the initial clinical survey and how to identify the … · 2016-05-06 · so it’s really critical...

MODULE twO tRANSCRIPt: INItIAL MEtABOLIC SURVEY | COPYRIght © 2016 FUNCtIONAL NEUROLOgY SEMINARS LP | PAgE 1

THE INITIAL CLINICAL SURVEY AND HOW TO IDENTIFY THE LESION BEFORE EXAMINATION (MODULE TWO)

Transcript – Metabolic: Initial Survey of Appearance

Presentation by Dr. Datis Kharrazian

So listen, we’re going to hear… so hang in there with us. What Dr. Brock went over is, he went through the peripheral nerve localization form. Those two forms, if you know how to really use your brain region localization form and your peripheral localization form, you’re going to pretty much assess the central and peripheral nervous system very quickly, very efficiently, okay? Trust me: When you go on and try to learn this stuff, just from textbooks, and you’re randomly out there and not know what questions to ask and how to fine-tune it and how to localize it, it’s a nightmare. So when you have those tools that are already made for you, and then we’re going to keep going over imaginary cases with them that will really make it real easy to learn this material if you’re new with it.

Now, the thing I want to go into is how to identify key metabolic factors that impact neuron mitochondria from the initial survey. So remember, we talked about the forms that we’ve talked about to localize the region, and in Module Two, where you were, in addition to talking about what you observed, where you were implementing these forms. So the use of office forms and the use of your observational skills are all part of the initial survey, right? So you can look at your forms, kind of look at your patient, you haven’t done your exam yet, and you should have a pretty good idea what’s going on with them.

Now, what we covered so far is, we’ve gone into neurological assessment, the localization form, the peripheral one, and then then survey. Now we’re going to get into the metabolic portion. Now, I want you to learn a few simple things that are very easy and I have a little quickie form for you, that if you implement, you’ll find some of the major factors that are impacting this pathway. So, I’m not going to give you, in thirty minutes, an entire metabolic survey for every metabolic disease or nutritional thing, but I do want to give you the key things to look at clinically, when you’re looking at this model of neuron mitochondrial ATP production, right? The key things being poor circulation, anemia, dysglycemia, inflammatory mechanisms, autoimmune. These are all the things that can really sabotage us.

So, what we know is, you can do the best evaluation, do the best neurological workup, localize the region, but if there’s an underlying factor that is preventing oxygen to get to the brain, or glucose to get to the


brain, or there’s something causing significant inflammatory mitochondria uncoupling, you’re not going to get anywhere with your therapies or treatments. Does that make sense? You could have a person that has poor circulation, and you put him on all these different nutrients for their brain, but none of them reach the brain. They’re taking hundreds and hundreds of dollars worth of CoQ-10, mitochondrial support, and the best fish oils ever, but they don’t have healthy circulation, so it’s a failing model. If someone who’s severe anemic, and you go, “Oh, they’ve been anemic forever, I’m going to have to just load them with all the other supplements,” you’re not going to change their brain, okay?

So these aren’t just metabolic factors, these are, like, absolute clinical deal-breakers. Like, use your ability to change your brain. When it’s hypoxic, when there’s anemia, when there is severe dysglycemia that’s not addressed, you don’t have the possibility to change it.

So, we do have certain priorities, and our priority’s dictated by what neurons need. So what I want to do is, I want to give you your metabolic initial survey, that’s really focused only on these items. Right? The deal-breakers. Because we know if they have hypoxia, or circulation issues, or not getting enough fuel to brain, we just aren’t going to get anywhere with the basic pathways. So, we’ll look at body composition, general appearance, nails, what they’re wearing, their attire, neck, eyes, skin, and hair, and get a general idea of what is going on with them.

So, let’s start with poor circulation and anemia findings first. So, on your general survey, the minute you see an individual, the minute you see a patient, you immediately are looking at their skin, you’re immediately looking at their hands, you immediately look at their nails, and you should already have some general idea of what’s going on with them, right? Are they pale? How are their nail beds? And these are things… I mean, I can see them from here, across the room. It’s not like you need to focus in and do an exam, okay?

So, the first thing you want to look at is just the paleness of their skin. So for the most part, there’s a little bit of pink, a little bit of circulation, with people that have healthy red blood cells. And as people start to become anemic, they get to be more pale. Do you guys see those? And you guys see these brown spots here? This is… these are glycosylated end products. This is inflammatory immune reactions against the skin, right? So these are what happens when you have oxidative stress. You see them on people as they age, because they’re getting oxidative stress. The sooner you see these, the more oxidative stress you’re concerned with. You can see general paleness with that individual.

So, another key thing you’ll just see as… the minute you see a new patient is, you’re looking at their lips. Pale lips are a clinical sign of anemia. You guys can see how it’s pink here, but see how pale it is on the top? You guys can see the paleness there? You guys see that, you’re thinking, “Wow. I need to run a CBC. I need to see what’s going on.” And if you look at the big picture, here’s what you can do? You’re going to go through a detailed initial survey, you’re going to go through your forms, you’re going to do a history, you’re going to order some labs, you’re going to do a detailed neurological exam, and then you have all this information in front of you, and at that point you should clinically giggle. Because it’s so easy. Right?

When you don’t have that information, and you’re just trying to jump to some kind of treatment or therapy, it’s a nightmare, It’s so inefficient. It’s actually more efficient to you clinically when you just have this process and the step-through. It’s thorough, it’s complete, you do it with every single patient, instead of trying to recreate the wheel for each new symptom or new condition.


The other thing that may not be easy to see right away, unless you pull the eyelids down, is pale eyelids. Clinical sign of anemia. So paleness, uneven, is a sign of anemia, and then bluish nails are a clinical sign of hypoxia. So if you guys see blue nails like this, you’ve got to make sure you’re listening to their lungs, right? Making sure you listen to their heart, making sure you’re looking at some lab work, because there is a factor here causing hypoxia to distal tissues.

Now, the feet… the fingernails and feet and hands are really important to us, because clinically they’re distal tissue. Right? And the brain is distal tissue. Distal from the heart, and from your chief oxygenation regions. So when we see someone who’s got poor circulation in their hands and feet, we pretty much can bet they have poor circulation in the brain, okay? So distal, distal, findings in extremities are important for us as potential consequences that are happening in the brain. So you want to look at nails. They should be pink, not blue. And then the other thing you’ll see is, with people that have poor circulation, the white spots on their nails, which is a clinical sign of poor circulation as well.

So, here’s the thing. Your nails are always going to get beat up, just from doing things, and you get around. And then you get little spots on them. But if you’re circulation’s healthy, you immediately heal that. So the people that have poor circulation end up having different dots and different lines. Now, in the world of nutrition, they have all these different things. These lines mean that, and these lines mean zinc, and these lines mean calcium, and these little spots and arrows mean – I don’t know – molybdenum, and whatever, okay? Because there are no source for this. This is folklore nutrition passed on from generation to generation to generation. Right? It’s not specific for zinc. It’s not specific for all these things. But we do know, all types of spots happen when you can’t get all the nutrients to your distal tissue: your nails. So what is your blood carrying? Guess what? It’s carrying the zinc. It’s carrying the calcium. It’s carrying whatever mineral you want. If it can’t get to the tissue, nails can’t heal.

So one of the things we just look for generally is, are their nails healing? Because there’s always going to be some trauma to nails. Those traumas are going to cause little white spots. And then, do they have enough healthy circulation to heal. So if you see lots of spots in nails, you see blue nails, you see cold hands.

So here’s the scenario: Someone comes in and they have cold hands. Oh, let me make it even better. They come in and they have – thank you for the timer – they come in and they have bags of supplements, they put them down – pchrpchr! – earthquake happens, and you go, “What do you take?” “Oh, I take these. There’s more I take; I just forgot to bring them.” “Okay, when?” “Oh, every day.” “Alright. Okay.” And then you look at their nails, and first of all, you shake their hand, and their hands are freezing. And you look at their nails, and they’re white, and they have white spots all over. You guys understand that there’s a circulation issue. If there’s a circulation issue, no matter how much they take, it’s not going to matter if you’re trying to rehab the brain.

So it’s really critical for us to look for these anemia and circulation issues as a key factor in our initial survey. Does that makes sense? It’s not just something we’ll get to. It’s like, it’s a deal-breaker here if this is involved. So you want to look at those.

Now, if they have really severe hypoxia, lack of oxygen to their nails, you get this clubbing, deformity takes place, and lip discoloration is not a clinical sign of hypoxia. So you guys, any time you see hypoxia, you’re thinking of, “What’s going on with their heart, what’s going on with their lungs, what’s going on with their


red blood cells, and what’s going on with general circulation?” With a lot of these cases, you have to pull out your stethoscope, listen to the heart, listen to the lungs, order some lab work, and see what’s there to see what’s going on.

Another key sign of poor circulation is fungal toenails. And you guys know fungal toenails don’t happen because you get a fungal infection. It’s not like you stepped into a fungal antigen and now you have inoculation, and now you’ve got this fungal toenail, and now you’re just… you suffered from this infection. That’s not what happens. What happens is, you wear shoes and socks, and you sweat, and you create the environment for fungal growth. However, if you have healthy circulation, then in the circulation there are natural killer cells, and T-cells, and immune cells that then can not have a fungal overgrowth opportunity happen. So, people that have poor circulation, and they can’t get their immune cells to their distal toenails, will start to show up with these patterns.

Now, this is telling us, that probably since it’s distal tissue, we’re seeing it challenged by the fact that they wear shoes and socks, and now they have these expressions. We know that they probably also don’t have healthy circulation to the brain. You guys understand? Okay.

One of the things I’m going to commit to doing for you guys between now and the next session is, I’m going to make you guys a video on the next step, once you find each of these clinically. Okay? When you see poor circulation, you see anemia signs, you get that. We’ll put it up on the ancillary videos, and you guys can look at that and I’ll even simplify, run through all the anemias really quick, so you guys make sure you know all those if you need to do them. Because we need to also throw in some of that stuff for you. Okay?

Now, we talked about poor circulation anemia. So, here’s your general takeaway. The minute you see someone, just look at their skin, make sure they’re not pale. Look at their nailbeds to make sure they’re not cyanotic, right? If they’re wearing… if you can see their toes, make sure there are not fungal toenails. Look at their lips, make sure they don’t have any pallidness in their lips. And just get an idea of what you think is going on with their health. Right? As a key thing. If you see any of those signs abnormal, then you need to know that you could have a deal-breaker if you’re trying to rehabilitate the brain.

And, it could be because they come in for a chief complaint of chronic depression. It could be because they come in for a chief complaint of anxiety disorder. It could be because they come in because they’re fatigued, but their fatigue is really brain-based. It could be any one of those types of things.

Now, the other thing that you will always do is, when you see a patient, obviously they’re not… a patient’s not going to come in in a bikini, but you’re going to basically look at body composition. Right? And for the most part. I mean, Brandon’s… Dr. Brock’s patients might, but…

Dr. Brock

All of them. Mandatory.

Dr. Kharrazian

All of them. Mandatory. Okay. So, the point is this: When you guys look at a new patient, you guys are going to look at body composition. And for the most point, if you’re looking at one of the key factors, which is


blood sugar, if you guys see people that tend to be more on the overweight side, you would suspect that they have greater tendency to be insulin resistant. So if they fatigue after meals, or they crash… and if you see people that are normal weight, or even underweight, you would suspect, do they have any potential for being hypoglycemic? Right? So people that are hypo… let’s say we’ll start with normal weight. Normal weight or underweight – okay? – if you see them also tell you that they feel better and energized after they eat, and they get shaky and lightheaded and irritable between meals, they crash in the afternoon, that’s a hypoglycemia event. And those people will have a hard time healing their brains. So you want to start to screen for that. Okay?

Then you have people that are more on the insulin-resistant. They eat a meal and they pass out and they crash, right? They may be towards diabetic range. So one of the key things is, you’re looking at your metabolic factors that can impact brain. Once you’ve ruled out hypoxia and circulation and blood flow issues and anemia, just by looking at their nail beds and their skin and their lips and so forth, you get a general idea of looking at their body composition, and then seeing if there’s any factors that you may suspect, right?

So, the more overweight they are, the more tendency insulin resistance is an issue; the more underweight they are, you see someone that may have some circulation issues. So let me give you an example. Someone comes into your office, and they have severe depression, and they can’t focus, and they can’t concentrate. They fill out the brain function assessment form, the brain region localization form, they have all these frontal lobe, motivation, drive types of symptoms. You shake hands with the new patient, hand is freezing. You look at their nails, their nail beds are white with spots all over it. They’re underweight, and you see… they go, “I just need to eat something really quickly,” and they brought in for their lunch a power bar. And that’s the only thing they’ve eaten and it’s three o’clock.

Do you understand, like, for those factors, they’re all telling you they’re hypoxic, they’re hypoglycemic, right? They have poor circulation, and now you want to try to rehab their frontal lobe without addressing that? It’s not going to work. So those are the things that you want to pick up on, on a metabolic survey.

Now, as we get into blood sugar-related issues, if they’re really progressed with diabetes, uncontrolled diabetes, these Beau’s lines are a clinical sign of uncontrolled diabetes or peripheral vascular disease. And if you guys start to see these types of lines, you’d be very concerned about peripheral nerve disease as well. You definitely want to go in there with a tuning fork and look at their vibration perception, because they’re likely to have some injury to those areas.

Acanthosis nigricans is a common skin presentation of chronic insulin surges. Insulin surges impact melanin, which makes the skin darker, so you might see those with some people that have chronic insulin issues. Okay?

But the biggest clue that someone has any type of blood sugar issues, typically just body composition. You guys have all seen the overweight, insulin-resistant, inflamed person. You guys have all seen the underweight, hypoxic, poor circulation, hypoglycemic patient, right? So when you see them, just know that those are factors that could impact any kind of rehab that you do.

Now, what I want to get into is some of the clinical findings associated with inflammation, autoimmunity, and chronic inflammatory response. So, chronic inflammatory responses can uncouple mitochondria, right?


Now, the brain is one of the most vulnerable tissues to chronic inflammation, simply because there’s not a very high antioxidant reserve system in the brain. Okay?

So, chronic inflammation has this inflammatory, degenerative process on the brain. So if someone’s had chronic inflammatory bowel disease, or some kind of chronic inflammatory autoimmune disease of some kind, you know over a period of time that there’s going to be some issues with brain health and brain integrity. Right?

Now, sometimes when people come in and they have brain-related chronic symptoms, they may have an ongoing inflammatory cascade that you want to address, because if you don’t, they’re going to fatigue really quickly when you do brain rehab and brain exercises. And also, those inflammatory models will reduce ATP and potentials to have plasticity development and mitochondrial function.

So we want to look for chronic inflammation. Now, you would be surprised, if you start looking at nails, how common these different types of things are. Okay? Now, on initial survey, you can get a general clue what’s going on with nails, and you should do that when you first see the patient, but you should actually examine the nails during the exam, which we haven’t gone into yet. We’re just talking about the initial survey. And the way you do this is, you actually get a magnifying glass, in high light, and you just look at nails. And all of these things show up that you never though before. So, you know, you don’t want to just like, “Oh, nails! You got ’em! Yep!” You want to, like, go in there; you go, “Wow, do I see nails? Do I see anything pitted?” You know – more of those types of reactions.

So when you see rippled or pitted nails like this, you’re going to see this with inflammatory joint diseases and autoimmune diseases all the time. Okay? The inflammatory response causes these rippled or pitted nail reactions on the skin. Here they are. Here’s more progressed. Okay?

Now, another thing that a lot of people have are vertical lines. And vertical lines like this, if you see them like you see on this illustration here, you see vertical lines going through the nails, you’d be thinking of iron deficiencies, protein malabsorptions. You guys, the most common cause is chronic inflammation, just intestinal permeability. If you really look, you’ll see a lot of people start to have these vertical lines like this. If you had hypoxia and protein malabsorption, and then you had poor circulation and dysglycemia, on top of anything you find on a brain region localization form, you’ve got a whole cascade of things that need to be addressed.

Vitiligo is an autoimmune condition against melanin and often accompanies most autoimmune diseases. This is more common than you would think. If you start really looking at skin, a lot of people that have autoimmunity start to have this. And we know that the brain is often a common site for autoimmunity too, that’s not multiple sclerosis. Meaning, when we see people that have chronic brain-related symptoms, and chronic inflammation, many times when we run neurological antibodies, like myelin basic protein, or myelin- associated glycoprotein, or neurofilament antibodies, they’re outside the range. They’re elevated. So there are lots of people that have subtle neuroautoimmune diseases that haven’t progressed to the point where they have hard neurological signs like MS, but they have chronic brain symptoms and brain inflammation and depression, and poor brain endurance, and those types of things too.


So any time you see any sign of one autoimmune disease, you look for other signs. And it could just be like they come in and they have arthritic type of joint. They have an… already they have a rheumatoid nodule. They have some joint deformity, and they have chronic inflammation, and you see some changes in their melanin in their skin as in vitiligo. They have all those things together, and wow, there’s some autoimmune component to this, right? And, “Why are you here?” “I have chronic dizziness and vertigo.” “Wow, do you have cerebellar antibodies?” Right? Those are things that you want to think about as you do the workup.

Now, the other key thing you’ll see all the time just inflammatory reaction to skin. And usually inflammatory reactions are often accompanying systemic inflammatory conditions. So you have people that have inflam-matory reaction to their skin, like eczema, rosacea, or… Because they have an inflamed diet. Or they have an inflamed gut. Or they have an underlying inflammatory condition. So the skin is actually the immune system. And immune cells in your gut and throughout your body and your lymph nodes have cytokine messenger releases that interact with immune function and responses on your skin.

So, you guys have all seen kids that have, like, eczema, and then they change their diet and the eczema clears up, right? So whenever you see someone come in and your initial survey is that you see these inflammatory skin reactions on their skin, those inflammatory reactions are probably not localized just to the skin, and they’re probably systemic. Especially if they don’t go away with something like topical cortisone cream. Right? If they don’t go with a topical anti-inflammatory substance, and they tell you they’ve tried topical cortisone and it doesn’t go away, you probably know it’s an inflammatory systemic response. Not just a local response. Okay?

Now, those are the inflammatory mechanisms that you want to look for. So, you know, they come in, you look at them, look at the general body composition. Are they underweight, maybe hypoglycemic? Are they overweight, maybe insulin resistant? Do they have paleness? What’s going on with their nails? Do you see signs of circulation issues? How are the… do they have any fungal overgrowth in their tissues? Do you see any signs of cyanosis? And then now you’re going, “Do you want…” Now you start to realize that if you have any of these key, obvious things that are there. Right?

Now, because what if you see a patient comes in that no one’s been able to help… No one’s been able to help ever! They’re so chronic! And they happen to even be a doctor, and no one’s been able to help them. And they come in and they have raging hypoglycemia, and their toes are as blue as can be, and they have no brain function. They can’t focus, they can’t concentrate, they can’t get through the end of the day. And they wonder what supplement they need to take, and you do a blood… you do a CBC for the first time in twenty years, and they’re anemic. You’re shaking your head going, “Why? Why?” Because these things are, like, so obvious that you ignore them.

How’s the circulation, how’s their blood flow, how’s their respiration, right? You guys listen to the heart, you guys listen to the lungs. Do you know your heart sounds? Do you know your lung sounds? If you don’t, there’s great apps. Make sure you start listening to them. Alright? Make sure you can pick up on these things, because they make a difference.

So, let’s go through an exercise. Tell me what your metabolic impressions are.


“Hi, my brain doesn’t work. What do you think?” “Well, I think it’s, you know, serotonin. I’m going to give you some 5-HTP, some tryptophan. Get you all working up. Your depression will change in a minute.” It’s not that. I mean, this is probably a person who’s got some hypoxia, oxygenation issues going to the brain. This is a bigger problem, right? Okay.

What about these? What do you guys see right here? Some clubbing. How does the nail color look? It looks a little pale, right? Now, you guys, if you touch their fingertips and compare it to their wrist, what do you think it would tell? What do you think you would feel? Or if you touch their fingertips and then compare it to their forearm? It’s probably going to be colder on the fingertips, which means they have poor circulation. So they may have a circulation-related issue.

How about this? Let’s say it’s chronic depression, brain fatigue, and anxiety. So you’re immediately thinking what? Thyroid? Maybe some kind of metabolic disease? Do you see the hair loss? Right? Thinning all like that, all over? It’s very, very thin hair. And this is probably some swelling, myxedema. I mean, you’ve got to definitely rule out thyroid issue if it hasn’t already been done. And then tell me about their face. First of all, is one side, like, older, and does one side look younger? Right? So if you kind of look at this, this side looks a little younger, this side looks a little older. So is this a change in facial tone? Maybe. Potentially. Do you see a difference… do you see a head tilt? Yeah, you see a head tilt. They’re kind of tilted, so the right side is up, right? The left side’s down. Do you see that one… do you see the difference between the eye positions? Right? So right away you’re thinking, “Wow, this person could have a thyroid, there’s some hair thinning, they have some facial weakness there, they have a hypertropia, Those need to be evaluated further. And then I don’t know if you guys can see the pupils very well, but is there a difference in pupil size? And there is. There’s a… the right one’s slightly larger, which can then tell you some things about sympathetic tone. Okay?

Now, let’s say you fill out… this person fills out the brain region localization form, and they have all these symptoms of autonomics – sympathetic and parasympathetic – and they have all these symptoms associ-ated with depression, frontal cortex issues, and then you run their lab work, and their TSH is elevated – let’s say 8 – and their HbA1c is elevated at 8. Right? So they’re in the diabetic range and the hypothyroid range, and they’re taking all these different things for depression nutritionally-wise, or they’re trying to support their brain with mitochondria support, and all these things we do, but they haven’t addressed the underly-ing mechanisms, right? The underlying metabolic conditions.

Alright. What about this? Right? So you see some autoimmune-type responses, the melanin type of reac-tions there.

How about this? Take a look here? What do you guys see? This is an enlargement. She’s staring at something, or she’s not. She’s really happy to see something, or shocked, or whatever. So what happens is, this is like, we see that, we’re thinking of maybe potential hyper, right? Now, when you have too much thyroid hormones in your bloodstream, thyroid hormones increase metabolic activity to muscles, and they make muscles contract, and one of the first places you see that is with eyelid muscles. They’re very sensitive to thyroid hormones, so when someone has too much thyroid hormones, the eyelid muscles contract, and they have this, like, staring effect. Okay? So you see that with a thyroid line here. Now, is this thyroiditis? Or is this a goiter? How would you know? Well, goiters never change size. Thyroiditis is swell and unswell. So they increase and decrease in size. They increase and decrease in size, you know it’s an autoimmune response. That make sense? So these are usually autoimmune types of thyroiditises that take place.


Okay, what do you guys think if you guys saw this? So you guys see the vertical lines, right? Those are associated with protein malabsorption, inflammatory conditions, that can impact your patient’s outcome. That can happen with intestinal permeability. But remember, this is like… there isn’t one thing or the other. The intestinal permeability can now cause brain inflammation. Or, their injury to brain can impact their brain-gut axis, and now they have intestinal inflammation, now they have this vicious cascade. Okay?

So, here’s what I have to try to tell you guys: It’s… the diagnoses and assessment is not the hard part. The hard part is, how do you untangle the webs you’ll find? That’s where the true skill really comes in as a clinician. “I have all these things overlapping; where do I start first? Where do I start second? Do I try to treat them all at once? Do I put them on every single supplement? Do I give them every type of brain rehab? Do I just give them more because it’s better? Do I know how to do less?” That’s where the real skill comes in. You guys understand? But part of it for sure is, you’ve got to identify the mechanisms involved, which is where we’re at.

Okay. Now, you guys know Leonard Nimoy? So I guess he has… how does his skin, vascular circulation look? Not so good right now, right? Well, he’s got COPD. He’s dead now? Sorry – he’s dead. He died. I don’t keep up with Extra and TMZ and whatever. Sorry! Anyways… So, but you can see the poor circulation. So when people start to have poor circulation, you see it in the nose. You see the cyanosis there? And then you see the pinkness and red? Like, you see here, see how it’s blue discoloration? And then you see some flushing areas, and some paleness? That’s what you see with people that have pulmonary diseases. You see those mixed types of reactions there.

Okay. Do you want to… What’s the success do you think you would have with this child if he had ADD, ADHD, some kind of developmental delay, and he’s – first of all, having to use oxygen. Now, is he pale to you? Yeah. Because, you guys, his normal skin color is actually what you see around his eyes. Okay? So to go in there and throw him into therapy and trying to do all these things could be not as effective unless you treat the underlying lung issue, right? Respiratory issue. Maybe he’s got chronic asthma. Why does he have chronic asthma? Maybe he’s got environmental metabolic chemical things that are causing vasoconstriction, maybe he’s not producing enough adrenal medulla catecholamines, maybe it’s a combination of all the above. Those are all factors. Okay.

How about this? What do you guys see with these nails? Do you see spots? There they are here, right? You see some spots. Do you see the lines? So now you see lines, you see spots, right? They’re kind of pink but not all around? They’re a little bit of whiteness. But for the most part, you see lines and you see spots. So, circulation, inflammation, may be some factors that are involved with that.

And then how about this? So, fungal toenails, right? Poor circulation to the toes.

So, we’ve gone over the brain region location forms, and Dr. Brock went over the peripheral nerve localiza-tion form, and he’s going to continue to go into this initial survey form. In your notes you have this – and I went over the neurological assessment before the patient encounter – so here’s just a quick form.

What’s your body composition? Is it normal? Are they overweight? Are they obese? Are they underweight? Are they significantly underweight? What’s their attire? Are they coming into your office on a sunny day and they’re wearing a jacket? They have thermoregulation issues, right? Are they wearing a t-shirt and


it’s freezing outside? Do they have any metabolic concerns? How’s their hair? Is it thinning? Do they have patchy hair loss? Is it coarse? Is it dry? Is it healthy and shiny? How’s their skin? Pale, dry, psoriatic, inflammatory, discoloration? How’s their lips? Dry, pale, cyanotic, other? How are their nail beds? And then how’s their thyroid line?

And obviously you guys know this, but sometimes when you have a form, and you just have to go through the practice, and then you go back and watch slides and watch images, you really start to integrate into your thought process, right? So what typically happens is, people go to course, they learn all sorts of information, and they don’t know how to apply it and how to absorb it. So we make these clinical quickie forms for each of these sections that are clinical, that are related to the exam and your clinical workup, because we want you to actually go through the thought process which you just learned, so then you can review it and it can be fresh, right?

So sometimes you just look at the nails, you’re not really sure what you’re looking for. So it’s nice to have these little forms. You can take them out on Tuesday and do it with a few patients, and do one on the other day, or just kind of get used to them, and then go over your notes again, and then it’ll start to make you really implement the information. Okay?

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the initial clinical survey and how to identify the … · 2016-05-06 · so it’s really critical...

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