Men's Health Review and STIs

0:00:05.5 Walden: Alright, good evening everyone. We are live, so of course, as always, I am going to just kind of wait a few minutes and let everybody load on in here. I know you guys are out there because you guys were emailing us and asking us, “Are you ready and what’s going on?” So just going to give it a minute for us to prep and get settled, so while we do that, let’s kind of check in with each other, so I’ll check in with y’all and let you know how things are going, so things are going really great at LOS, we have a lot of things in store for you. We are really excited, really excited about the next… Gosh, six months, year even, planned for you guys and planned for you, for you as the NP collective, so it’s gonna be really, really exciting, so I can’t wait to share that with you, and I’m gonna share more details towards the end of this. When we are done with Liz. So first and foremost, let me… Let me get myself together because I don’t even do that, guys, as you guys are loading in there, and I see we’ve got some folks kind of joining in, so that is perfect. That is perfect.

0:01:20.8 Walden: Alright, so with that being said, we’re gonna go ahead and get started because I’m always respectful of your time. So hey guys, it is Professor Walden, and today, I have been talking this up and I have been prepping you guys for this. It is lab day with Liz, I am so excited so Rohr Liz with us today. If you follow her on IG, I do. So hopefully you guys will all run out if you are not, and you will follow her. She is like the lab guru of the NPs, so I am so very excited that she decided to grace us with your her presence, but I’m gonna read a little background for you just to kind of let you know what’s been going on. So Liz… Hopefully, I’m saying this correct. Is it Liz Rohr? So Liz Rohr has been a family nurse practitioner and primary care provider in the federally qualified health center setting since 2015. She’s also the founder and CEO of Real World NP LLC, an educational company for new nurse practitioners in primary care. She’s been a nurse since 2009, she obtained her BSN from Boston College and her MSN from UCLA.

0:02:31.0 Walden: I went to USC, so… [laughter] She’s passionate about inclusive care, mentorship, teaching, and particularly enjoys women’s health and GI topics. When she’s not pouring over textbooks or crafting educational videos, you can find her snuggling her German Shepherd mix Charlie or playing with her daughter Amelia, so super sweet. So let’s go ahead and bring Liz on. Hey Liz how are you? 

0:03:00.5 Rohr Liz: Thanks so much for having me. And I apologize again about the delay for everyone who’s here live, I appreciate your patience, it was miscommunication on my part, so.

0:03:06.0 Walden: Right. No it’s perfectly fine, trust me, they’re gonna start pouring in and they’re already here so… As you could see. [laughter] But we are very excited, when we mentioned you before they… Well, actually, I didn’t mention to you. We just said labs. We said… That’s all we said. So they were very excited. So you and I both know that as a new nurse practitioner labs can be scary.

0:03:31.0 RL: Oh yes.

0:03:32.2 Walden: And it is, it’s just a scary thing because while we are taught kind of the basics and things like that, we’re not really given that, that deep dive that we probably feel we need once we kind of enter into this NP world. And so I’m just excited that you’re here just to at least start approaching that topic with us. And we’ll probably do some other stuff together, you guys, so calm down already. I know you’re gonna ask those questions. [laughter] Alright, so again, always being respectful. I’m gonna add Liz’s PowerPoint up here. And so we’re gonna go ahead and I’m gonna let you get started. Alright? 

0:04:15.6 RL: Awesome.

0:04:17.5 Walden: Alright.

0:04:19.2 RL: Cool, so I think… Let me see if it works… Okay, I’m gonna toggle, I can’t see… I’m not gonna be able to see my face on the screen, but hopefully the camera works out well. Anyway, I’m gonna toggle back to my screen share, but… Thank you so much for having me. I’m really, really excited. When I was a new nurse practitioner, I was so overwhelmed by labs, and I think the context was that I started in my job and I had a full inbox full of lab results that I didn’t even order that I was responsible for. And the approach that I took was really kind of like a hacked approach, is how I describe it, where it’s kind of like… I had a high calcium level, I went into up to date, I furiously looked into it, and then I just did my best from there, but I always felt this really unease about…

0:05:08.9 RL: Did I get the whole thing? Did I fully understand what I was doing? It was kind of like I was flying by the seat of my pants, so when I made this company, the first… I asked the people what they wanted to hear about and it really aligned with what I wanted, which was lab interpretation, that was the first thing that I needed to do as a new grad that I was so overwhelmed by. So anyway, in this presentation, I would love to tell you all the things that I know about lab interpretation, but I actually have a full course that’s over eight hours, almost nine hours long, so I can’t possibly fit that in, but I’m gonna really focus on the main mistakes that new nurse practitioners make and what to do instead, so the main pitfalls to watch out for.

0:05:54.3 RL: And then I’ll also be talking about two of the most common labs in primary care, CBC and LFTs. And looking at the foundations of each of them, and this is actually directly from my course, and so when you understand the foundations, you understand what the labs are showing you, it is a lot more helpful in terms of the next steps of differential diagnosis and the next plans of care and the algorithms of management, things like that. So yeah, and then I also just wanna mention before I jump in, is that I have a whole YouTube channel that has a lab interpretation playlist on it that has case studies of other labs that I don’t cover tonight that are really common in primary care, and that’s all free, that’s all online. So definitely check that out if you’re struggling with labs in primary care, and hopefully those can be helpful as well. So anyway I’m gonna toggle to my other screen. So, okay, so here are the main mistakes of lab interpretation.

0:06:53.8 RL: The first one is not knowing how to triage labs, which ones are the worst ones to worry about and which are just kind of fine? Not really fine, but basically the context is when you open up your inbox, there’s all these bright red or bright blue like high, low, deal with this lab exclamation point, but the most important thing right out of the gate is to know off the top of your head which labs of the ones that were ordered or that you’re ordering are the ones that you need to freak out about. Because as a new grad, you wanna freak out about everything, but I’m here to tell you that there are certain ones to freak out about and certain ones not to.

0:07:35.5 RL: So the DIY way to go about this is to have… If you were to like this is the approach that I take to lab interpretation that I recommend people take is that there are values for each lab segment of when to worry and when not to worry. And you can do this, you can look at, for example, hypercalcemia, and what is the worst case scenario with hypercalcemia? When is that lab value of when to freak out? Same thing with LFTs, for example. LFTs are a really great example, which I’m gonna get into, but basically nurse practitioners will see something that’s slightly out of range and kind of panic. When the reality is when it comes to LFTs specifically, you have a huge buffer, and this is again something you can find in a resource like up-to-date where you can say like, “Okay, with LFTs there is mildly elevated, moderately elevated and severely elevated.” And actually the severe like red flag when to worry and freak out alarm bells is actually way outside, like in the thousands range versus in the hundreds range. Versus something like potassium, where there’s… The reference range is about 3.5 to 5.0-ish, if you get to six, that’s a red flag, right? 

0:08:57.8 RL: So that’s the first place to start, is what are the labs to worry about, and then the next step is when are the when to worry values for each lab? Bare minimum, like you could just bare minimum do that so that you know when you open up your desktop, you’re like, “Okay, potassium of 6.5, I’m gonna freak out. Sodium of 134 is like one point lower ’cause the reference range is about 135 to 145, approximately. That’s okay.” You still wanna pay attention, but you don’t wanna freak out… Right, and so just like, I guess quickly off the top, the ones that are most concerning are sodium, potassium, there’s a bunch, but I think those two for sure are the most concerning. But yeah, that’s kind of like a very quick entry point of like, hey, I don’t really know the full work up for high calcium, but I know not to freak out until it gets to like symptoms at 11.5 to 12, ’cause the reference range is about 10. So that kind of thing, but yeah, so triaging the most important ones to look at. If you can gain that skill of just knowing like, “Hey, this one first, this one next, this is okay, I still need to address it, but I don’t need to freak out.”

0:10:07.8 RL: That’s the first place to start. So the next one is ordering labs that they don’t know how to interpret, and actually I just wanna pause for a second and please, I’m practicing really hard, slowing my speech down. But if I’m talking too fast, please Latrina, you can interrupt me at any time. And I can’t see the chat. So just let me know if I’m talking too fast. Is that okay? Am I doing okay? 

0:10:34.9 Walden: You’re doing great.

0:10:37.8 RL: Okay, so, and I say this with so much love and compassion because I was the new nurse practitioner that I would look at it, I always say up-to-date because I’m obsessed with that resource, any resource that you’re looking at is totally cool, but whichever one you do, I basically, I would look at an algorithm and I’d be like, Oh, hypercalcemia, for example, I’m gonna order a PTH, ’cause that’s a part of the algorithm. I’m gonna order vitamin D, I’m gonna order all these different labs, I’m gonna order a PTH RP, which again, is part of the work up, just as a side note, like… You need to know what that means. I think that the main thing I just wanna caution new nurse practitioners, especially, is that we don’t really know what we’re supposed to know and what’s okay not to know, and so just putting your ego aside and just being okay with not knowing what PTHrP is and that’s okay.

0:11:32.1 RL: And it’s okay to ask, and it’s just important not to order a test that you don’t really know what it means and how to interpret it yet, because you can open up a can of worms. Like fecal Calprotectin, for example, is like another lab where it’s like, you’re looking at blood in stool, for example, that’s kind of like a zebra lab that is potentially part of the algorithm of work-up, but a GI specialist may or may not order that. So I guess the moral of the story is just like, check yourself and don’t let your ego get in the way of wanting to prove to yourself and to others that you know what you’re doing because you do, but you’re also new and that’s okay. But also trying your best to be observant of the scope of primary care, because if you look at a resource, for example, up-to-date, it’s gonna give you the algorithm from A to Z. But primary care, and depending on the culture of your current practice might only be A-F.

0:12:29.4 RL: So it’s really important to just kinda check yourself with that, and the kind of keys for that are asking, looking at the referral notes that you get from specialists, asking colleagues, time, unfortunately, I wish I could speed that up. Hopefully I can help with that, but… And knowing what resources to look at and then just kind of trusting yourself of like, “Okay, I’m not quite sure, and it’s okay.” And then the other thing, the last mistake that I see for new grads is kind of like a too cookie-cutter approach, and… I love algorithms. I think that they’re very, very helpful and they’re there to support us, but at the same time, we have to be careful about really understanding them as well. So one example I wanna give is about low testosterone, so patients come in all the time saying, “Can you check my hormones, please.” Or specifically cis male patients say things like,” I’m fatigued. My libido is low, I really need to check my testosterone.” And maybe they’re 30 years old, right? Maybe they’re 50 years old. There’s a very beautiful simple algorithm for testing of testosterone fasting in the morning between 8:00 and 10:00, and repeated on two to three occasions…

0:13:44.3 RL: Oops. No, it’s okay. Oh, I’m sorry. I’m at the office. No, no, I’m good, I’m good. Yeah, I’m good. Thank you. Sorry I’m at the office. But any way for low testosterone, it’s very beautiful and it’s very easy to interpret and to treat. However it’s really important to know that actually most of the time with low testosterone, the answer is, no, I’m not gonna check it for you, because you have to understand the risks and the benefits. Who needs a low testosterone checked? Who needs treatment for it? What are the risks and benefits of treatment? And looking at that whole patient, ’cause I think that we’re so eager to simplify things that we rely on those algorithms of like, Oh okay, one, two, three, four, five, check. So I think it’s just really important to stay cautious, it’s a fine fine balance, so I think, just being mindful that not everything is as straightforward as we think it’s gonna be.

0:14:44.0 RL: So here are some key points for interpreting labs in general, this applies basically for any lab you interpret for the most part, and then this is also ties into some of the pitfalls I see for new grads and all of these pitfalls, I’m speaking from personal experience and with so much compassion, so there’s no judgement here, I’m just trying to help you avoid the mistakes that I made. So basically what happens with new grads, what I did, and I still see people doing is that I have this calcium of 10.9, what should I do? Like, okay, take a step back, let’s ask some questions. And so following these key points and this algorithm of approach will help you, first of all, explore the lab, but then also present it to your colleague when you’re not sure what to do. So number one, do they have symptoms? 

0:15:32.2 RL: Right, so if they have a high calcium of 10.9, do they have any symptoms at the time that you ordered it? Any at all, even if you don’t know what the symptoms are of hypercalcemia, did they have any symptoms? Right, which is like the sub-segment of that question is, why did you order it in the first place? Did you order it because it was like a screening lab, or did you order it because they were having symptoms of some kind, because if they don’t have symptoms, and it was an incidental finding, meaning, you ordered it and it was just there, it’s way less likely to be dangerous, you can put your mind at ease a little bit more just with those two questions.

0:16:11.1 RL: This is super, super, super important. Is this brand new? Or is it old? So what previous labs do you have to compare to and is it the same? Worse or better? Because if you have a white blood cell count of 15… Oh my God, that’s super high. The normal reference range is about 4000 to 11,000, so if you have 15,000, these are all conventional units in the US, I have some people in my audience that are from Canada and have different units, but this is all US units, like white blood cell count of 15 or 16 last year, and then 15 today. And they already saw hematology and you already have a series of differentials to compare to, you don’t have to freak out as much. Same thing with LFTs, I had a person a couple of months back who had… Her LFTs were in the 200 to 300s, and I was like, “Oh my gosh, that’s really concerning,” but it’s like she didn’t have any symptoms. I had some to compare it to, she had known fatty liver with celiac disease that was undergoing treatment by GI.

0:17:11.5 RL: Right? And so I didn’t have to freak out. Even now… Even now, after several years, I was like, “Oh my gosh, what do I do about this right now?” It’s like, Okay, it’s okay, it’s fine. But you still have to address it, but we don’t have to freak out. Basically, I’m just helping you not freak out about labs. So the other really key point for basically any lab is that rapid increases or decreases cause more symptoms and are more serious. So if your calcium… Again I keep going back to calcium, it’s just on my mind. But if you have a calcium that’s normal, and then you check it three months later and it’s at 13, like top two differentials for hypercalcemia are hyper parathyroid-ism and cancer. So if you are looking at an increase of from 10 to 13 in three months, likely they’re gonna have symptoms and likely it’s something more dangerous, it could be a cancer, versus it’s been 11, 11, 11, 11, 11 since the last 10 years, and she’s already following endocrine, right? For hyper parathyroid-ism, we know that, right? And then so triage. So I think that this takes time and it takes a lot of…

0:18:17.8 RL: All of the learning of the labs take time and you have to put in the effort of reading and learning about things and seeing it over time, but you also… Like another kind of hack entry point is like, what is the worst case scenario for calcium? What is the worst case scenario for LFTs? And spoiler alert, and we’ll talk about this, but it’s basically… LFTs is liver failure. It’s like the one main worst case scenario. Right? So are they jaundiced? Abdominal pain? Vomiting? Or are they not? It’s a little more nuanced than that. But what is the worst case scenario for low platelets? A brain bleed. What is the worst case scenario for hyponatremia? I was like, what is low sodium? Hyponatremia is brain swelling. So just like a hacked way of like, even if you just looked all those things up and had a little note of like… I mean spoiler alert, this is in the lab course but that’s a hacked way of doing it yourself is like you just go through and like what is the worst thing here, how would I know? What would I look for? That kind of thing. Okay, so how are we doing? I wanna check in ’cause I do talk a little bit fast. Everything okay, Latrina? 

0:19:20.1 Walden: Yeah. You’re doing okay.

0:19:22.0 RL: Okay. Anybody have any questions before I jump in? I’m gonna talk about CBC and LFTs.

0:19:29.8 Walden: Okay, I think they’re good right now, I’m sure as things come up, I will jump in there with you.

0:19:35.5 RL: Awesome, awesome, cool. Okay, so these are foundational pieces to interpreting CBCs, and so if you understand what you’re looking at on the actual CBC panel, it can help you go into the differential diagnosis and the next steps of investigation and treatment. Okay, this is super important. Like first, right off the bat. So those key points, questions that I was talking about, like white blood cell count of 15, for example, all of those questions that I talked about, is this new? Do they have symptoms? Why did you order it? What is the worst case scenario in the situation? The next kind of step in addition to those pieces for CBC specifically, is, is it one element or is it multiple? Are we just looking at high white blood cells, or is it high white blood cells, low platelets, high hematocrit and hemoglobin, etcetera, etcetera? Because that whole picture is really informative, and I’ll talk about that in a second, the kind of easy way to look at CBCs.

0:20:40.9 RL: The next most important thing is what do the cells look like, and I feel like I say this all the time. You basically can’t do anything with an abnormal CBC without a differential, so if you have anything abnormal on a plain CBC, you have to add a differential. The differential, I’m gonna talk about the differential, the peripheral smear, that kind of stuff in a second, but basically that tells us what the cells look like and do they look normal or do they look like scrambly messed up? Very technical term, I’ll talk about that more in a second though.

0:21:12.3 RL: The other component of a differential is looking at the different cell types as well as the absolute counts. I’ll talk about this more in a second. Okay, so what are the components of a CBC? White blood cells, those are the number of leukocytes. Hematocrit and hemoglobin is the concentration in the plasma of the protein carrying oxygen. And a note I wanna say about hematocrit and hemoglobin is that when it comes to hematocrit, it’s a percentage, it’s a calculation, whereas hemoglobin is typically directly measured by the machine, so that it is a little bit more accurate than looking at the hematocrit and hemoglobin. So if you have to choose one, then pick the hemoglobin.

0:21:55.3 RL: If you hear people talking about, “Oh, the hemoglobin was seven,” or “The hemoglobin was 10,” that’s kind of why they’re choosing that instead of the hematocrit. Red blood cells are the actual number of cells, and it’s actually important to differentiate hematocrit, hemoglobin and red blood cells, because sometimes there are cases where the hematocrit and hemoglobin are low. No, they can either be low or normal, and the red blood cells can be high. And that can be in the case of a thalassemia trait, where somebody has tons of tiny little red blood cells or a little bit of anemia that’s stable. So, that’s important to look at the RBCs specifically.

0:22:36.0 RL: MCV is the red blood cell size, and so you’re looking at are they large size, small size, normal, expected. RDW is like the hidden champion of the CBC. Clearly, I’m obsessed with labs now, I used to hate them and be terrified, just so you know, so you can feel this way too, eventually, if you would like. Red cell distribution with the RDW is one that not many people are comfortable with, but really it’s very helpful because what it’s looking at, it’s a percentage, and the typical percentage is around 14 or 15, and basically what it’s telling you is that the red blood cells that exist today compared to the ones that are already in your body, it’s talking about the distribution of the widths.

0:23:28.1 RL: And so what is the size difference between them? As you know, the red blood cells turn over about every 120 days, and so if the ones from today compared to the ones from three months ago are smaller and smaller and smaller, the RDW is gonna increase, and what that tells us… It’s especially relevant in anemia, so if your hematocrit and hemoglobin is low and the RDW is high, it’s meaning that all of the cells are getting progressively smaller, which happens in iron deficiency anemia, versus another type of anemia, like anemia of chronic disease. It’s not like it’s progressively getting smaller and smaller, and worse and worse and worse. So, the RDW is really helpful. If the RDW is high in comparison to a low hematocrit and hemoglobin, it is more suggestive of an iron deficiency type of situation, so I super love it. It can take a little while for that to sink in, but it’s super helpful. Platelets repair injury to the vascular epithelium, they’re responsible for blood clotting, an important note about platelets that I wanna make is that they are an acute phase reactant similar to an ESR CRP, in that when there’s inflammation, the platelets will go high, and that can be a temporary reaction.

0:24:42.8 RL: And so, I just wanna point that out because they can fluctuate a lot and it isn’t necessarily a huge problem if platelets are high, you still wanna investigate it, but just know that that’s a thing. The MCHC and MCH, I actually collaborated with the hematologist to put my resource together, and it’s basically a throwaway lab, it’s just not very useful, it’s the average hemoglobin per red blood cell, but quite honestly, in the differential diagnosis algorithm management, it’s the same. It’s like, doesn’t mean anything. Okay, do we have any questions? I just wanna check in. Doing okay? 

0:25:21.9 Walden: You’re doing great. No questions. I think they’re all just taking it in.

0:25:26.6 RL: Okay, if you want me to slow down too, then I totally, totally will.

0:25:31.2 Walden: No, you’re fine.

0:25:34.6 RL: Cool. Okay, so, with the differential and peripheral smear, basically, when you order a diff, a CBC with differential, it’s an automated breakdown of the components by a machine into the different cell types. It’s looking at neutrophils, basophils, lymphocytes, etcetera, etcetera, and it can also detect abnormalities in size or shape, as well as, like I said, the types of white blood cells.

0:26:01.1 RL: However, a peripheral smear is like the same thing as the differential, only it’s a physical person who’s taking the blood on a slide underneath a microscope and looking at it to verify what has been reported in the differential is the same, so if you had somebody… For example, I’m gonna go back to high white blood cells again. One of the worst case scenarios for high white blood cells is like a leukemia or something, some sort of hematologic malignancy. And so if you have a high white blood cell count of 25 or 50, for example, you’ll do the differential, it’ll break down this percentage of neutrophils, this percentage of lymphocytes. Oh, and then there are blasts, there are lymphoblasts.

0:26:41.9 RL: And that might say that on the differential, but it might not. That’s when you order a peripheral smear as an add-on at the lab, and then usually a physician will look at it and say, “Yep, there’s lymphoblasts on here that is confirmed,” or it will just say confirmed, which is so lackluster of a result, but sometimes… Typically, that’s what that means. If you’re looking at the algorithm of work-up for an abnormality for the CBC. So, either your lab will automatically add that on. For example, a patient who had a white blood cell count of 60, they automatically added on the peripheral smear because the lab had a process to make sure that that was obtained because that’s a dangerous situation. So, continued.

0:27:25.0 RL: So like I said, there’s neutrophils… Oh, I’m gonna talk about this left shift thing, and this comes up a lot. So, bands are immature neutrophils or immature granulocytes, and if you’re looking at a high white blood cell count of 25, for example, when you look at that differential and it says percentage of neutrophils, percentage of immature neutrophils, granulocytes bands, whatever your lab says. If the most predominant type of white blood cell is neutrophils, immature neutrophils or bands, that’s called the left shift, that’s called Bandemia, and that, in that particular case, that might be consistent with an acute bacterial infection.

0:28:05.2 RL: But aside from just describing that phenomenon, that’s it. I mean, I think that people get thrown by that terminology, but that’s basically the moral of the story there. So, lymphocytes, those are things like CD4 cells, CD8 cells, natural killer cells. Eosinophils can be a grab bag of a couple of different things, but it’s typically in a primary care setting, more of an allergy-related thing, potentially parasitic, potentially some sort of heme malignancy process, but something to investigate if that’s the most predominant one, the highest percentage.

0:28:43.0 RL: Monocytes are those macrophages, antigen-presenting cells, and basophils are the smallest percentage, they’re similar to mass cells, they have histamine, they attract other cells to the area. And then one of the things, actually I think it’s on the next slide. Well, I can say it here too, but basically, you should really never see monocytes or basophils be the predominant percentage. Again, if your white blood cell count is 25, basophils and monocytes are only like 1%. If it’s… I can’t remember actually off the top of my head, monocytes, I think it can be up to 10%, but if you have 30% monocytes or if you have 10% basophils, you wanna think hematologic malignancy, potentially, you should never see those be super high.

0:29:25.1 RL: And then the other thing to keep in mind is that your lab might automatically do this or they might not. There’s an absolute count. So again, if you have a white blood cell count of 25, it might say neutrophils are 75%, but what is that absolute count? And you can just Google this, it’s like MDCalc is a really good one, where you basically put in the white blood cell count total, the percentage of the neutrophils, and it will tell you how many actual cells that means, because the absolute counts helps with your decision tree algorithm. And you can really only get absolute neutrophil, lymphocyte, and eosinophil counts, you can’t get that calculation for the other ones.

0:30:06.2 RL: Okay, couple of peripheral smear red flags or differential red flags, this is not comprehensive, but this is basically what you need to know for primary care. Anisocytosis is a size variant, it basically just means the size of the cells are all different. For example, iron deficiency anemia, the cells that are being produced now are a lot smaller than the previous ones. Anisocytosis just means they’re all different sizes, and it’s not necessarily a red flag, but you definitely wanna think about that, like why are they all different sizes, what is the reason potentially for that? Don’t ignore it, but don’t freak out.

0:30:39.4 Walden: Poikilocytosis means a shape variant, it can be a red flag and it warrants evaluation. Basically what it means is that the cells that you’re looking at could be all abnormal shapes, they could be shredded, they could be spherical, they could just be a number of different shapes, and depending on each of those is a different tree of decision-making for algorithm of workup. However, blasts are never normal, anything that ends in blasts, lymphoblasts, myeloblasts, those are hematologic malignancies, and you need to act on those immediately. Don’t forget those.

0:31:19.6 Walden: The other thing, like I said about basophilia, like basophils, if you have a lot of basophils that’s not expected, and so that could potentially point to bone marrow dysfunction, like the bone marrow itself is like freaking out, and so it’s producing all these cells that shouldn’t be there. You definitely wanna investigate that one as well. Again, same thing with monocytes, if it’s a predominance of monocytes, maybe the bone marrow is freaking out because it’s a malignancy, so you definitely investigate that.

0:31:49.6 Walden: Smudge cells are another kind of more common one in primary care. I don’t see this very often, but these are the most common things I’ve seen for peripheral smears, it could be suggestive of a chronic leukemia; however, chronic heme malignancies are not really an emergency, and that was the moral of the story with the hematologist that I worked with, it was just like, “You know what? Don’t freak out, it’s okay.” So just don’t ignore those.

0:32:14.7 Walden: Schistocytes again, this is potentially something you might find and it points to cell destruction, so just think about why is that happening? And again, more things pointing to bone marrow dysfunction, if you remember back to school, when we did the stem cells of what was released from the bone marrow, and that whole tree of how the cell is developed. Metamyelocytes and myelocytes were precursors. And so they’re like pre-cooked cells, so if you have a bunch of those on the peripheral smear, it means that the bone marrow is not working and it’s releasing undercooked cells and you have to look into that.

0:32:55.6 Walden: Okay, so that… Actually, do we have any questions first? How are we doing? 

0:33:01.1 RL: There are questions.

0:33:02.5 Walden: No questions, that’s absorbing, okay. This seems very jargony, but if I can really simplify CBC results for you, there’s kind of like two categories. Is there some… And I’ve talked about this a little bit so far. Is there a bone marrow problem, is there something wrong with the bone marrow that it’s freaking out, it’s making all these weird looking cells that are shredded that are malformed, that are undercooked, or is there something reactive going on? Which we’ll talk about in the next slide. What is the difference between that? 

0:33:35.5 Walden: So something reactive. So basically, the bone marrow reacts to something in the body, typically it’s some sort of infection, acute infection, like bacterial, viral, some sort of inflammation, whether it’s acute or chronic. Things like rheumatoid arthritis, Crohns, etcetera. Smoking can cause things. And so before I get into the malignant thing, the moral of the story with this is that whatever algorithm you’re looking at for whatever component, or white blood cells, platelets, hematocrit and hemoglobin, they typically can fall into these two main categories. It’s reacting to something, or it’s malignant. That’s not across the board, but typically speaking, that’s why it has problems.

0:34:27.9 Walden: So again, malignancy can point to something wrong with the bone marrow itself, so something like a leukemia, myeloproliferative disease, CML, ALL, stuff like that. And then a couple of other causes. Medications, you wanna think about those. There are some hereditary things, this is a very overview of like… This is just the general conception of way to think about it, and then as you get into each of them, whenever you’re presented with one, you just have to go down that tree of like, “Okay, here are the next steps.” This is just like the 50,000 foot view.

0:35:01.2 Walden: People without a spleen. That’s important to keep in mind. Physical stress, like some sort of trauma, car accident, stuff like that, exercise, and then there’s some very rare endocrine problems, but this is not for you to memorize these things, but it’s just to have that general perspective of like, okay, if there’s an abnormality, is there something actively reacting in the body? Is there some sort of heme malignancy, is it not those two things? What are the next steps to take? And it depends on what lab you’re looking at, but typically speaking with CBCs, that’s like the general pathway.

0:35:36.3 Walden: Okay, I’m gonna hop into LFTs. What are we thinking? Any questions? 

0:35:41.7 RL: I know exactly what they’re thinking, and I’ll tell you at the end.

0:35:47.2 Walden: Are they thinking this is overwhelming and too much information? 

0:35:50.6 RL: We know that, but [0:35:51.5] ____ I’ll tell you, trust me, I know exactly what they’re thinking.

0:35:57.2 Walden: As I’m going through this, I’m like, “This is kind of a lot.”

0:36:00.5 RL: No, you’re fine though.

0:36:02.1 Walden: Okay. Well, hopefully at the bare minimum, so that’s like all the stuff… That’s a general 50,000 foot view of CBCs. But I guess the moral of the story so far of what I’ve talked about is like, what are those key points to keep in mind for any lab. The main mistakes, just be cautious, don’t be too cookie cutter, try not to order labs you don’t know how to interpret quite yet or get help, take a look at the specialist notes, referrals and… Yeah, and then the other… The main things about the questions to ask yourself, the key points, ask those every time, for every single lab.

0:36:41.3 Walden: Bare minimum, if you can do that and understand that a CBC with diff, understand what that is, you’ve succeeded, right? Just those two alone are enough. But seriously, the key points of the labs of like, “Is it new? Is it old? Do they have symptoms? Why did you order it?” That will carry so much for you in terms of your stress level and what steps to do next and knowing to just calm your body down of like, “It’s okay, I can do this, they’re not gonna die right now, it’s okay.” Or they might, and then you know that, but you know the red flags to watch out for.

0:37:13.3 Walden: Okay, so I’m gonna come into LFTs and hopefully this… Just understanding what these labs are looking at will help you feel more comfortable with them. Okay, a really important point about LFTs, the way that basically everybody talks about it is, what is the upper limit of normal? So, the reference range approximately is like 10-40, it’s like textbook, but it depends on your lab, but basically the upper limit of normal is 40, if the normal range is 10-40, so how many times the upper limit of normal is like… Okay, the AST and the ALT are 160. Oh, sorry, that’s for ALT and AST, that’s the reference range for those two.

0:37:57.1 Walden: So if the ALT is 160, that’s four times the upper limit of normal, and the reason that’s so important is that, that calculation will help you triage mild, moderate or severe elevations, which have a lot more fire under your bum to act on faster. But if you can just remember the way that people talk about LFTs, is, what is the upper limit of normal? That will really help you, especially for new grads who look at LFTs, and they’re like, “Oh my gosh, what do I do? It’s slightly abnormal, I’m very uncomfortable.”

0:38:32.0 Walden: I wanna check all the labs right away, I wanna have them come back in right now. It’s like, okay, just take a deep breath. How many times the upper limit of normal are we talking? Like two or like 15? Because 15 is truly severe. That’s like in the thousands, right? So just keeping that in mind, like first step, how many times the upper limit of normal is it? Same thing with CBCs. There’s much more information to be had if you’re looking at multiple elements versus one. So when it comes to LFTs, there’s AST… And I’m gonna talk about all these in the next slides. AST, ALT, bilirubin, protein, albumin, that’s… Alkaline phosphatase. Those are the main ones. And so if you have a high AST by itself, or a high alkaline phosphatase by itself, is different than if you have multiple. Right? So this is again, just high level, first step approach aside from those key points, next step is, How many times the upper limit of normal, and then how many elements are there. And that’s just the basic information to help you help yourself, but also to present to a colleague if you need help.

0:39:43.1 RL: The other thing to keep in mind, just as you are approaching the LFTs is like, do they have any comorbidities that may be of interest, right? Do they have CHF, do they have diabetes, do they have hypertension? Just keeping that in mind, ’cause that can influence the decision tree. Right? So I wanna talk about the components of what you’re actually looking at and what it means. I found this very empowering, to be like, Oh okay, I know exactly what I’m looking at, and it helps with… The thing that I love about LFTs is that, and I love GI in general, but it’s functional, I can picture what’s happening. Versus CBC, it’s like just one bone marrow sitting there. Versus the liver, the gallbladder, etcetera, etcetera. So anyway, ALT is actually an enzyme that’s inside liver cells, predominantly liver cells, and so when those cells are injured, it releases the ALT, AST. AST also an enzyme in the liver, but also is specific to bone, muscle, brain and kidneys. And the reason I say that is because if you’re looking at these labs, ALT is much more specific to liver, and I’ll talk about that more in a second. But outgoing phosphatase, I actually hated, and isolated alk phos elevations are like every single day in primary care, but if you understand it, you’re like, Oh, this is…

0:41:06.6 RL: I’m not worried about this anymore. But basically it’s an enzyme of the liver, but also the bones. Those are the two predominant sources. And basically what happens is that it’s released with the pressure on the biliary tree. So when you see the alk phos, just think about that functional, like what’s going on with the biliary tree, the bile duct? Is there something pressing on it, is there something stuck in it, or alternatively is it coming from the bones, in fact, and it’s not actually coming from the liver, right? Which I’ll talk about in a second. But yeah, is it inside versus the outside, is it incoming from within the biliary tree or is it pressure on the biliary tree from a liver mass? Bilirubin comes from the breakdown of hem. So this one can be very confusing to wrap your head around, but basically hem gets broken down, and there’s indirect and direct bilirubin. So indirect, also known as un-conjugated, which makes it a lot more confusing, but basically the hemoglobin is broken down in the serum, traveling along, bound to albumin, goes to the liver. I think about it as indirect, meaning that it’s not just…

0:42:27.9 RL: It’s not just bilirubin by itself, it’s bilirubin bound to albumin, so it’s like going together. Gets to the liver, that gets broken apart, the direct/conjugated bilirubin exists in the liver, it goes to the small intestine, and then it gets excreted in the stool, predominantly, but also some goes into the urine. And the reason it’s important to understand this is that you’re not just looking at bilirubin and memorizing something, you’re like, Oh, I know what bilirubin is now, I know the process of bilirubin. So one of the first steps with interpreting bilirubin is to look; is it total bilirubin? What is the indirect and what is also the direct? Right, and then you can look and see, Is it direct that’s higher, is it indirect that’s higher? And a general rule of thumb, if direct is the higher one, they’re a lot more sick and you wanna look more into that. And that’s kind of like a very broad rule of thumb but, typically speaking, if there is a liver problem, the direct is gonna be higher, versus indirect could be from something not great, but it also is just less serious than the direct one being high.

0:43:40.1 RL: I’d love to go on and on about bilirubin, but I’ll keep it at that. GGT is also another liver lab. It’s not on the LFT panel, but it’s an enzyme in the liver and the biliary tract, it’s also in some of the other organs as well, kidneys, seminal vesicles, pancreas, spleen, heart, brain. Just keeping that in mind, that it can be from other sources, not to memorize that last part. But GGT is specifically important when you have a high alk phos, because that can verify going back to the source for alk phos, there’s liver and there’s bones, so if you’re trying to verify if it’s from the liver, you can order a GGT to help you see that. That’s getting a little bit into the weeds of algorithm of workup, but just high level GGT is another potential enzyme to look at. Okay, so people talk about LFTs as liver function tests, when in fact it’s not really that. Those are just talking about kind of like injury. I mean, bilirubin is a little bit functional, but if we’re talking about how the liver is actually working and if it’s doing its job, albumin is actually one of the markers you wanna look at because it’s synthesized in the liver.

0:44:50.8 RL: Low albumin can be from a number of things, but that’s a potential source, is that the liver is not doing well, so the albumin is low. PT INR, all of the clotting factors except factor eight are made in the liver. So if your INR is always… High, I always get those messed up… But if the INR is high, the PT INR is high, it’s showing prolonged clotting time, which means that the liver is not really working well. Bilirubin, plus or minus, like I said, if it’s the direct version, and it’s not being cleared by the liver into the intestines, into the stool, into the urine, it’s gonna get kinda backed up, and that’s why the levels are gonna be high in the serum. And sodium, this is just like, again, fun fact, very high level, if we’re actually looking at a patient… The reason this is practical is in the new grad situation, it’s like, Oh my god, the LFTs are high, I’m gonna freak out; I don’t know if I have to deal with this right away, I don’t know what to do. It’s like, Okay, take those other steps we talked about, but then also if someone really had a malfunctioning liver, you would see other things, like low albumin, high INR, and their sodium might be low.

0:46:01.8 RL: There’s something called a MELD score, if you have a patient with cirrhosis. Which is just kind of like, fun fact, I probably should have taken that out of here ’cause it’s just getting on a tangent. But looking at that whole picture, right? 

0:46:14.4 RL: I’m a professional nurse, so I love this slide. But basically, this is the same thing, high level, looking at LFTs, and looking at CBCs, is like what is the very highest level way I can look at this, and break this down in a fundamental understanding way, and then I can go down those pathways of differential diagnosis based on the lab value I’m looking at. And so, these are jargon-y words, but is it hepatocellular or cholestatic, and I promise I’ll tell you what that means. I just tell you that so you can sound really fancy, if you want to talk about it that way at your job, but basically you’re looking to see, when you’re looking at LFTs, AST, ALT, bilirubin, albumin, stuff like that, you’re trying to… You’re being a detective, and you’re like, Okay, where is this potentially coming from? Is this a liver problem, the hepatocellular, or is it a bile duct problem, cholestatic problem? 

0:47:11.7 RL: So hepatocyte injury, the primary problem is from liver cells getting messed up, for some reason. So the pattern you would see is that the ALT and the AST are very high compared to the alk phos. So, like I said, upper limit of normal. If it’s 10 to 40, you’re ALT and their AST are 300, and your alk phos is in the normal reference range or it’s slightly elevated, like two times the upper limit of normal, depending on the reference range for alk phos, if you have both of them high, which one is higher? The ALT and the AST are higher in that case, which means that it’s more likely a liver problem. The bilirubin may or may not be elevated if it’s a liver-specific problem. Cholestasis or cholestatic problem, like a biliary tree problem, again, the primary problem is coming from either the biliary tree, the bile duct or the gall bladder, your lab results are gonna show abnormalities with the alk phos, maybe also the AST and ALT, but, like I said, if you’re looking at the upper limit of normal…

0:48:18.6 RL: If it’s four times the upper limit of normal for the alk phos reference range, compared to a couple of points elevated of the ALT and the AST, you’re gonna decide that the alk phos is the one that’s heavier, that’s taking more of your attention and is more likely to be coming from that physical source. And again, bilirubin may or may not be elevated in either of these cases. But this is one very high level way to look at LFTs, of what do each of these values mean, what are the main ways to approach it in terms of the upper limit of normal, multiple elements, and which one is the highest one to start with? That’s like the general entry point approach, combined with the key things to remember about any lab, right? 

0:49:05.9 RL: And then that, hopefully from the very get-go, is gonna be like, Okay, this is not an urgent thing, it’s only two times the upper limit of normal, they’re not having any of the symptoms… And again, liver failure is the main symptom for any LFTs, jaundice, abdominal pain, things like ascites, stuff like that over the long term. But hopefully that’s empowering for you to understand what those labs actually mean, and then what are the first steps to be like, Where do I go for investigating this? So a couple of other things that you might find. Isolated alk phos elevations by themselves, with nothing else abnormal, has its own workup, and that’s a specific… There’s a specific algorithm for that. And something you might see, it doesn’t fall under that cholestatic pattern necessarily; it could. But yeah, you might also see isolated, bilirubin by itself, and that again has its own algorithm of workup. But yeah, for the most part, this has been a little bit of a conversation in the lab course group, but basically low levels of pretty much any LFTs are typically not concerning. There are some rare, rare cases of that being a problem, but again, I collaborate with a lot of specialists when I put this together, and the GI specialist who had a lot of experience, for the most part said that that is not something to be concerned about.

0:50:33.0 RL: I think the bottom line is that if it makes you uncomfortable, you need to do what you have to do to sleep at night. And so if you feel like, you know what, I can’t rest knowing that this… Like this is basically like a PubMed article that we were sharing amongst each other compared to nothing, basically nothing written and up-to-date about it. So, anyway, if it makes you uncomfortable, I always tell this to my new grads is like, do what makes you feel like you can sleep at night, right. Oh, so this is where I talk about symptoms. I forgot I had this in here. So liver labs triage. So again, worst case scenario, this is all very high level stuff, will hopefully will make you feel really confident. Acute liver failure is the worst case scenario. What are the signs and symptoms? Altered mental status, jaundice, it could be their sclera under their tongue, their skin undertone, right upper quadrant pain, nausea, vomiting, malaise. If you were really worried about somebody with an AST or ALT that’s in the several hundreds of thousands, you could order an INR as an add-on to see what was happening. Definitely tag in your colleagues and supervisor, don’t do that by yourself, but…

0:51:39.3 RL: Oh, this is just like a fun fact. Carotenoderma is the fancy name for people who have a lot of beta-carotene in their diet, which I saw a lot when I lived in California, ’cause everyone loves kale, at least they did where I lived. Orange palms, soles, knees, labial folds, and the forehead, can have an orange-y undertone to them, which is specific to that and is not jaundice. So, just fun fact. And then signs of chronic liver disease, you probably will notice this in the patient that you’re ordering the labs on in the first place, but if you’re working backwards from labs that somebody else has ordered, what are the other signs and symptoms that would clue you into this being a potential chronic problem? Things like muscle wasting, the spider naevi, pulmonary anathema, gynecomastia. A whole bunch of other things I can say here. But yeah, so typically speaking, you can kind of assess, when you have that lab front of you, what are their symptoms, do they have signs that this is a chronic problem or not? So again, acute or chronic, you always wanna compare it to the last labs; is this a brand new phenomenon or is it a previous one, and then you just…

0:52:44.8 RL: If it’s an acute problem, there’s algorithms basically for mild, moderate, and severe. And then if it’s a chronic level, you wanna see is it stable or is it worsening? Like the example that I gave, with that woman who had the persistently elevated LFTs, her current ones were in the 200s, but her last ones were also in the 200s, and she was already undergoing treatment, monitoring, collaboration with GI, so it was handled. But I just like… That is the first step to look at, is like, have we ever seen this before, is it getting worse or not? Because you don’t just have to keep ordering labs because you’re uncomfortable, it’s like what are you gonna actually do about it next? [chuckle] ‘Cause that’s the temptation. Right? Again, guided by their symptoms. So what do they need to do about it? So for this particular patient, we had a very candid conversation about like, do you fully understand your celiac disease diagnosis and what that means, and how that is influencing your liver, that you might actually head towards a transplant if it doesn’t get better. That was the conversation that we had, versus, is it alcohol use disorder? Are they waiting for a transplant? Do they have hepatitis? 

0:53:51.0 RL: What is the underlying thing, and what do you do… What do you do about it? Not just re-check their labs, right? And another kind of hack way to see if it’s a chronic thing versus a new thing, you might see a low albumin less than three. But, yeah, that’s pretty much it. That’s all I got. Right at time.

0:54:11.9 Walden: You did great. Alright, so there were a few things… I appreciate that. I’ll tell you probably what they were thinking was…

0:54:20.0 RL: Yes.

0:54:23.1 Walden: So a lot of folks were just saying that they need… I know Tammy is in here and Annabel and things like that, and they were just saying how they just needed all of this.

0:54:33.1 RL: Oh, good.

0:54:34.8 Walden: And so I know they were of taking it in. I know it was a lot…

0:54:41.6 RL: Information overload. Now that I’m at the end I’m like, that was probably too much.

0:54:42.8 Walden: No, no, no, it was great, because… Depending on what you wanna do, right? It was kind of what we wanna do, we wanna give you kind of this overview, and then if we need to deep dive into these different little pieces, and we just do that as well. But I know you guys were just kind of taking it in and absorbing it all, and I want to be sure and let you guys know that it might take a few days, you might have to watch this again, you might have to come back with notes, or just kind of take it all in so that you can digest what was saying. Don’t think that you have to know it all, all of a sudden. Like you were saying.

0:55:22.5 RL: Yeah, I think that’s one thing I majorly wanna stress about lab interpretation, and also part of the reason that I chose this particular thing to share, because a lot of what I shared just now was like the back-end stuff that you don’t really get looking at those immediately consulted resources of UpToDate or Hippocrates or something. And it’s that fundamental understanding. And then, additionally, the thing I wanna hyper-stress, especially for new grads, I think that there’s this conception, and I don’t think people believe me, is that I went for three and a half years before I knew it to this depth.

0:56:00.6 Walden: Yeah.

0:56:00.7 RL: And most people… I don’t know if most people, but a lot of people don’t get to that place. And I think that there’s just so much pressure for new grads to know it all yesterday, and it’s like, No, no, no, no, this is a life-long skill, so take your time to absorb and learn this and understand it, so that you can continue to do your job, and it’s okay to take time.

0:56:18.4 Walden: I think that’s something… I mean, you’re right, I think… We’ve talked about this, the level of work that goes into just trying to explain it… Learn it first, and then explain it like we’re talking to a five-year-old because sometimes that’s what we need. It takes time and it takes work, so these are safe spaces that we create, so that you don’t feel out of character or out of place when you ask a question. It’s okay if you don’t know what AFT is, let me explain to you what that is and what that means. Because the more you understand what it means and how it works, the more likely you’ll understand how to diagnose.

0:57:00.6 RL: Yeah, for sure.

0:57:01.0 Walden: I think one of the things that you said… So I took a few notes, but one of the things that you said was the symptoms, knowing when to run the labs. And for me, as a practicing nurse practitioner, I need you guys to understand, and the students that are watching, just to understand that one of the ways that I know when to freak out and when to not is if your patient has symptoms. That is so key, because if they’re fine, you are fine.

0:57:36.8 RL: Yeah, just take that pressure right off for a second. You’ll investigate it, but it’s okay.

0:57:41.0 Walden: Yeah, we’re gonna look into it and see and make sure they don’t develop symptoms…

0:57:44.7 RL: Yes.

0:57:47.0 Walden: But if they are coming to you, and it’s okay, and especially as you get to talking to them and they say, Oh yeah, so and so told me that five years ago.

0:57:57.5 RL: Yeah, yeah.

0:57:58.7 Walden: You can take a deep breath and just say, Okay, this might not be something that I need to panic about. The other thing is the knowing… I don’t know when you were in nursing school, but when I was in nursing school, one of the things that I was taught was just trying to figure out what is normal and abnormal. That’s how I survived nursing school. If you knew what was abnormal, then you knew you had to fix it. The same kind of situation is here. When you are talking to your patients, and you are looking at the labs, and you realize that something is abnormal, you now have the authority to go and fix it.

0:58:39.2 RL: Right.

0:58:40.2 Walden: So you can start doing that deep dive, you no longer have to wait on the physician or whoever to kind of do that further investigating. So that is a really good point as well.

0:58:52.0 RL: Yeah. And just to go back to the other point I had about the knowing which ones to triage and freak out about, just if you can even cursorily have a sense of that, like, low protein you wanna investigate, but don’t freak out, but don’t ignore it. Right? And the same thing for hyperlipidemia, you wanna look at… You wanna address it, but which ones are going to kill your patient, right now? Let’s just start there.

0:59:19.8 Walden: Exactly.

0:59:22.1 RL: And like don’t ignore… I rarely see this, but I see it sometimes of new grads, ignoring something ’cause they don’t know what to do about it. So like a slightly high calcium or slightly high protein; it’s like, no, you still wanna look into that. Sorry. I know you’re really uncomfortable but don’t ignore it. [laughter]

0:59:37.2 Walden: Yeah. That’s like… I always tell my… If it’s like one under or one below, ’cause you always get those one above, one under. I’m usually not worried about it. Like you said, it’s when you’ve got the plus five, plus ten, you look at it and you’re like, That’s not right. I don’t know why it’s not right, but if all your spider senses kind of go up, you know this isn’t correct, those are the things that you want to investigate. Maybe run… Re-run the lab to give yourself some time to figure things out. Was the lab done even correctly? 

1:00:12.4 RL: Right, right, right.

1:00:13.9 Walden: Sustain the… And that gives you some time to start digging.

1:00:20.2 RL: Totally, totally.

1:00:21.0 Walden: No, this was exciting. I know it’s a lot.

1:00:24.0 RL: I know. It is a lot, it is a lot.

1:00:25.5 Walden: It was great, it was absolutely great. You got a lot of like, This was great. Just to let you know they loved the information. So I really appreciate you coming and talking to them. So if there are any questions, you guys, please feel free, again chat in our group, or you can email us and then we’ll get them back to Liz. ‘Cause I’ll let Liz explain this.


1:00:49.8 RL: Yeah, don’t forget about the other case studies that I have. They can take their time going through the case studies on the YouTube channel. It’s, and there’s sodium in there, TSH is in there. There’s a whole bunch. Hopefully those are helpful.

1:01:02.5 Walden: Yeah, they need to go through that stuff, and again, take notes and just kind of be patient with yourself sometimes. We’re still gonna keep talking about it. I’m always gonna give you these resources and give you things to kind of look at and direct you, to Liz. But no, labs can be overwhelming.

1:01:21.2 RL: They’re really overwhelming.

1:01:23.9 Walden: And you just need to take a deep breath, and we’re telling you, it’s okay. We don’t know it all as well, we are studying right along with you, but we’re here to explain it to you so that you understand it and you know how to treat your patients. So yeah, you’re getting some, I follow you.

1:01:39.9 RL: Oh yay, awesome.

1:01:44.9 Walden: Someone’s asking, they said they know UpToDate is a great resource, but are there any books that you recommend to kind of help get a good overview of labs? 

1:01:51.4 RL: So honestly, and I’m not just saying this ’cause I have a course, the reason I made the course is because the resources out there for books are just… I don’t know if you’ve found any, Latina, but I can’t tell you how many I’ve purchased and it’s like, it’s just not to the depth of understanding that I’ve wanted. So I think UpToDate is really quite honestly my best resource recommend, but I think until you under… So I guess the only other one potentially… So I had this MGH pocket guide, I think it was family medicine, and it tells you algorithms, but it doesn’t really… So I feel like I still feel like it’s a hacked way, because it’s kind of like, Do this, then do this and this, but it’s like there’s a little bit of a missing piece of the understanding. So that’s as much as I have. Do you have any books that you recommend, Latina? 

1:02:39.6 Walden: I’ve got a few and I’ll list… I’ve got, I’ll list at least one that I love, because it’s written in layman’s terms, which is what I appreciate. But I will tell you that I do the same thing, and I do the same thing for a lot of even explaining the disease processes and things like that. Kind of one of my hacks, you guys, is that I will look things up and look at different resources. So I will look through two or three or maybe four resources, ’cause I need to see kind of what is that thing that is consistent across all of the resources, that’s how you determine those buzzwords that you learn and things like that, because there’s usually a word, a phrase, something that’s consistent through all the resources, but I also like an understanding, if I understand, why I can do that the rest. And so it’s a lot of digging, it’s a lot of studying, so that’s why I pulled this together for you, that’s why [1:03:41.3] ____ her course for you, it’s why I do this, to kind of point you in those right directions, but what we’ll do is we’ll get… I’ll give the name of the book Liz has and I’ll give the name of the book that I have.

1:03:53.7 Walden: And you can kind of start there with your understanding for labs. It doesn’t get any easier, guys, you gotta keep studying.

1:04:02.0 RL: It is such a skill. It is such a skill, but if you… I’m obsessed with my lab course, yeah. But anyway, it’s a lifelong skill, regardless of the resource that you use, for sure. And it takes a lot of time. But it’ll get there.

1:04:18.4 Walden: Yeah. So be patient with yourselves. A lot of us are new, a lot of you guys are new in here, and it might be year five and we’re still throwing things at you and you’re still like, Holy crap, but you’ll feel a lot better, obviously, in year five than you’re gonna feel right now.

1:04:38.3 RL: Totally. And the bare minimum, if you can just get worst case scenario, when to freak out, you’ll be good to start with that, and then you can fill in the rest to feel that confidence later on.

1:04:51.8 Walden: Yeah, yeah. So that’s a good question though, ’cause it… Cool, but what we’ll do is we’re going to… Yeah, no, we’re gonna do some follow-up, you guys, ’cause you guys know me, so I like a good homework, and I still owe you homework from the student loan stuff. But I appreciate, Liz, you guys will see Liz again, so don’t worry. She will be back with us. But I’ve appreciated you and I appreciate this presentation. And so, yeah, no, I’ll see you in a little bit. So hang around though, and I’ll wrap up. Alright guys, so I am so excited, I’m glad that you enjoyed it. Again, I know that you were taking it all in, please feel free to come back, re-watch, remember you have this in your portal. As soon as it downloads, we’ll have that available for you, so if you missed the beginning of this… No worries. You can watch it from the beginning and we’ll get that to you. But it is a lot to just kind of take a deep breath, the homework that you guys are gonna receive, don’t worry, it’s not gonna be intense ’cause I know you’re like, She’s crazy.
1:06:00.4 RL: She’s gonna give me all this extra stuff, but again, it’s to just ensure that you are taking this all in and to kind of point you in some of the right directions so that you’re able to digest what is being given to you. So that’s also really important. With that being said, I’m excited that you’re here and that you listened and you learned, and it’s gonna be some exciting times for you guys, so we’re gonna wrap up, you have another… We have another chat next week, so that’s gonna be exciting as well, so I hope that you are back with us next week. We’ve got some exciting stuff coming for you in the next month, but I am going to… I’m a lover of suspense, so I’ll keep you in suspense. With that being said, you guys have a good night, and if you have any questions, please let me know so I can let Liz know, if we need her to explain some future things, okay, guys. So just being respectful of your time and I appreciate you guys. I’ll talk to you soon. Bye.