Are his neurologic"},{"speaker":"And the options are","startTime":379.39,"endTime":382.874,"body":"abnormalities likely to improve?"},{"speaker":"And the options are","startTime":382.884,"endTime":385.518,"body":"(Cathy) Stopping the glucose"},{"speaker":"And the options are","startTime":382.884,"endTime":385.518,"body":"and adequately supplementing thiamine"},{"speaker":"And the options are","startTime":385.518,"endTime":387.14,"body":"should stop the progression."},{"speaker":"And the options are","startTime":387.14,"endTime":389.246,"body":"And hopefully,"},{"speaker":"And the options are","startTime":387.14,"endTime":389.246,"body":"his acute cognitive deficits"},{"speaker":"And the options are","startTime":389.246,"endTime":391.466,"body":"will improve during the hospitalization."},{"speaker":"And the options are","startTime":391.466,"endTime":394.262,"body":"But the cerebellar changes"},{"speaker":"And the options are","startTime":391.466,"endTime":394.262,"body":"will require long-term therapy"},{"speaker":"And the options are","startTime":394.262,"endTime":396.086,"body":"and may not be fully reversible."},{"speaker":"And the options are","startTime":396.086,"endTime":397.53,"body":"And the other thing that he'll need"},{"speaker":"And the options are","startTime":397.53,"endTime":401.026,"body":"is, obviously, alcohol cessation"},{"speaker":"And the options are","startTime":397.53,"endTime":401.026,"body":"counseling as well, long term."},{"speaker":"And the options are","startTime":401.026,"endTime":405.118,"body":"(Charlie) Great. So, the teaching point"},{"speaker":"And the options are","startTime":401.026,"endTime":405.118,"body":"of this case is that chronic alcoholism"},{"speaker":"And the options are","startTime":405.118,"endTime":409.402,"body":"can result in thiamine deficiency"},{"speaker":"And the options are","startTime":405.118,"endTime":409.402,"body":"and the Wernicke-Korsakoff syndrome"},{"speaker":"And the options are","startTime":409.402,"endTime":412.501,"body":"which can be precipitated"},{"speaker":"And the options are","startTime":409.402,"endTime":412.501,"body":"by glucose administration"},{"speaker":"And the options are","startTime":412.501,"endTime":415.524,"body":"without prior or concurrent"},{"speaker":"And the options are","startTime":412.501,"endTime":415.524,"body":"thiamine replacement."},{"speaker":"The classic symptoms are","startTime":415.524,"endTime":420.74,"body":"ophthalmoplegia, ataxia, and confusion"},{"speaker":"The classic symptoms are","startTime":420.74,"endTime":422.999,"body":"and they can also include"},{"speaker":"The classic symptoms are","startTime":420.74,"endTime":422.999,"body":"long-term memory loss"},{"speaker":"The classic symptoms are","startTime":422.999,"endTime":424.985,"body":"which is not always reversible."},{"speaker":"The classic symptoms are","startTime":424.985,"endTime":427.67,"body":"(Cathy) To learn more, you can read"},{"speaker":"The classic symptoms are","startTime":424.985,"endTime":427.67,"body":"about this in \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"The classic symptoms are","startTime":427.67,"endTime":430.045,"body":"on Cardinal Manifestations of Disease."},{"speaker":"The classic symptoms are","startTime":430.045,"endTime":431.711,"body":"♪ (music) ♪"}]}