Episode 433 – RLR – A Red Leg

Clinical Problem Solvers are you tired of not getting publications and getting your manuscripts rejected? We can't help you with that, but if you want to listen to these episodes add free then subscribe to RLRCPSolvers.com you'll also get teaching videos and exclusive teaching figures and if you want to be a sponsor for these episodes reach out to us. The best power and drum you will be so impressed. Oh, it's the mathematician and the magician laying out the order of deduction. It's RLR. Welcome back clinical problem solvers. Prof. I think it's so powerful that for every episode you've started and I've ended. What does that mean? Let us look at the deep meaning of that. Why do you start an eye-end? Well, you know, I think we're like peanut butter and jelly. You've got to have both of us. There has to be a start and there has to be a finish and if I were ever going to have anyone finish anything related to clinical case. Prof. Friends, do you know I discovered pistachio butter? Have you had pistachio butter yet? No. Oh, dude, you got to try pistachio butter. Do you like pistachio in general? I do. I love pistachio. Don't want your Persian. Of course, you love pistachio. Of course, it's like a requirement by law. You know, Prof. Res. Yeah, you know, my sister bought us this like pistachio like buckle of a thing and I put it in my assay bowl and oh my god. I become addicted to like a little bit of pistachio in assay highly highly recommend. So it's not too strong that it overwhelms the senses or it's just like an ingredient that compliments all the other ingredients in your assayers. You're so smart, man. You're right. You have to put it in very small doses otherwise it totally down its flavor. Wow. You can imagine your obsessive younger brother took like a month to figure out exactly how much pistachio butter I could put in without dominating the flavor. What else is in your assayable? Like what are the other ingredients that you must have? So banana, frozen banana, frozen blueberries, frozen assaye cubes, half a teaspoon of sunflower butter, a quarter teaspoon pistachio butter blend blend blend and enjoy. That's it. Wow. No peanut butter. No peanut butter. Do you like peanut butter? Yeah, I do. Peanut butter is too caloric. You know sunflower butter is a little bit less caloric and according to Chad CPT who I love more and more and more and more because it saved me from taking the art of the vet. It says it's healthier. So I found his way to a lot of brownies. I have so many stories for you, some of which I've saved for this moment, but I think it's yeah, Professor, I don't even know what to tell you, but maybe I'll tell you off later. So NAR, Karen and I were, I'll tell you more detail, were viciously attacked by a coyotes, two of them. I love this story so much. Not the fact that you got attacked, but the fact of when NAR got upset and started teasing them. So I have to tell our beloved RLR, see this story. I'm the reverted to the story. We're running in the pouring rain and all of a sudden I hear my wife hear a screaming and I turn on and there's two like large coyotes. Very healthy looking right next to us. Like literally like and they're both going for NAR because you know, they don't care about humans. And this monster who is like honestly pretty short looks much smaller than them height wise, but is you know, he probably weighs just as much as they do combined. He turns around and he'd like just faces off with them and one of the two coyotes cramps. And so these NAR just come like chases after the coyote, like keeping up with it. Then what was really interesting for us is the other coyote, the one that's not being chased because there were two of them, catches up to NAR and like like nips him in the butt. Like literally like pokes him in the butt. And all of a sudden NAR is like, oh shoot, he so he sits, he's calm, he's like, I'm outnumber here. And so he starts to like just be more like barrel-chested sitting down and like keeping an eye on them. And that's that's when the humans came and chased the coyotes away. Yeah, it was crazy, absolute crazy. One of the scariest things I've ever experienced. Was it was there a part of this story where once they grabbed the stick or something that NAR started to happen. This is another story. This is not one of the two days ago. I was, yeah, I haven't told you a story. Dude, how many coyotes are there? Offer as we were on like, there's so many. We were in an actual legally allowed off-leash area of a dog. Like it's not, we weren't, we take NAR off-leash many places because he's very well trained. We were actually allowed to have him off-leash. And it is wide open grass. Like there's, and there's so many people around. But it was raining. And so they weren't that many people around. But this is in the heart of San Francisco. Like you should do not expect the coyotes to run up to you at 7.30 in the morning. You know, like well after sunrise. I was absolutely crazy. Wait, so then what happened? You and Kira started running towards NAR. Like, no, so we were all we were running and they snuck up from behind us. Yeah. And they were like running towards NAR. Kira saw them first because NAR was ahead of her. And so she like kind of sung the alarm. We all turn around NAR, turn around noticed. And I think they were going to size up NAR. But he's crazy. He doesn't, he's like no concept of that. And so he starts to chase after one. And then one of them like realizes that maybe because he, he, he, he looks small. Yeah, but he's not. And so then he started to chase after one of them. And then the other one was following behind. So it was coyote, NAR, coyote. And the other, the coyote behind NAR like reaches NAR first and like, like pokes him in the butt. And that's where NAR is like, oh shoot, maybe I shouldn't like take both of these creatures on. But he had scared them enough that they kind of back with then you and Kira went and pushed the coyotes away. Yeah, exactly. Yeah. With a stick or just like, no, I'm just like presence and noise. Yeah, presence. Yeah. Damn. Absolutely. Well, listen, call me Santa Reza because I have news for the audience that's relevant. Unlike your coyote story. They probably already fast-forwarded through that story, Robby. This is the relevant news. Santa RR for the holiday spirit. Whatever holiday it is that you celebrate. Want to give your beloved friend or family member 40% off their first came in for RLR. Meaning they would get it off their first payment that would be normal amount. And if you let us know who you refer or the person referred mentions your name when they sign up, you will get a Venmo or a PayPal for $50 from RR. Wow. So maybe summarize that, Robby. Like, what's the equation for them to know? 40% off first payment of a referral and you get $50 from one or a proper ask because I'm not paying nobody. I got to go to the rents, baby. Robby, I'm going to prove to all of them. I swear, I'm going to raise the bar this time. I'm going to prove to all of them that cares looking for my phone for chat GPT nor Coke, talklet, ingestion questions. I'm going to prove to all of them that RR is worth it with this case. This is going to be such a fun case. And so I will begin the story by telling you that you're going to be in very familiar territory and then you're going to be confused. So this is an older gentleman who has an history of diabetes and venous stasis and takes metformin and and sit a blipton for his diabetes. And he's had long standing venous stasis and he presents to the emergency room for one day of left lower extremity pain and redness. So let me stop there and see what you think with that. You won't believe it. We actually on service right now, have a patient who's on metformin and is on and gel P1 agonist who presents with left lower redness and edema. And I, you know, when I was teaching on the topic this morning, which I'll do so here, the first question I asked in turn was like, if you can determine one thing when someone comes in with lower extremity edema, what would be your first major branch point? And I said this is a read my mind question, but the first branch point should be whether it's symmetric or asymmetric, but this completely changes the ddx. Of course, when one leg is more swollen than the next, we frame it as asymmetric, but you have to be very cautious because sometimes a symmetric process may present worse on the left than the right, though we still frame it as symmetric. So there's just that one little caveat that just be aware that when you say it's asymmetric, you're really saying that it's one side dominant, but be open to the side that be open to the fact that both sides might have edema just one side is worse. In this particular case, I'm going to frame it as asymmetric and told I'm giving any data that might suggest otherwise. And you have to use base rate of disease when you're tackling any clinical problem. So if you ask the question, what's the most common cause of edema of the lower extremity? It's going to be one of two processes. Most often it's cellulitis, and if you say redness and edema, you're going to prioritize cellulitis until proven otherwise. And then your mind is going to start searching for clues to support this initial hypothesis. Like the fact that this patient has diabetes is immunocompromised. You're going to wonder, does he have any evidence of any comaicosis, any kind of tiniopedic that may have made him vulnerable to lower extremity cellulitis like our patient actually had? Then the other possibility with edema, you have to worry about DVT. Now, DVT of the lower extremity to cause erythema is not impossible, but I would say it's less likely based on my own clinical experience. Oftentimes it's just some edema you get an ultrasound and there's a clot. There are moments where you might have a rash with the clot when you have venous hypertension that leads to phlegmasia, ceruleadolins, you got to love saying that word, or the venous hypertension is so bad that you get arterial insufficiency, you get phlegmasia, albedoels. One of our colleagues in medicine right now would say, "Rez, why are you talking about that? Just stay focused on the facts." And you know who I'm talking about. Yeah, I was just going to ask you who. I'm not going to say that today, because I made it seem like it was a kind comment, but in reality when they didn't make that comment, I said, "When have you ever discussed a clinical unknown?" Because back then, profrez was in mature. Oh, remember now. Draw it. And then the other cause is rabbi. I think you just think anatomically, like, could there be something deeper like a fracture? Could there be a deeper infection like neck fast? But I think number one, two and three priority is like, is this cellulitis? Is this a clot? Is there a fracture? And don't forget, like, charcos are thropathy and someone with diabetes. Is a true thing where you get micro trauma because you lack sensation to a particular bone. But I'm very curious to hear more information. Yeah, yeah, absolutely. Superproprez. So upon arrival, he has a temperature of 100.6. His heart rate, blood pressure, respiratory rate, and ultrasound are normal. His physical exam is completely normal with the exception of abnormalities in both his legs. The right leg has chronic venastasis, changes but no acute abnormalities. The left leg has similar changes, but it has essentially a patch of erythema and endema that extends from the mid-encle. I would say almost to the knee, but not quite. It's not circumferential. It has irregular borders and warm and tendered a pulpy. So I'm really curious how close you are to a diagnostic threshold. But I'd also would love to put you in the shoes of the person taking care of this patient about what your next steps diagnostic in therapy would be. Literally, this is the patient that I saw this morning, just in a different VA. I think when you're making the diagnostic hypothesis of cellulitis, this patient meets every single criteria, meaning they have a vulnerability. I would look in between the digits. They have redness, they have warm, they have beaver. So for me, I've reached that threshold to label this as cellulitis. And then next what my mind would do is categorize it as suburative or non-suburative, because that has implications in terms of the antibiotics that I'll prescribe. And then to also restratify it as mild, moderate, or severe based on whether they meet surge criteria and whether they have hypotension. So so far, this is my mental working model is an individual immunocompromised from diabetes, who's presenting with left lower extremity, erythema, warmth, and redness. Beaver likely has non-suburative cellulitis. That based on the temperature, we don't have the white count yet, is mild to moderate. And the most common organisms include staff and strep that cause this superficial infection of the subcutaneous layer. And therapeutically, in addition to prescribing him at minimum, septraaxone, I would want to elevate his leg. Because when you have a demon, especially if you have a history of venous stasis, and now you have a demon from likely cellulitis, it's going to be hard for antibiotics to penetrate the subcutaneous tissue. So elevating the leg is very important. I would also mark it with a pan of where that patch of redness ends, knowing that within a day, it might actually worsen when you're treating cellulitis. It takes time for the redness to reverse. So bottom line, non-suburative, mild to moderate cellulitis, looking forward to the white count. With the fever, I'm inclined to send blood cultures and immune compromise status. I'm giving this pressure as normal. I'm not yet there to say I have to cover pseudomonas, so I don't think it would be incorrect if someone just said because of his diabetes, I want to use something like azocin as my preferred antibiotic for pseudomonal coverage. But I think you definitely want MSSA and strap coverage for this patient. And this is a fake question that actually it doesn't relevant to the patient, but I'd love because I imagine maybe some people who are more outpatient, have you may ask this question. If the patient says, "I don't want any blood work, I just want you to treat me for what I have." What do you think you would use, and would you be worried about him, or would you think he'd do just fine? Such a great hypothetical question. Ultimately, for me, what matters most is the patient. And I think we've talked about this so many times on our law in that, why do we even give antibiotics, right? And I mean, if it's up to Robbie, no one's getting antibiotics, and their body is just curing themselves. Of course, we give antibiotics because in a subset of patients, if you don't, they can get severely septic. We give antibiotics because we want to shorten the duration of the infection. We give antibiotics because we want to improve the symptoms of the patients. So in this case, it's clear in my mind that they definitely need antibiotics. However, does fever indicate that they must be hospitalized for IV antibiotics and get all this blood work? No, it really does it. Like if his pressure is fine, if we can monitor and track the retinas, and he has this mild fever, I am taking off my hospital is hat where I'm always thinking worst case scenario. I'm putting on my practical doctor hat, and I would say that, look, I'm going to choose an antibiotic like Augmented and give it to you, or Keflex and give it to you. Keflex more likely than Augmented. The reason I'm not as quick with naming the exact antibiotic is that I always look it up to see what the IDSA guidelines are. But I do know I want stripping them as a safe coverage. But to answer your question directly, I feel totally comfortable with not admitting this patient, if they don't want to be, with trialing oral antibiotics, but most importantly, with having contingency planning. Almost like when you sign out tonight, you're like, if this happens and this, I'll say, hey, man, if you're persistently fever out, if you become lightheaded, any of that, please go to the emergency department. That might mean that there's something more serious happening. But in most cases, they'll do fine with oral antibiotics. They really will. You know, I ask you that question, Prof. Frez, because unlike most cases I present to you, this is a case from my hospital team. And a truth be told, I'm so glad that I wasn't taking care of this patient on the ER because I think I would have discharged him, and I'm glad he didn't get discharged. I'm going to use small little hints here or there, Prof. Frez. Enjoy them. So one other quick question, ultrasound, yes or no, DVD ultrasound. Absolutely. How come? Because, okay, so I would say this, that if they came to my clinic, they had a fever, they had erythema or diabetes, then I wouldn't, honestly, because I have an alternative explanation. I have like a very strong hypothesis that I can justify. Like, man, immunocompromised, fever, streaky redness, that's not uniform. This is cellulitis. So no, I'm going to take that back. But if he gets admitted, yeah, it's a great question. I don't. I wouldn't. Like, you know, the truth is our patient got an ultrasound, but he had like a prior, a total hip arthroplasty just two weeks ago. So thermosis was on the table. But even in his case, when you have shiny redness of the skin, I just don't see DVT causing that. I don't know what you're expecting, but this is just my own clinical experience, man. Every time I'm diagnosed with DVT. Yeah, you know, I'll show you. This is where, you know, I wasn't taking care of this patient. He got an ultrasound. It was negative. So let's get that off the table. He got the ultrasound. I'll tell you my practice pattern is that a DVT is not a medical emergency and the ability to be able to fix a problem and treat a patient with cellulitis and watch them improve in 48 hours, gives you enough time to use response to treatment. So if the patient's syndrome completely resolves in 48 hours, you don't need an ultrasound. And most people who come to the emergency room with a DVT have had their clot for many, many days. So that's why I often try to skip it. So, for us, he gets into bad. His leg is elevated. He gets started on IV vancomycin, even before anything is done except his blood work, of course. Blood cultures are obtained and they're cooking. But this is the labs that are available. His white count is 11. And everything else is normal. His CRP is 30. And I will tell you that he gets admitted mostly for social reasons, because there was nothing screaming, admit this patient in terms of the usual blood work. And the next day, in a true honest mistake, the intern accidentally orders another CRP. And the CRP the next day is 300. His exam is still the same. The cellulitis really hasn't changed much. And we do a thorough head to tour of you systems and he has no other symptoms. But he says that his right leg now is bothering him a little bit. And when you examine his right leg, you don't see anything there, but he says he's tender right above his ankle and feels just the way he felt before the redness came around and his left leg. And I'll stop there just to see what you're thinking. And Robbie, just for our audience to know the normal CRP level, I know it's less than five. Less than five, thank you. So the 30, I would just for just to quantify it, a 30 is a mild elevation. 300 next day is extremely high. Yeah. You know, sometimes it's really difficult to interpret labs that you wouldn't necessarily say, right? Like, gosh, once we had a patient with CDI, that someone sent an ESR in CRP and it came back really high. I didn't know two patients with CDI have really high ESR. It's feasible. And then I was like, you know, they had some red cells in their urine, some protein. Like, could this be a GN? Who knows? But it ended up actually being a GN. In this particular case, I think now we have the data. And we have two things. One is that it's really, really elevated. And that's sort of, I'm even though I don't trend CRPs for cellulitis, it just seems unlikely when the patient's getting antibiotics. And you really got to change in the clinical syndrome, meaning that his right leg now is experiencing discomfort. Though on inspection, there is no abnormality. So what would this do for me? By the way, I, you know, vancomycin is good. But really, if you just have cellulitis, that's non-separidic. It's probably inferior to ceptriaxone based on the quickness of action and the efficacy against your strep species. Our patient is actually on vancomycin and ceptriaxone, but I don't even think he needs vancomycin. I think ceptriaxone is just fine. But, you know, whenever you have a high CRP and any kind of skin changes in someone who has diabetes, you start wondering, could they have necrotizing fasciitis? Like, honestly, that was just my reflex that's bad. It would be odd to have neck fasci in two locations. In oftentimes, patients with diabetes who do have neck fasci, they really show their neck fasci. Unlike individuals who don't have immune compromised status and end up having mono-microbionic fasci, which starts in the inner and then moves outward. So this would prompt me to look at his sodium more closely. And basically, the components of the lernic score, which includes glucose, but that can be tricky in someone who has diabetes. The sodium can even be tricky. You have to make sure you correct where the glucose, because it's best friend. But, yeah, it would be like, honestly, like, this is what I would do next before I think about anything else is ask, like, what is the sodium? And can this be a deeper infection that I haven't picked up on? Prof. Friends, I would tell you that his sodium was normal, actually. But to take you to the tension point, we were worried. And the truth is, I actually hadn't stopped the patient yet. And I, my resident outstanding earned a lot of autonomy. So she went for a CT scan. I was just, I was keeping an eye on the chart, but we hadn't talked about it. And I think it was a very wise thing. She went for the CT scan. And we locally at UCSF, they cite a really paper, even though it's a small study, because it was done out of the San Francisco General Hospital, where they took about 30 to 35 patients who had, who went to the OR for an exercising fasciitis and stratified them my positive CT or negative CT. And they learned that the negative predictive value of the CT scan, the modern CT scan, is basically 100%. And so, thankfully, that was the case for this patient. He had no evidence of findings of negatizing fasciitis, but they did see the soft tissue stranding that reinforced the diagnosis of cellitis. The blood culture turns out to be a very powerful and interesting clue. So I'm telling you, the blood culture is positive, but I would just love for you to teach us what you, what the base rate would suggest the blood culture in this case like this might show. Yeah, absolutely. In cases that involve, if you go to our website and you go to infection 1.0, what are the most common sites of infection? Long, urinary, skin and soft tissue. And then you have GI and bacteremia, but for pneumonia, for urinary tract infection and for simple cellulitis, the yield of blood cultures is so low. It's very low. I can't tell you a specific number, but it's so low that it shouldn't be a reflex that you send blood cultures when someone's coming in with community acquired pneumonia when someone is coming in with mild cellulitis. It's just, yeah, or someone is coming in with simple cystitis, like there's no reason to send blood culture. So the base rate is low. What tips the base rate to favor the sending of blood cultures, not because it's going to be 100% positive, but because it's much more likely than 5% than 10%, is really the Sir's criteria and how sick the patient is. So I think if they were hypotensive, if they were febrile with a white count of 20,000, like the more you get on that side of the spectrum of Sir's and severe sepsis, I think the more likely it is, the blood cultures are positive, and the more pressed you are to send blood cultures for a possible answer. So you're super professional. So sorry, I had to move to my mute button. I was absolutely super, but I think in him, though I wasn't the one ordering them, I imagine that the combination of the fever and the white count tip the ordering provider, and I looked it up beforehand, pro-friends. I tried to get a number from my team because I was making this point. It's less than 5% of patients with uncomplicated cellulitis have a positive blood culture. So it's positive in the situation. What would the base rate suggest the bugs might be? What do you, what, now that you know you're getting a call from the micro lab, what do you think the micro lab is going to tell you? It's a great question. And I will say, Robert, did you learn like, because his white count was just 11,000, right? Yeah. Like, is that, does that really tip it to conflict? Like, what makes it complicated? I guess that would prompt no strict definition, honestly. And to be honest with you, like I said, I wouldn't have ordered the blood culture. Yeah. Yeah. I'm not sure I would have either, but, but I think I would have, because like once they're in the hospital, we're just so biased. Yeah. Right. Even, but, but that's not a reason to do it. I mean, but that was the same. Like, I can't tell you how many times I've gone to morning report where we've done pet CTs, biopsies, today, you know, mono. Yeah. Yeah. Because they're in the hospital. I told my team when they ask you any time for any reason, someone to ask you what's the most likely organism. Just say two. Stafford's draft. And you'll be 99% right. And this goes out to all our listeners. And I'm sure all the smart people, I can see Austin and Alec the twins right now messaging you. No, no, no, you got to think about this organism and that. I'm going to double down and say staff and streps. So yeah, grand positive organisms, either in chains or in clusters would be my guess. That means it's a very wise guess preference. And, but the reason I'm presenting this case to you is because it is not the right answer today. We're going with this. Well, first two out of two blood cultures show Graham negative rods. He has no abdominal symptoms as you as normal. He has no abdominal pain, no nausea, no vomiting, no diarrhea, no abdominal history whatsoever. Good luck. I mean, this is much easier than if you said they had grand positive rods. Like, Graham negative rods. We have some experience with the raw. But I will say I'm surprised, but we did say initially that the history of diabetes prompts the consideration of pseudomonas. And I think that becomes a real contender in this case with the history of diabetes. But the more common causes of Graham negative rod. Bacteremia is all you got to think about is the in terobacteria species. And the most common causes of UTI. And this includes E. coli, klepsial proteus, merabalus, and such. But E. coli as a cause of a skin and soft tissue infection would be quite odd unless for some reason the feces contaminated the skin and served as a source for E. coli or that this patient has multiple infections because they're immunocompromised. So they have the skin and soft tissue infection. But they have something else that's happening that has escaped the surface. I think I would prioritize pseudomonas just given the history of diabetes and given the clinical syndrome of cellulitis. But if you told me that the organism was, for example, klepsiala or E. coli, I would have to pause to be honest. Then I'd have to look up how common is that in diabetes. Glad to really start worrying about some kind of gastrointestinal pathology and a breach in the GI tract and stuff like that. So I think whatever you tell me next will guide what I do, what I put into GPT. You guys know when proffers is thinking hard he starts to do this. What I'm doing is bouncing on my chair cloning I like, well, this is a little pain and I'm not knowing. Proffers, you and I heard of this diagnosis in the second or third year of medical school. And that's what the best part is. I had no idea what the bug was and I thankfully didn't have to discuss it. I just waited anxiously for it. But then when I saw it, I kicked myself. I knew this. So I'm going to try to help all because I don't think anybody has figured it out yet. So I'll share a reflection with you to help you get there. This diagnosis is not going to be a mystery to almost anybody. The body, the bugs and the body, you can think of them as a donut. The outer part of the donut is the skin that has grand positive organisms on it. Yeah. Right. And then the inner part of the donut is the insides of our body. The GI tract, the GI tract, the GI tract that has gram negative rods in it. Yeah. So I want you to visualize it. But a big, big, big assumption we make is bugs from the outside, meaning from the world. We always think that an exogenous organism, not living on the skin or in the GI tract, is an atypical organism. So we think, oh, could they have ricketsia or lepto? I will tell you not all exogenous organisms are intracellular. Tb is intracellular, histo is intracellular, ricketsia is intracellular, lepto is intracellular, covid is intracellular. But there are bacteria that live in the world that don't live on our skin, that are gram positive or grand negative. That aren't that are gram positive or gram negative. So preference, he has an exposure, an exogenous exposure that it readily explains this syndrome with ease. All I heard was world environment, intracellular, this gram negative, gram positive is not all exogenous. Proper as Sydney and Gino. You're kidding me. What does he have? Now, yeah, once you take it there, I will answer that. But this is also the explanation of the cell you light is or yes. So this Bart Nella, almost not the cause. Pasture. Yes, multi soda. Yes. He has four cats that scratch him by them. So on and so forth. And yes, his box. Past culture's group has pasture alone. And yeah, he, it is unfortunately described whenever it causes hematogenous dissemination to cause multifocal silatists or silatists that goes in multiple different places. And so his leg was likely an early warning sign that he was getting silatists in that leg too. Bilateral silatists is very, very rare because we don't believe that patients can have two independent silatists at the same time, but there are a subset of organisms that can cause multifocal silatists because of dissemination and atropism for the skin. And pasture is one of them. So his right leg was actually no a signal, not noise. I've seen this once before with group A strap act dream. Yeah, where the patient had two areas of silatists, his right leg and his left armor and the left arm developed after the right leg. So he was appropriately treated with saffraxone, the narrow togment and did fantastic. And we told them after we got real with him about his cats, ultimately the conversation ended like this. I look forward to seeing you again when you get this infection next to them, sir. Well, I'm so curious because he was not going to change anything at all. That's the case. Let me ask you a duration of antibiotics for this seven days. Yes, seven to ten days. Seven to ten. You know what I chose. I chose six profits. And so is the mechanism, the exposure comes from scratching from the cat. But then the other leg, it's from hematogenous spread to the other legs presumably. You don't know he could have been bitten or scratched on the other leg. The classic exposure pasture also the mouth. Yeah, with biting, but you know, it's gets in and around their body. You know, it's just a quick funny story before we end this session. First of all, a really cool case and probably so fascinating. And like if he had just gotten maybe some of these oral antibiotics outpatient, you would have done fine. Yeah, like augmented. I think was my first. So I don't know. Like if you had discharged them with augmented, like he probably would have been fine. Yeah. But I want to thank you back probably on 30 or resident. It's the San Francisco VA. It's during our Eminem. And you know how popular those sessions are all the attendings. Everyone wants to show their intellectual might in terms of the residents and Lawrence Tierney, our mentors mentor, always sat in the front at like the table where all the attending sat and he had the leather chair and he always put his hands in the back of his head. And around noon time, he would eat the lawns, he would pay attention, but you would see him like dosing off almost like Donald Trump does is off now. Like once you're like that busy and old, you're tired, you does all and you can't blame the person. But Lawrence Tierney wrote a book, book of pearls. And in that book of pearls, there is one pearl that said, you don't need to be scratched by a cat to get cat scratch. You don't need to be bit by a cat to get cat scratch. The cat can just lick you and you can get the infection just from a lick. And so they're presenting the case and they come to like Reza and they always hold on me. You know, I think that is a compliment. I'm going to be flexing brag about that. He said, Reza, what are your thoughts here? And there's cat history. I don't remember the case. I was like, do you know what? The patient had exposure to cat. And oftentimes we think the cat has to bite or scratch, but even a lick can lead to an infection. And this was in Lawrence Tierney's book of pearls. At this point, the chief resident goes to LT and LT is asleep. He goes with his hands right. And then they wake him up and he wakes up like in front of everyone. He's like, so the cat can just lick anything. I'm not really sure that makes me regret. It's a dude. Do you wrote it? I swear to God. I think she wrote it. I turn red and I just want to melt. And the guy who told me it can be done by a lickset. That doesn't sound like that. It's so good. Oh my gosh. You know, I think this patient proved you after all these years to be right, because the patient did not have any obvious bite or scratch marks. And he denied that he was bitten or scratched. So I think LT didn't listen to this, but I just want LT to know we love him and miss him. And I actually write on my desk at this portrait. And I swear to God, Robbie, I'm not lying to you. I swear to you, it's me, Gapri and LT. And I promise you. And I'm not just saying this to say it. I said, there's only one person missing from this. And I wish he was in this photo, and that's you. And I might actually just take a picture of his cut it out and put it because you guys are my core. And like, and that's so cute. I haven't hear for inspiration. Yeah. That's a wrap.