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SMED 175 Podium: Alright. So should I. Just get started. Okay, welcome back.
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SMED 175 Podium: you’re almost there. Right class is done, and in a few weeks or a month or so. You won’t care anymore about all this stuff, right? And then just move on to the next stuff. So I’m excited for you. I’m going to miss seeing a lot of you around
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SMED 175 Podium: after you move to your respective campuses. So
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SMED 175 Podium: But the good news just put everything in perspective. You know your
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SMED 175 Podium: forefathers right, your upperclassmen, the graduates right? We have. We. The last few months we’ve had 4th year students working with my partners, and I
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SMED 175 Podium: everybody’s gotten through this they managed to pass. They managed to move on with life, and life gets better after this. So right now you’re kind of you’re kind of in this gopher hole that just seems like you’re never going to get out of it. But you will so hang in there. Life does get better. Okay? So put your time in like you’re like, you probably know you need to. And then
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SMED 175 Podium: move on with the rest of the stuff, because then there’s this like rapid change, right when you go from second year to 3rd year, all of a sudden it’s like swimming in oil all over again because you’re on rotations and you get Wbas. And you’ve got all these other things to do, and you don’t know where you’re supposed to be, and you don’t know anybody, and you’re not sure where to park and all that, but that, too, gets better. So anyway, I’m excited for you.
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SMED 175 Podium: So
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SMED 175 Podium: I kind of have some high yield things that I wanted to go over that will hopefully cover lots of different topics. So we’ll do the Ras system, the glomerular hemodynamics hip.
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SMED 175 Podium: important parts of the tubule
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SMED 175 Podium: go over acid-based stuff. Do you guys have acid-based stuff on your Cbsc, so maybe this is kind of timely because that might help you think through things. Or maybe you’ll realize that all the questions you got right
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SMED 175 Podium: or not. But it’s just so much information, right? And so remember, this stuff is not infinite, you know. At some point you’ll just keep going over it enough times where you’ll make enough sense out of it so that you can practice whatever version of medicine it is you hope to be practicing. So
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SMED 175 Podium: anyway. So we’ll do some acid based stuff. We’ll do acute kidney injury stuff. Hyperparathyroidism is such super rich stuff for testing purposes. So it’s worth spending a little bit of time on that. And then, lastly, we’ll just kind of go over some glomerular disease, and then, whatever else you all want to go over. So if you have questions, let me know, because
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SMED 175 Podium: you may have some perspective or some recent exam question experiences that I haven’t had. So let me know.
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SMED 175 Podium: so as far as Ras goes, and the way I wanted to structure. This whole thing is, I took questions out of Amboss.
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SMED 175 Podium: and then just figured I could kind of work through how to think about the questions. And what are they asking? And more importantly, what are the clues that they’re giving you? Because if you can just work your way through the clues that helps you get rid of answers or
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SMED 175 Podium: helps you solidify an answer, or sometimes they’re just plain old red herrings. But if you think through it.
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SMED 175 Podium: that’s the key feature. So
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SMED 175 Podium: so let’s just start off with the ras stuff. And this lovely renal plasma flow, filtration, fraction, glomerular filtration rate, and all that. So 55 year old type 2 diabetes comes. The
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SMED 175 Podium: doctor’s office feels well. Blood pressure is 155 over 60 labs show a glucose concentration of 150. So it’s up there a little bit, and the hemoglobin a 1 c is elevated, correct. So goal hemoglobin a 1 c is well, normal is under 6% somewhere in that range. So this is definitely elevated. And this person gets treated with or started on lisinopril.
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SMED 175 Podium: Okay? So which of the following findings would you be expecting to find after starting Lisinopril?
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SMED 175 Podium: So does this question make sense?
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SMED 175 Podium: Yeah, okay, you want me to go through it or not. Really? Is it too straightforward?
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SMED 175 Podium: So I’ll tell you what, I’ll just draw stuff out. So what’s that?
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SMED 175 Podium: Go go for it? Okay, we’ll do that all right. So
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SMED 175 Podium: alright. So a few things here so license. Apparel is an
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SMED 175 Podium: ace inhibitor right? And ace inhibitors, as far for all intents and purposes for testing purposes. Ace inhibitors work where?
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SMED 175 Podium: Right? So if you have this thing right?
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SMED 175 Podium: So here’s the glomerulus blood’s flowing this way.
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SMED 175 Podium: What hormone regulates the afferent arterial.
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SMED 175 Podium: What! What vasodilates the the incoming pipe?
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SMED 175 Podium: So that’s prostaglandin e 2. If you care
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SMED 175 Podium: so prostaglandins vasodilate the incoming pipe, and then what regulates the outgoing pipe, mainly the efferent side.
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SMED 175 Podium: So that’s gonna be what angiotensin? 2. Right? Okay.
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SMED 175 Podium: So when you sprinkle Prostaglandin on the afferent side, vasodilates sprinkle angiotensin 2 on the efferent side. It vasoconstricts. Now you’ve made a sprinkler head right? So you got pressure coming into this fenestrated bunch of blood vessels and you wind up with Gfr, right? So this is our Gfr
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SMED 175 Podium: right here and now we’re going to put somebody on Lisinopril, which does what?
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SMED 175 Podium: So it’s gonna prevent the formation of Angiotensin. 2. Right? That’s the whole idea. So I guess we could do that part of things. So
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SMED 175 Podium: so Rennon, Andrew Tenson, 2 and Aldo right. Those are kind of the big pieces of the Ras system.
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SMED 175 Podium: So if you put somebody on an ace inhibitor.
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SMED 175 Podium: where where does the where does the ace inhibitor work, at which step it’s gonna block here, correct.
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SMED 175 Podium: And so at 2 levels are going to go down.
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SMED 175 Podium: Okay, what if they asked you
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SMED 175 Podium: about somebody having been put on an arb. So what if they get them on? Valsar? 10 low, sar, 10
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SMED 175 Podium: can, whatever whatever sartan they put them on?
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SMED 175 Podium: Where do the sartans work.
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SMED 175 Podium: They work on the receptor. Right?
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SMED 175 Podium: So what happens to Angiotensin? 2 levels? If you put somebody on an ace inhibitor.
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SMED 175 Podium: they go down. Okay, what happens to Angiotensin 2 levels if you put them on an Arb.
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SMED 175 Podium: and so you’re you’re blocking this side of things. So the so with an ace inhibitor the Angiotensin. 2 levels go down
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SMED 175 Podium: with an arb angiotensin. 2 levels go up. You’re blocking it because you have an Angiotensin receptor blocker. But in this instance renin levels will be increased. Angiotensin. 2 level will be low with an ace. Inhibitor.
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SMED 175 Podium: Random level would be high. Angiotensin
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SMED 175 Podium: to level would be high with an arb, right? So just know that difference they like. I think they like that part. So in terms of trying to answer this question, then do you remember how the filtration fraction? What that means?
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SMED 175 Podium: Okay? So the filtration fraction is what?
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SMED 175 Podium: Yeah? So filtration fraction equals Gfr over the renal plasma flow? Right?
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SMED 175 Podium: So what’s happening in this person’s
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SMED 175 Podium: hemodynamics here? So if we vasodilate here with the ace inhibitor.
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SMED 175 Podium: my writing looks horrible on here anyway. So ace inhibitor here, you vasodilate that right? So if you open up the previously constricted outgoing pipe, the Gfr goes
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SMED 175 Podium: down right? So Gfr goes down.
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SMED 175 Podium: So you know that this number went down.
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SMED 175 Podium: And what happens to the renal plasma flow? It’s going to go up because you sprayed out less right? So this goes up
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SMED 175 Podium: so down, divided by up equals down. Right? So filtration fraction goes down.
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SMED 175 Podium: So which answer is this on here, whichever looks like this. So filtration fraction is going to be down. It’s going to be one of those
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SMED 175 Podium: Gfr. We said was down. So it’s going to be
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SMED 175 Podium: one of those, and then the renal plasma flow is increased.
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SMED 175 Podium: and there’s only one that’s increased. So it should be.
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SMED 175 Podium: D, does that make sense?
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SMED 175 Podium: So a lot of these things are just mental math. You know what’s what numbers going or what
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SMED 175 Podium: what properties going up, what properties going down, and then you should be able to sort that out. But as far as the filtration fraction effects of an ace or an arb, they’re the same. The difference is going to be what the angiotensin 2 levels are. So I can see them asking something like that.
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SMED 175 Podium: So any questions on this one, okay.
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SMED 175 Podium: think more often about the 8 parent or 2. Well.
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SMED 175 Podium: if nothing is changing there, and we have a certain volume of blood coming in the glomerulus. I’m going to dilation of the heat bearing change, renal plasma flow
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SMED 175 Podium: when what’s coming in it either goes to the Google playlist or it leads to the EPA,
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SMED 175 Podium: or, okay, to answer your question. So the file from the flow doesn’t change. I mean, that’s the board.
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SMED 175 Podium: Okay, the plasma foil stays the same.
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SMED 175 Podium: Yeah, what’s okay? So the the amount of blood going into the system
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SMED 175 Podium: stays constant. I mean there’s a constant amount, or there’s a set volume going in right? And so the question is, how much of it got sprayed out into the tubule, and how much stayed in the peritubular capillaries.
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SMED 175 Podium: So does that make sense?
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SMED 175 Podium: And it’s just a matter of what direction that plasma is being told to go? Or where’s the path of least resistance? Is it to go? Is it to go out
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SMED 175 Podium: into Gfr more, or does it stay in the blood vessels that makes sense.
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SMED 175 Podium: But that that’s the idea behind it.
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SMED 175 Podium: Did? I explained it. Right? Yeah. Okay, so just a matter of what
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SMED 175 Podium: what’s going to be the path that allows the Gfr to happen right? And as long as you got that pressure differential there, it’ll happen. But if you don’t, then it won’t. Okay.
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SMED 175 Podium: Alright any questions on this.
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SMED 175 Podium: Okay?
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SMED 175 Podium: And we can go as slow or fast as you want on all this stuff.
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SMED 175 Podium: There we go, all right.
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SMED 175 Podium: So filtration fractions are good to know about
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SMED 175 Podium: right, because those are just such easy. Those are kind of easy points. So those are good formulas to know about. I’m not a real big fan of having to memorize too many formulae. But there’s a few that are worthwhile. So so in terms of this, this is kind of just what we went over. So Gfr, is this differential between the afferent and efferent pressures nsaids and aces and arbs affect that.
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SMED 175 Podium: So remember what’s the effect on the filtration fraction. If you put somebody on ibuprofen.
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SMED 175 Podium: we’re on some kind of an nsaid.
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SMED 175 Podium: So the easy way to remember this is, if you manipulate the efferent side
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SMED 175 Podium: that’s going to change your Gfr.
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SMED 175 Podium: And so your filtration fraction is going to change. If you manipulate the afferent side, everybody suffers right. Gfr goes down and the renal plasma flow goes down. So the net effect of putting somebody on an Nsaid is. There’s no change in the filtration fraction. There’s a reduction in net flow. But the ratio doesn’t change
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SMED 175 Podium: right? So. But that’s a key feature. So that’s an easy gimme one. If they give you nsaids or something about the afferent arterial there. Just remember that there’s tone that change there.
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SMED 175 Podium: The other surrogates to remember. So Gfr the chemical we use to check, for that is inulin right? And then pah! Is renal plasma flow. So it’s same idea. So filtration fraction equals Gfr over Rpf
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SMED 175 Podium: filtration fraction equals inulin over. Pah! Okay, so that’s that stuff that you’ll probably see something in there about Inulin.
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SMED 175 Podium: And then if they give you that concept, that
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SMED 175 Podium: something showed up in the urine in a concentration greater than the Gfr.
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SMED 175 Podium: Right then. That means that whatever molecule it is you’re looking at is getting is getting Gfr. It’s getting filtered, and it’s getting secreted right? That’s pah! So pah is going to be greater than your Gfr.
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SMED 175 Podium: that makes sense. So that’s again, those are just topics or concepts they like you to know about.
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SMED 175 Podium: And then, if you want to look at the whole system, look at the whole organism. The whole person.
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SMED 175 Podium: then the way that we do this clinically is because Gfr is a
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SMED 175 Podium: miserable thing to determine. Clinically, we use this surrogate called clearance.
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SMED 175 Podium: The formula for clearance is UV over. P. So it’s your urine concentration Times. The volume divided by the plasma concentration. So know that concept that it’s kind of the clinical surrogate for Gfr, okay, so any questions on that.
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SMED 175 Podium: And then the UV. Over P. If they give you stuff a lot of it, you can just do the math in your head pretty easily. They’ll give you a number like the urine concentration is 100. The urine volume is 50. The plasma concentration is 20, you know, just something like that, and you can kind of do that in your head pretty quickly. So
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SMED 175 Podium: any other questions on this part but the Raz system. They love the raz system. And then the other part that I didn’t really emphasize on here too much is the what turns renin on.
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SMED 175 Podium: Okay. So what tells the body to crank up renin for this whole system to do its thing. And just remember it’s low blood pressure.
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SMED 175 Podium: low, tubular
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SMED 175 Podium: Osmole delivery. Usually it’s chloride. But just know that you’re you’re not delivering very many osmoles. And then a big
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SMED 175 Podium: adrenergic pulse, like a big, a big burst of adrenaline will do that as well. So sympathetic activity, so
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SMED 175 Podium: low blood pressure, low tubular flow rate, and a surge of adrenaline.
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SMED 175 Podium: A surge of sympathetic activity will turn on Renin, and then the whole thing turns on right.
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SMED 175 Podium: and then the
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SMED 175 Podium: the rest of it has to do with what drugs are you on? Are you on an ace or an arb. Are you on Spironolactone? Are you on? You know? However, they decide to manipulate all that stuff.
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SMED 175 Podium: and then I can’t imagine they won’t ask about gynecomastia with spironolactone, because it has anti-androgen properties. So
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SMED 175 Podium: anyway, any questions on that one.
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SMED 175 Podium: Okay, so know the razz system because it is
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SMED 175 Podium: going to show up time and time and time again on the test, I think. Okay. So next 1 70 year old is brought into the er 1 h after being found unconscious by her neighbor. No medical history is available. Temperatures up a little bit. So pulse rates 120
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SMED 175 Podium: is that normal.
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SMED 175 Podium: though it’s fast, right? So there’s a clue there and then the blood pressure is 70 over 50.
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SMED 175 Podium: So by exam taking strategies, what’s this person’s volume? Stat intravascular volume status.
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SMED 175 Podium: It’s going to be low, right? So you have decreased volume. So the heart rate goes up to compensate. So the cardiac output can maintain itself.
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SMED 175 Podium: Okay, so Gfr is 70.
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SMED 175 Podium: So they’re just telling us that it’s a little bit on the low side. And there’s an increased filtration fraction. Which of the following is the most likely cause of these findings.
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SMED 175 Podium: so is it. You know, myeloma, aspirin, diarrhea, kidney, stone, or pyelonephritis. So you’re just working through this whole thing.
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SMED 175 Podium: Blood pressure is low, pulse rate’s high. So volume status is low.
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SMED 175 Podium: so the Ras activity should be
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SMED 175 Podium: increased right? So Ras is going to be up, and
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SMED 175 Podium: if the Ras activity is busy, what
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SMED 175 Podium: are the a t 2 and Aldo levels, what should they be?
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SMED 175 Podium: They should be up right? So the A. T. 2 is going to vasoconstrict
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SMED 175 Podium: the periphery, and the Aldo is going to help us hold on to sodium. Right? So we’re going to try and volume expand ourselves.
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SMED 175 Podium: So
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SMED 175 Podium: which of these, do you think is pertinent to this whole thing? Is this person, you know? Do they have a do you think this is an infection. Do you think it’s an obstructing stone? Do you think it’s diarrhea? Do you think it’s salicylate poisoning and myeloma? And so they’re only giving us so many hints here. Right? We get the fact that they’re hechycardic. They’re hypotensive.
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SMED 175 Podium: and they’re unconscious.
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SMED 175 Podium: That’s kind of all we know. And so
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SMED 175 Podium: how do we go through all this stuff? Well, if the person has
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SMED 175 Podium: hypotension tachycardia, the Renin level should be very high, right?
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SMED 175 Podium: The so the
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SMED 175 Podium: like. We mentioned earlier, what turns on renin production, hypotension, low flow, state, and all of that stuff.
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SMED 175 Podium: So just appreciate that that they gave us a lot of clues here for volume status.
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SMED 175 Podium: And so the Ras activity is going to be increased.
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SMED 175 Podium: Intravascular volume. Depletion is what it tells us, and then at 2 constricts, the efferent arteriole.
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SMED 175 Podium: So the renal plasma flow is going to go down right.
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SMED 175 Podium: That makes sense.
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SMED 175 Podium: So if the because at 2 is going to be working on the outgoing pipe. So it’s going to vasoconstrict that to try and increase the Gfr.
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SMED 175 Podium: so
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SMED 175 Podium: this is the body trying to protect itself right? So trying to preserve the urine output, it’s trying to preserve the blood pressure, and so on and so forth. So does it make sense that this person probably has diarrhea, and not
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SMED 175 Podium: an obstructing stone
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SMED 175 Podium: or myeloma. I mean, none of these other things really fit. This. Does that make sense? Okay? And just based on the clues here. There’s like absolutely nothing there about like for myeloma. What hints would you be looking for?
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SMED 175 Podium: Anemia, hypercalcemia, bone pain? Right? They kind of give you some other clues that myeloma was in the mix.
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SMED 175 Podium: If they’re going to give you a nephrolithiasis question, what kind of stuff would you expect as hints?
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SMED 175 Podium: Maybe hematuria on the Urinalysis. Maybe some flank pain, maybe some weird history about gastric bypass surgery or something like that, just something that puts them at risk for stones. Yeah.
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SMED 175 Podium: anemia. Yeah. So crabs or crab for myeloma is calcium renal failure, anemia, and
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SMED 175 Podium: within bone pain. Right? So. But so that’s you know, they’re going to give you clues like that. So I’d know myeloma, because that’s probably going to be on there, I would imagine. Yeah.
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SMED 175 Podium: Oh, what pushes me away from it.
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SMED 175 Podium: pyelonephritis doesn’t necessarily mess with your glomerular hemodynamics.
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SMED 175 Podium: The volume status, for sure, would now, could somebody with pyelonephritis be hypotensive tachycardic that kind of stuff.
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SMED 175 Podium: possibly, but I would have expect them to give me a little bit more information about flank pain, you know, cost overtebral angle, tenderness, stuff, and infected looking urine
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SMED 175 Podium: stuff like that because you can’t, I mean, so the based on the info they give us diarrheas can be a pretty compelling answer, and the others are just harder to justify without trying to add more
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SMED 175 Podium: to the story that they didn’t give us.
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SMED 175 Podium: So. And that’s that’s always my problem is, I always think outside of the story, and then I get it wrong. So.
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SMED 175 Podium: but does that help? Yeah, okay, alright. So
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SMED 175 Podium: tubule highlights know the segments of the tubule kind of like we went through in class. And if you can just envision all these compartments doing what they do.
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SMED 175 Podium: that’s
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SMED 175 Podium: that’s 80% of the game right there and then, if you can add on pharmacology on top of it, then you’re like 99% of the way there. Okay? So when I say pharmacology, drugs or hormones, right? So, endocrinology thrown in there, too. So just to go over these boxes really quickly remember the proximal tubule, right? So it’s the the 1st and major site of reabsorbing stuff.
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SMED 175 Podium: So what does it reabsorb it? Reabsorbs everything. Okay? It expends the most energy. Right? So it’s like what’s going to chew up the most atp because it absorbs reabsorbs like 70% of the stuff that gets filtered out. So just remember, it’s an energy hog, and it’s got lots of mitochondria, but it reabsorbs everything. It reabsorbs, sodium, potassium
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SMED 175 Podium: water, calcium, phosphorus, bicarb protons amino acids album all this stuff gets reabsorbed there. And so
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SMED 175 Podium: what else do we need to know about the proximal tubule?
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SMED 175 Podium: It’s the major site of bicarbonate reabsorption
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SMED 175 Podium: right? And if that gets messed up where somebody’s on. It’s messed up. Because, let’s see.
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SMED 175 Podium: why does Bicarb get reabsorbed? Or how does Bicarb get reabsorbed in the proximal tubule?
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SMED 175 Podium: There’s an important enzyme there.
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SMED 175 Podium: So it’s
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SMED 175 Podium: carbonic anhydrase. Okay, that allows us to to reabsorb the. So it flicks it into Co. 2 and water. And then we can that. And then it turns it back into bicarb in the body in the bloodstream. So
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SMED 175 Podium: if you mess with that system, so how do we mess with carbonic acid pharmacologically.
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SMED 175 Podium: definitely know this one. So it’s acetazolamide, right? So acetazolamide pickles, carbonic anhydrase and so more bicarb will show up in the urine so you’re it’s a bicarb losing event.
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SMED 175 Podium: Okay, that is. And now you’re losing bicarb.
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SMED 175 Podium: So now the body has an excess of protons.
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SMED 175 Podium: So now you’ve got an acidosis.
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SMED 175 Podium: It’s coming from the kidneys. So it’s a renal acidosis.
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SMED 175 Podium: and it’s an acidosis that’s coming from the tubules in the kidneys. So it’s a renal tubular acidosis. And it’s type 2. So a type 2, Rta is like being on Acetazolamide. There’s other things that can cause it, too. But don’t worry about that.
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SMED 175 Podium: So Acetazolamide is very important, and then topiramate topamax is another drug that’s into carbonic anhydrase inhibitor will do the same thing. So know about that if you got one of these weirdo amino acid dumping syndromes, or you get children with failure to thrive and all that kind of stuff. It’s because they’re not reabsorbing amino acids in the proximal tubule, right? Because no other part deals with it. So the way I like to look at this is
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SMED 175 Podium: the proximal tubule reabsorbs everything.
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SMED 175 Podium: Okay. So all that stuff glucose?
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SMED 175 Podium: What is a so glucose gets reabsorbed there?
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SMED 175 Podium: How do we? How does that
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SMED 175 Podium: kind of get manipulated? Now? Therapy wise?
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SMED 175 Podium: We put people on these newer drugs.
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SMED 175 Podium: Yeah, so sglt 2 inhibitors, right? So sglt, 2 channels are in that area. And so if we put people on sglt 2 inhibitors. They’ll pee off glucose.
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SMED 175 Podium: What would they want you to know about that? It increases your risk for utis right? Because you’re adding sugar to your urine and bacteria like sugar, so stlt 2 inhibitors can cause that, and then they can also cause a euglycemic
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SMED 175 Podium: dka.
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SMED 175 Podium: But I don’t know if they’ll ask you that it’ll probably be more just uti risk and dumping glucose and all that.
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SMED 175 Podium: So just remember all this stuff gets reabsorbed in the proximal tubule, and then, after that, everything else is just fine tuning of very few things. If you go to the go to B, the loop channel right?
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SMED 175 Podium: That’s just sodium getting reabsorbed right.
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SMED 175 Podium: and then loop diuretics, work on those sodium channels. Go to see who works. What happened. What happens at C box C
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SMED 175 Podium: get more sodium being reabsorbed, except it’s at a lower osmolality, because sodium is getting plucked out. As you
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SMED 175 Podium: sodium is getting reabsorbed as you go up right. So the osmolality decreases as you move back up
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SMED 175 Podium: and so loop diuretics make you pee more
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SMED 175 Podium: because the sodium concentration is so high at that level, and then thiazide diuretics don’t make you pee off as much, because the amount of sodium you’re messing with is so much less concentrated. Right? So thiazides work up here. So this is just so. B is sodium reabsorption
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SMED 175 Podium: that looks terrible. Thiazide channels, sodium reabsorption
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SMED 175 Podium: right? If we go to D, what happens at D,
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SMED 175 Podium: that’s my favorite cell. Right? So what receptor lives there?
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SMED 175 Podium: That’s the epithelial sodium channel, right? So the Enac sets a principal cell. So enac channels live there. So again, sodium gets reabsorbed here and now.
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SMED 175 Podium: This is the principal site where Aldosterone works right?
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SMED 175 Podium: And then this is the major location where we dump potassium. See the principal cell’s main place. We pee off K, so and then the next cell at E
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SMED 175 Podium: is going to be potassium being reabsorbed.
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SMED 175 Podium: and and who gets exchanged for potassium
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SMED 175 Podium: protons. Okay? So protons show up here.
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SMED 175 Podium: So what’s the most acid part of the tubule.
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SMED 175 Podium: the the distal tubule, or by the collecting duct in that area, right?
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SMED 175 Podium: So. And and those are all the pieces you need to know. But then go back and look at that principal cell, because we were just talking about licorice.
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SMED 175 Podium: and how all that stuff fits in. But just the principal cell is this huge pharmacologic target? Because you have drugs that mess with the enac receptor itself.
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SMED 175 Podium: So what drugs block the epithelial sodium channel? There’s Amilaide, and there’s trimethoprim that’s part of the Sulfa antibiotic the Trimethoprim sulfamethoxazole so trimethoprim and amiloride mess with that. And Pentamidine is another drug that messes with that
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SMED 175 Podium: when I say messes with it, it blocks it right. And so
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SMED 175 Podium: Then Aldosterone gets blocked by which drug
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SMED 175 Podium: spironolactone, and then its non gynecomastia friend is a plarinone.
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SMED 175 Podium: I don’t know if they’ll ask that or not, but that could be so, a lot of drugs work in this area. And then this is the spot where the licorice works.
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SMED 175 Podium: Yeah, can you explain the relationship between prizide diuretics and calcium.
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SMED 175 Podium: Sure, if you, if you look at the nitty gritty of the thiazide channels.
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SMED 175 Podium: the on the blood side of it, there’s a sodium calcium exchanger
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SMED 175 Podium: that exists in the Thiazide channel that does not exist in the loop channels.
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SMED 175 Podium: So as you’re moving sodium into back into. So as you’re moving, so
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SMED 175 Podium: I’m trying to condense like way too many.
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SMED 175 Podium: It’s way too many channels. But the net effect is, you reabsorb sodium from here.
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SMED 175 Podium: then the sodium gets into the cell right?
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SMED 175 Podium: And then the sodium has to get out into the back into the bloodstream.
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SMED 175 Podium: And this sodium reabsorption here is exchanged for calcium.
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SMED 175 Podium: It’s a 2 plus right? So anyway, does that make sense? And so, under normal circumstances, as the sodium is getting reclaimed.
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SMED 175 Podium: calcium is exchanged for that going the opposite way, so you’ll dump calcium into the urine.
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SMED 175 Podium: So then, if you are dumping calcium into the urine
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SMED 175 Podium: just as a thought experiment, what are you increasing your risk for?
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SMED 175 Podium: Yeah, you’re increasing your risk for calcium-based stones, right?
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SMED 175 Podium: So what drug could you put somebody on to reduce the amount of calcium showing up in the tubule.
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SMED 175 Podium: So how do I? If sodium going in
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SMED 175 Podium: is the reason for calcium going in here?
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SMED 175 Podium: What can I do? Is I can block this with what
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SMED 175 Podium: with a thiazide. So you’re just tricking calcium to stay in the bloodstream
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SMED 175 Podium: instead of going into the urine. And that’s a clinical trick, for they’re going to ask that. So what’s the difference between a loop channel and a thiazide channel? It’s this effect it has on Calciurea.
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SMED 175 Podium: and that’s a good one to know about loop diuretics.
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SMED 175 Podium: They make you pee a lot right, because the the Osmolality is so high at that point. But
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SMED 175 Podium: Trying to think of tricky questions they would ask you about that.
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SMED 175 Podium: Thiazides are more of a favorite testable one, because they mess with the calcium. They can be used therapeutically for hypertension they can be used for
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SMED 175 Podium: Now, there’s probably the 2 main uses for it, but then they also have a lot of metabolic side effects, right? So you can get gout from thiazides. So that’s a pretty famous side effect. You can get hyperglycemia as a consequence of chronic thiazide. So anyway, so understand where these drugs work. And a lot of times it’s more just knowing where they work. So if you know these boxes.
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SMED 175 Podium: you’ll be able to visualize what’s happening where? Okay?
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SMED 175 Podium: And then, lastly, don’t forget about what receptor is down here helping with water.
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SMED 175 Podium: It’s terrible.
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SMED 175 Podium: So the V 2 receptor, right?
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SMED 175 Podium: So the this is where adh works. So antidiuretic hormone comes from, where
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SMED 175 Podium: posterior pituitary right, and it’s released in response to either hypotension or high osmolality in the body, and so adh gets released. And that’s our way that we reclaim water.
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SMED 175 Podium: And then
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SMED 175 Podium: there’s a drug that messes with aquaporin. So then remember the aquaporin, 2 channels that get inserted to reclaim the water. What drug messes with our ability to make aquaporin? 2 channels
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SMED 175 Podium: lithium? Okay? So that’s so lithium.
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SMED 175 Podium: We’ll mess with aquaporin 2 channels so that they get pickled. And you cannot. You actually don’t make them, and you can’t reabsorb water.
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SMED 175 Podium: And so now you’re peeing off water all the time. And when you’re peeing off water all the time, what’s that called
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SMED 175 Podium: when you can’t reclaim, that’s gonna be you’re gonna you’re gonna make this urine.
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SMED 175 Podium: And it’s going to be really bland. So it’s just really insipid urine.
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SMED 175 Podium: So it’s diabetes insipidus, right? Diabetes insipidus is an antidiuretic hormone problem. So that’s what Di is. And then the question is, if it’s central, it means your brain. Your pituitary is not making adh. If it’s nephrogenic, it means your kidneys aren’t responding to the adh. Okay? So that’s that’s like everything you need to know about Di. Okay.
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SMED 175 Podium: if they give you some kind of a graph like, I don’t know some kind of a chart, and this person’s got like really high urine output.
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SMED 175 Podium: and they’ve got really low urine, osmolality and their serum sodiums really low.
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SMED 175 Podium: you know. Then just have to think about, am I?
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SMED 175 Podium: Is that going to be diabetes insipidus? And the answer would be, well, maybe because they’re peeing off lots of water.
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SMED 175 Podium: But then, how do you tell the difference between psychogenic polydipsia and
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SMED 175 Podium: and Di, and the difference has to do with the serum sodium level. Okay? So the the people with
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SMED 175 Podium: psychogenic Polydipsia will will self correct their serum sodium level very rapidly, whereas people with Di can’t because they can’t reclaim the water that makes sense.
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SMED 175 Podium: Okay?
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SMED 175 Podium: So anyway, know these boxes because there are.
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SMED 175 Podium: I can. I just hope you, I hope, when you see your your questions. You smile when you see these things. Okay?
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SMED 175 Podium: So any other questions on that.
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SMED 175 Podium: Okay, I think your question may have shown up here a little bit.
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SMED 175 Podium: So let’s see here. 17 year old boys brought to the doctor’s office by his dad. 7 month history of fatigue, recurrent leg cramps, increased urinary frequency. Blood pressure is normal. Pulse is pretty normal. Physical exam shows dry mucous membranes.
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SMED 175 Podium: So here this person has a sodium that’s 130. So maybe a little low potassium. Are you guys getting good with these numbers now?
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SMED 175 Podium: So I mean, a K of 2.8 is definitely low. So this person’s hypokalemic
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SMED 175 Podium: magnesium level is is lowish, calcium level is high ish, and then the urine calcium is, what am I trying to do here?
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SMED 175 Podium: Oh, here we go arterial blood gas on room air shows. So Ph is 7.5 5,
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SMED 175 Podium: and the bicarb is 45. The serum bicarb.
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SMED 175 Podium: What’s a normal serum? Bicarb level
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SMED 175 Podium: like 25. Okay, so just 2425, something like that. So this person has a bicarb of 45,
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SMED 175 Podium: that higher, low.
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SMED 175 Podium: Ty. So what do you call that
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SMED 175 Podium: metabolic alkalosis? Right? So this person convincingly has a metabolic alkalosis along with a ph that is
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SMED 175 Podium: alkalotic right? So we have an alkalemic. Ph, and so this person has a
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SMED 175 Podium: they’re they’re alkalemic, they have a metabolic alkalosis. They have a low. Why why do you think the calcium
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SMED 175 Podium: potassium levels low.
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SMED 175 Podium: So what regulates? So that’s a good thing to know about what regulates calcium.
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SMED 175 Podium: what regulates potassium. So remember the way that gosh dang it. But remember the way that potassium moves into cells. Okay, so that’s an important physiologic thing to know about. So Ph regulates that.
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SMED 175 Podium: Okay? So if you’re alkalotic, then protons are going to move out
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SMED 175 Podium: of the cell to try and compens to try and trying to say
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SMED 175 Podium: they’re trying to. What’s the word I’m trying to say. Now, proton is going to go out to do what to the Bicarb.
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SMED 175 Podium: Can’t think of the word right now.
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SMED 175 Podium: Buffer. Thank you. I could thank you. So you can try and buffer the bicarb. So as the protons come out of the cell, potassium moves in. So alkalosis is a really potent way to become hypokalemic. Then remember, insulin activity moves potassium into cells, and then the other thing is going to be beta adrenergic activity. So beta 2 receptors will move.
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SMED 175 Podium: we’ll move potassium into cells as well.
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SMED 175 Podium: So if we have this person who has this metabolic alkalosis, and they’re hypokalemic calcium level is a clue here
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SMED 175 Podium: where? So let’s just go through the answers. So where do you think this problem is happening? Okay, so
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SMED 175 Podium: is this an ascending loop of Henley?
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SMED 175 Podium: And that’s going to be like Loop channel.
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SMED 175 Podium: Okay? Distal convoluted tubule Tubule is a thiazide channel.
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SMED 175 Podium: Descending loop of Henley is what happens in the descending loop of Henley water. Yeah.
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SMED 175 Podium: If alcoholic system, why do we get?
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SMED 175 Podium: Oh, why hypokalemia? Because the potassium is moving from the plasma into the cells
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SMED 175 Podium: as protons are coming out of the cells to buffer the bicarb
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SMED 175 Podium: that’s in excess. Does that make sense?
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SMED 175 Podium: Moves potassium into the cells?
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SMED 175 Podium: Correct? Yep.
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SMED 175 Podium: And then the story will get a little bit
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SMED 175 Podium: messier, too, because something else is going on. The Collect wanted to say. Collecting duct.
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SMED 175 Podium: We mentioned collecting duct. What do you normally think of as going on there.
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SMED 175 Podium: V. 2. Aquaporin to water reabsorption. Okay? And then the last part proximal convoluted tubule. Right? That’s the proximal tubule at the beginning. So what do you think this? What is this person acting like? They’re on?
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SMED 175 Podium: So this patient, this child has a low potassium. They have a which of these segments is overly active.
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SMED 175 Podium: What’s that?
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SMED 175 Podium: So
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SMED 175 Podium: if you think of the different channels, because ultimately it’s going to boil down to channels right? So what channels are getting messed with. So
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SMED 175 Podium: what drug does it look like this child is on?
314
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SMED 175 Podium: So they’re they’ve got a metabolic alkalosis. They’re dumping potassium.
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SMED 175 Podium: What’s that?
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SMED 175 Podium: Well, maybe. But then, okay, there could be a loop. But then the calcium levels up a little bit.
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SMED 175 Podium: Right?
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SMED 175 Podium: Yeah. So this person’s acting like they’re on a thiazide diuretic.
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SMED 175 Podium: So my answer here would be.
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SMED 175 Podium: would we agree that it’d be the distal or the distal convoluted tubule because it’s acting like they’re on a thiazide who acts like like. And this child’s not. We’re not told. The kid’s on a thiazide. What
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SMED 175 Podium: condition acts like somebody’s on a thiazide.
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SMED 175 Podium: That also causes your magnesium level to drop.
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SMED 175 Podium: Okay? So that is, if it happens with the loop channel.
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SMED 175 Podium: the g 1. Gittleman’s right. So this is, this is a case of Gittleman’s. Okay? So it looks like somebody who’s on a thiazide diuretic when they’re not. So it’s a loss of function. Mutation of the Thiazide Channel.
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SMED 175 Podium: Okay. So so that was a good prelude with with your with your calcium question. So the way I personally remember Gittleman’s is Gittleman’s like they’re on a thiazide.
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SMED 175 Podium: and they have a low magnesium, and Gittleman’s has a G in it, and magnesium has a G in it. So if they give me a magnesium level. It’s usually Gittleman’s.
327
00:43:15.080 –> 00:43:20.799
SMED 175 Podium: So that’s how I remember it. And then what’s the name of it? If it looks like you’re on a loop channel all the time.
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SMED 175 Podium: We’re a lot of loop diuretic that’s called barters.
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SMED 175 Podium: So Barters is a. It’s like being born on Lasix, if you will. Okay.
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SMED 175 Podium: So here’s my messy drawing.
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SMED 175 Podium: Your predecessors have told me that if you just kind of study this chart.
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SMED 175 Podium: this is most everything you need to know to answer your questions on the exam. So, and this is kind of the level of detail. So here I’ll just to answer the question that we just went over the thiazide diuretic is what it looks like that child was on. And then, if it’s going to be Gittleman’s or a thiazide, they’re going to throw calcium and magnesium in there as clues for that. Okay, so just to run through this
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SMED 175 Podium: glomerulus, right? Prostaglandins promote blood flow in at 2, gives us back pressure to maintain a Gfr
334
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SMED 175 Podium: stuff gets filtered out. Most everything gets reabsorbed.
335
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SMED 175 Podium: and then if we have
336
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SMED 175 Podium: Acetazolamide in the mix, or we have some other conditions, those can lead to the type. 2 renal tubular acidosis because of impaired
337
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SMED 175 Podium: bicarb reabsorption. Sglt 2 inhibitors work out here, and those lead to Glucoseurea. Remember the descending limb the main job of the descending loop of Henley is to reabsorb water right? So water comes out. That’s how we concentrate the stuff in the tubule, and then on the way back up. It’s sodium getting plucked out right. So loop channels, pluck it out thiazide channels, pluck it out, and the Enac plucks it out.
338
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SMED 175 Podium: And then we just talked about the potassium and protons and all that stuff out here. One thing that
339
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SMED 175 Podium: they love to bring up as well is the fact that the protons how do they get trapped and stay in the tubule? So you can pee them off.
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SMED 175 Podium: Okay, ammonia is really important for doing that
341
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SMED 175 Podium: so ammonia will turn into ammonium. So you get nh 4 plus that stays in there, and then you pee off ammonium anion.
342
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SMED 175 Podium: And so where does the ammonia come from, do you remember?
343
00:45:50.650 –> 00:45:58.669
SMED 175 Podium: So there’s a parent molecule that gets metabolized up in the proximal tubule. Do you remember glutamate
344
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SMED 175 Podium: so glutamate gets metabolized into
345
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SMED 175 Podium: ammonia and a bicarb. And so it’s this really incredible biological economy. Because if you have somebody who’s acidotic. So if you have an acidosis.
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SMED 175 Podium: ammonia is going to trap the proton, keep it in the urine, and so glutamate
347
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SMED 175 Podium: gets metabolized, you know, in the proximal tubular mitochondria, and you’ll make ammonia, and you’ll make
348
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SMED 175 Podium: and you’ll make the
349
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SMED 175 Podium: what’s going to ultimately become bicarb. So you trap a proton, you make a bicarb. So that’s the renal response to an acidosis. Okay, so know about that. So glutamate? I can totally see them asking that question. So glutamates metabolized in the proximal tubule into ammonia and bicarb. And that’s how the kidneys regenerate bicarbonate.
350
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SMED 175 Podium: So another thing I don’t have on here that I should add, remember, when you turn on the V 2 receptors
351
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SMED 175 Podium: that causes aquaporin 2 channels to insert. So you reabsorb water. You also insert urea channels. So the uta one.
352
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SMED 175 Podium: there’s a urea channel that gets inserted as well, and so Urea reabsorption starts to happen there and then. What Urea does? It’s at least worthwhile going over quickly is
353
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SMED 175 Podium: urea channels will insert, and you’re going to start reabsorbing
354
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SMED 175 Podium: Urea as well. So Urea comes in.
355
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SMED 175 Podium: and then Urea gets picked back up again by these Uta 2 and 3 channels, and then Urea
356
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SMED 175 Podium: swirls back around, and if antidiuretic hormone is active.
357
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SMED 175 Podium: then you’re going to keep reabsorbing water, and you’re going to keep reabsorbing Urea, which allows you to pull in more water as well. So you not only have like gobs of sodium out here, right?
358
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SMED 175 Podium: You also have Urea doing this thing, so they like you to know about that Urea cycle, not the
359
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SMED 175 Podium: biochemical Urea cycle, but just the urea cycling from the collecting duct
360
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SMED 175 Podium: back in the loop of Henley back around and Adh just tells you adh activity determines. If Urea is going to get let go into the urine, or if you’re going to hold on to it.
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SMED 175 Podium: So if somebody’s hypotensive, for example, right? What kind of
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SMED 175 Podium: renal failure are they at risk? For.
363
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SMED 175 Podium: say, they’re hypotensive and volume depleted, remember, we call that
364
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SMED 175 Podium: pre-renal. Okay? So when you’re pre-renal, your ras activity is jacked way up and your antidiuretic hormone activity is jacked way up. And so when you ask, well, why does that bun to creatinine ratio go up?
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SMED 175 Podium: Well, the Urea is getting reabsorbed because of the adh activity that makes sense. So that’s why the bun is going up when you’re pre-renal.
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SMED 175 Podium: if that makes any sense. Okay, so just know about the urea. If you see that you’ll recognize it. And you’ll say, oh, I got that
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SMED 175 Podium: any questions on this. Don’t forget about lithium, lithium pickles the cells from being able to make aquaporin 2 channels, so you can’t reabsorb water, and then that’s called nephrogenic di
368
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SMED 175 Podium: and then the other, while we’re at it. Other antidiuretic hormone stuff is
369
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SMED 175 Podium: excess antidiuretic hormone activity. And so favorite questions on that is.
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SMED 175 Podium: if you have high antidiuretic hormone activity, and you are
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SMED 175 Podium: hypotonic, right? You have low osmoles in your body that should shut adh off should.
372
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SMED 175 Podium: But if it doesn’t.
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SMED 175 Podium: then that’s called inappropriate, right? So that’s what Siadh is. Sidh is adh activity. That’s there for some non-hemodynamic reason. And the favorite thing is, if you see anything that has to do with a lung tumor, lung tumor, lung tumor, or lung tumor. The answer is going to be Siadh. Okay, so just know about that. So Sidh think tumors?
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SMED 175 Podium: The other one is Ssris.
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SMED 175 Podium: Okay? So Ssris, for whatever reason can cause excess adh release. So know those 2 tumors. And Ssris, okay.
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SMED 175 Podium: want me to go faster.
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SMED 175 Podium: No? Okay? Well.
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SMED 175 Podium: okay. It’s distal convoluted tubule. So noteworthy pearls. Here. We talked about this, what makes potassium shift into cells, and then aldosterone disorders worth knowing about. That will make you hypokalemic and give you a metabolic alkalosis, just because your Aldo system is cranked up. It’s
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SMED 175 Podium: the primary aldosterone secreting tumor which we call cons, or if you have adrenal insufficiency where you don’t make enough adrenal hormone and not enough Aldosterone. Then you get hyperkalemic right, because you can’t get rid of
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SMED 175 Podium: potassium.
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SMED 175 Podium: Alright. So here’s the I’ll notice
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SMED 175 Podium: we put licorice up here so for those of you who missed out on the
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SMED 175 Podium: the table discussion here. Licorice
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SMED 175 Podium: pickles the enzyme that blocks cortisol activity. So just know that there’s an enzyme out there that blocks cortisol from having Aldo like effects, and it pickles an enzyme. And that’s what licorice does. So it makes your
385
00:51:57.230 –> 00:52:04.890
SMED 175 Podium: makes you look like you’re hyperaldo. But your Aldo levels are normal because it’s not the problem. Licorice is allowing cortisol to do more of its thing.
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SMED 175 Podium: So definitely spend time with this diagram, or as you’re doing your questions, look at this because hopefully, you’ll just start. The the clouds will part, the light will shine down, and you’ll see like, Oh, I get it. This is
387
00:52:18.600 –> 00:52:25.290
SMED 175 Podium: making more sense to me. Okay, all right. Acid, base questions.
388
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SMED 175 Podium: Look for clues right? So hopefully. By now you have a good understanding of respiratory things, or Co. 2 mediated
389
00:52:32.680 –> 00:52:44.129
SMED 175 Podium: metabolic things are Bicarb mediated bicarbon protons. So look for things that are screwing with your breathing, either increasing it or decreasing it. So how do we increase
390
00:52:44.460 –> 00:52:59.470
SMED 175 Podium: our respiratory rate or our ventilation? Anxiety? Hypoxia will do it so if you have like a pulmonary embolism and get hypoxia from it. That’ll crank up your respiratory rate. So as you’re blowing off Co. 2, you’re getting a
391
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SMED 175 Podium: respiratory
392
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SMED 175 Podium: alkalosis. Okay. So if you have a respiratory alkalosis, think of things that are causing you to blow off Co. 2. For some reason, so anxiety.
393
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SMED 175 Podium: I mentioned the pulmonary emboli, for you know, like that’s what the PE is, and then things that slow it down will cause you to retain. Co. 2. So how do you slow down their breathing? Well, they can have
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SMED 175 Podium: crummy ventilation. So that’s what obstructive lung disease is. So Emphysema Copd. But then the other clues are going to be opiates and benzodiazepines because they suppress the respiratory center. If you hear anything about somebody who ingested something. There was a pill bottle they were found down they had cardiac arrest. These are all things that are either going to be an ingestion like aspirin, or it’s going to be a high lactate level because of
395
00:53:54.170 –> 00:54:10.900
SMED 175 Podium: hypoperfusion, injury, or something like that. Okay, so those are kind of the metabolic acidosis things to know about not taking their insulin right? That’s a risk for Dka shock, hypotension. That kind of stuff that’s going to make lactate levels go up.
396
00:54:10.960 –> 00:54:20.930
SMED 175 Podium: Okay? So just from hypoperfusion. And then, lastly, vomiting Ng, tubes are going to. What’s an Ng tube in the stomach going to do
397
00:54:22.430 –> 00:54:29.229
SMED 175 Podium: if you put an Ng tube in someone’s stomach and you turn it on, turn on the vacuum cleaner, and you start slurping
398
00:54:29.350 –> 00:54:33.170
SMED 175 Podium: stomach juice out what is stomach juice full of
399
00:54:34.380 –> 00:54:47.740
SMED 175 Podium: hydrochloric acid. Right? So Hcl, so you’re going to suck out all kinds of protons. You’ll have an excess of bicarb. So you’ll have a metabolic alkalosis. Okay? So those are the
400
00:54:47.740 –> 00:55:04.709
SMED 175 Podium: tricks there and then always, always. Always. If they give you an acid base thing, calculate the Anion gap, because that’s your answer to which you’re going to be a mud pile or a used car right? And then, if you have a non gap.
401
00:55:06.180 –> 00:55:24.129
SMED 175 Podium: it’s either going to be diarrhea or an Rta, and for testing purposes it’s almost always an Rta, so just know about that. So if you get the Anion gap and you well, that’s not very high. Then you say, Oh, that might be an Rta, and then the Rta trick is the type. Rta
402
00:55:24.650 –> 00:55:36.370
SMED 175 Podium: relatively, is in line with their serum potassium level. So if their serum potassium level is low, it’s a type one. If it’s kind of normal, it’s a type 2, if it’s high, it’s type 4.
403
00:55:36.650 –> 00:55:39.640
SMED 175 Podium: So that’s that’s my test. Taking strategy for that one.
404
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SMED 175 Podium: Why did I bring? Oh, so where are acid based things handled in the kidneys? So lungs are pretty straightforward. We either hold on to Co. 2, or you blow off Co. 2. It’s 1 or the other. Okay, for the way the kidney does it. Bicarb reabsorbed in the proximal tubule.
405
00:55:57.880 –> 00:56:17.990
SMED 175 Podium: and then the proton fine tuning happens way out in the intercalated cell, right? So that’s out there. So again, that’s the acid part of the tubule. And we talked about glutamic acid or glutamate metabolism being the way that the kidney regenerates a bicarb and allows us to trap a proton.
406
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SMED 175 Podium: if some of you don’t get that question, I’ll eat my hat. So that glutamate question is very common. And licorice, too, with that one and lithium everything on there. Okay, so okay, so 48 year old guy comes to the er he’s vomiting
407
00:56:33.600 –> 00:56:40.300
SMED 175 Podium: hint. He’s confused has a history of medication used for migraine headaches.
408
00:56:41.830 –> 00:56:56.940
SMED 175 Podium: headaches, anyway. No other histories available. Blood pressure is okay. Pulse rates a little fast at 100 0, 2 saturations, 87% agitated, confused lungs are a little bit crackly. So maybe there’s some fluid in there. Here are the labs.
409
00:56:57.670 –> 00:57:00.550
SMED 175 Podium: And so if we look at the blood gas
410
00:57:01.870 –> 00:57:07.050
SMED 175 Podium: again, Ph tells us that the overall picture is what
411
00:57:07.650 –> 00:57:11.279
SMED 175 Podium: so normal. Ph is 7.4 0, right?
412
00:57:11.540 –> 00:57:14.589
SMED 175 Podium: So this is a little higher than that.
413
00:57:14.790 –> 00:57:17.169
SMED 175 Podium: So this person has an Alkalemia.
414
00:57:17.750 –> 00:57:21.649
SMED 175 Podium: And then how are we going to describe this? We have a
415
00:57:21.880 –> 00:57:25.279
SMED 175 Podium: bicarb. Well, we have a Pco. 2 of 20.
416
00:57:26.600 –> 00:57:30.410
SMED 175 Podium: Is that high or low low? So we call that a
417
00:57:32.850 –> 00:57:44.540
SMED 175 Podium: let’s say respiratory alkalosis right? And then we have a Po 2, that is, don’t worry about. And then the bicarb is 18. So it’s 18, high or low.
418
00:57:45.190 –> 00:57:48.180
SMED 175 Podium: Low. So we have a metabolic
419
00:57:48.530 –> 00:57:58.380
SMED 175 Podium: acidosis. Okay? So now, so far, all we can say is, this person has a respiratory alkalosis. They have a metabolic acidosis, and the alkalosis is winning.
420
00:57:58.800 –> 00:58:09.350
SMED 175 Podium: Okay, that’s the net change of this whole thing, because the Ph is on the high side. So what are the clues here? Confused, found down
421
00:58:09.610 –> 00:58:11.110
SMED 175 Podium: pill bottle
422
00:58:11.950 –> 00:58:19.740
SMED 175 Podium: what drugs are used for headaches sometimes I don’t know all kinds of headache medicines, but there’s an old fashioned headache medicine that maybe he was taking.
423
00:58:19.960 –> 00:58:27.129
SMED 175 Podium: And if we look at the rest of the labs here oh, it’s an acid-base question. What’s the 1st thing I want to calculate.
424
00:58:29.070 –> 00:58:30.150
SMED 175 Podium: What’s that?
425
00:58:30.340 –> 00:58:33.360
SMED 175 Podium: Anion gap? Okay, what’s the anion gap?
426
00:58:33.590 –> 00:58:51.090
SMED 175 Podium: So? And you should just get used to calculating that real quickly. So that’s going to be 140 sodium, minus the major anions, which is going to be the chloride and the bicarb. So it’s going to be 140, minus 103 plus 17 is 120. So 140, minus 120 is 20.
427
00:58:51.620 –> 00:58:58.439
SMED 175 Podium: Then remember, we all get 10 gimme points because of all the stuff we’re not checking for. So you’re allowed 10 points.
428
00:58:58.880 –> 00:59:03.809
SMED 175 Podium: And so 20 is what the Xanion Gap is. But we’re allowed 10.
429
00:59:04.090 –> 00:59:08.730
SMED 175 Podium: So if you do, 20 minus 10 is 10.
430
00:59:08.930 –> 00:59:11.220
SMED 175 Podium: Okay, that’s the Delta Gap.
431
00:59:11.550 –> 00:59:21.680
SMED 175 Podium: Have you ever hear that term? That’s just that difference between your Anion gap and what you’re allowed and what your gimme points allow you for. Okay, so this person has what kind of a metabolic acidosis
432
00:59:24.160 –> 00:59:35.619
SMED 175 Podium: and anion gap metabolic acidosis. Okay? So there’s a positive anion gap here. So now, what’s your favorite way to go through the differential here?
433
00:59:38.300 –> 01:00:07.670
SMED 175 Podium: You know what you can think of mud pile mule pack, whatever it’s going to be one of those. Right? Okay? And then we’ll talk a little bit about what Winter’s formula is. So okay, so Ph was 7.4 8. So it’s alkalemic pco, 2 respiratory alkalosis. Bicarb was a metabolic acidosis. Anion gap is positive. There is a delta gap. So we know this person has an anion gap metabolic acidosis. So that’s going to lead us down, I think, on the next
434
01:00:08.730 –> 01:00:11.600
SMED 175 Podium: one of these, yeah, there we go. Okay? So
435
01:00:12.360 –> 01:00:18.829
SMED 175 Podium: okay, so we’ll we’ll get to our diagnosis in a minute. There’s this thing called Winter’s Formula. This is like the only
436
01:00:19.000 –> 01:00:24.410
SMED 175 Podium: blood gas formula. You should know, but you should know it. And so
437
01:00:24.610 –> 01:00:27.069
SMED 175 Podium: are you familiar with what Winter’s formula is?
438
01:00:27.240 –> 01:00:42.879
SMED 175 Podium: Okay? Well, I’ll tell you now. So no winter’s formula, make yourself a little card on this. So the question that winter’s formula helps you answer, should you ask that question is, if I have an underlying metabolic acidosis.
439
01:00:44.040 –> 01:00:49.120
SMED 175 Podium: What should my Eco, 2. Compensation be?
440
01:00:49.480 –> 01:01:02.719
SMED 175 Podium: Okay, what would be the appropriate level of compensation for that? And the answer to that is the Pco. 2. That you expect to see should be 1.5 times your bicarb plus 8.
441
01:01:03.060 –> 01:01:05.509
SMED 175 Podium: Okay? So the bicarb was 18
442
01:01:05.760 –> 01:01:14.810
SMED 175 Podium: so, or 17 or 18. So 18 times 1.5 is going to be 18, plus 9 is 27
443
01:01:15.170 –> 01:01:22.640
SMED 175 Podium: plus 8 is 35. So we should have a for a bicarb of 17 or 18, we should have a Pco. 2 of 35.
444
01:01:23.310 –> 01:01:33.779
SMED 175 Podium: Okay, that’s what it tells us. But our Pco. 2 was 20, not 35.
445
01:01:34.180 –> 01:01:38.780
SMED 175 Podium: So we now have a respiratory
446
01:01:40.080 –> 01:01:49.800
SMED 175 Podium: alkalosis. Okay? So we have a respiratory alkalosis on top of that metabolic acidosis. So it’s not just compensation.
447
01:01:49.920 –> 01:01:57.530
SMED 175 Podium: So what condition gives you a respiratory alkalosis, and then an anion gap metabolic acidosis.
448
01:01:57.810 –> 01:02:01.140
SMED 175 Podium: And there’s kind of only one the author that does that
449
01:02:01.280 –> 01:02:03.189
SMED 175 Podium: so. And that’s going to be
450
01:02:04.300 –> 01:02:07.069
SMED 175 Podium: this one here. Right? So it’s gonna be the
451
01:02:09.230 –> 01:02:39.129
SMED 175 Podium: it’s going to be aspirin. Okay? So aspirin initially causes your respiratory rate to go up because it stirs up your respiratory center, and so you’ll hyperventilate. And then the next phase is all this acetyl salicylic acid getting absorbed into the bloodstream, and you wind up with a metabolic, an anion gap, metabolic acidosis. Why is it so? Anion gaps? Just tell you that you basically tell you that you have a you have another substance there
452
01:02:39.270 –> 01:02:43.840
SMED 175 Podium: that’s making you acidemic. And so
453
01:02:44.390 –> 01:02:55.639
SMED 175 Podium: it’s either exogenous like you ingested it. Okay? So that’s going to be salicylic acid ethylene glycol methanol peraldehyde, which I’ve never seen.
454
01:02:55.880 –> 01:03:01.210
SMED 175 Podium: and then or it can be metabolic, it can be lactate, ketones, or uremia.
455
01:03:01.410 –> 01:03:12.790
SMED 175 Podium: so that those are kind of the main things that you’re going to think about. If you see a positive anion gap, and so you can use mule, pack mud pile whatever you like. I like to use luck, simp
456
01:03:12.920 –> 01:03:14.229
SMED 175 Podium: this one here
457
01:03:15.920 –> 01:03:24.790
SMED 175 Podium: because it separates out the metabolics from the ingestions, so you can pick whatever you want to use for that question.
458
01:03:31.270 –> 01:03:35.052
SMED 175 Podium: Oh, it’s oh, I’m sorry! So
459
01:03:35.980 –> 01:03:37.839
SMED 175 Podium: If they didn’t give you that.
460
01:03:38.240 –> 01:03:39.869
SMED 175 Podium: then you’d want to check that.
461
01:03:41.530 –> 01:03:45.400
SMED 175 Podium: I mean, if it’s if it’s there, it’s there right? We already know. Yeah. Good point.
462
01:03:46.060 –> 01:04:07.979
SMED 175 Podium: So the the answer to your question is, it wouldn’t necessarily be appropriate to do it here because you already have it. But if you wanted to know if is the compensation appropriate, then the answer would be, no, it’s not. There’s still way. Too few Co. 2 s. Floating around versus what we think the body should be doing
463
01:04:08.380 –> 01:04:19.029
SMED 175 Podium: correct. Yep. So winter’s formula, I can totally see that one showing up. So that’s why I bring it up. Yeah.
464
01:04:21.470 –> 01:04:49.660
SMED 175 Podium: Oh, so everybody, we, because the true Anion gap is everything positive, balancing with everything negative. And so we should have no anion gap in in reality. But since we can’t check everything, we just check the major things, so sodium is the major proton or the major plus charge, and the major minus charges are the chloride and the bicarb.
465
01:04:50.050 –> 01:04:56.359
SMED 175 Podium: So under normal circumstances, if you take your sodium and you subtract your bicarbon, your chloride.
466
01:04:56.710 –> 01:05:07.590
SMED 175 Podium: it’s gonna be about 10, you know, the difference is gonna be about 10. So if you have a gap of 10 or less, that’s pretty normal. But up to 10 is normal.
467
01:05:07.740 –> 01:05:13.510
SMED 175 Podium: But then, if you calculate it out and it comes back, you know, 25,
468
01:05:13.910 –> 01:05:17.229
SMED 175 Podium: then you’re 15 points higher than
469
01:05:17.420 –> 01:05:38.270
SMED 175 Podium: then. The gimme points we give you. Does that make sense? Yeah. So it’s just a way to adjust. So you don’t have to check the calcium and the magnesium and the the phosphorus level and the potassium level and the porcelain level, and the, you know, just whatever just all these different things to check so right. And then, if you have a so does that help?
470
01:05:38.380 –> 01:05:42.319
SMED 175 Podium: And then the other thing is, if they give you an Osmolar gap
471
01:05:44.740 –> 01:05:51.760
SMED 175 Podium: just for efficiency here, if you, if they give you an Osmolar gap as well.
472
01:05:52.310 –> 01:05:55.559
SMED 175 Podium: Then, you know you’re dealing with ethylene, glycol or methanol.
473
01:05:55.750 –> 01:06:02.799
SMED 175 Podium: Okay, that’s the so you’ve been an anion gap metabolic acidosis with an Osmolar gap. You’re down to 2 choices.
474
01:06:03.080 –> 01:06:07.289
SMED 175 Podium: Okay, I think I may even have a question on that. We’ll see.
475
01:06:07.400 –> 01:06:12.320
SMED 175 Podium: Do you guys want to take a break, or just keep going a little bit.
476
01:06:15.390 –> 01:06:26.330
SMED 175 Podium: All right. Well, I’ll just so salicylate toxicity is combined. You get the respiratory and the metabolic part. Other stuff ringing in the ears. Gi, irritation aspirin can cause ulcers
477
01:06:26.520 –> 01:06:32.489
SMED 175 Podium: because it can cause ulcers. You can get non-cardiogenic pulmonary edema. I doubt they’ll ask you that.
478
01:06:33.870 –> 01:06:37.420
SMED 175 Podium: Okay, 29 year old er
479
01:06:38.820 –> 01:06:49.490
SMED 175 Podium: brought in by the Paramedics 30 min after his roommate found him unresponsive, had been previously feeling well, had a party all night. Drink homemade liquor
480
01:06:50.270 –> 01:06:52.869
SMED 175 Podium: hint pulse is 126.
481
01:06:53.180 –> 01:06:54.889
SMED 175 Podium: Blood pressure is low.
482
01:06:56.297 –> 01:07:05.930
SMED 175 Podium: Don’t worry about the cardiac exam. Okay, so here’s our blood gas 7, 1, 8, 31, and the bicarb is 4.
483
01:07:06.850 –> 01:07:10.880
SMED 175 Podium: Okay, so Ph is high or low.
484
01:07:11.180 –> 01:07:21.050
SMED 175 Podium: low. Acidemic pco, 2 is low. So that’s a respiratory alkalosis, right? Just by definition.
485
01:07:21.660 –> 01:07:25.240
SMED 175 Podium: Bicarb is 4 metabolic
486
01:07:25.990 –> 01:07:32.710
SMED 175 Podium: acidosis. Oh, metabolic acidosis! I need to know if it’s the anion gap or not so what’s the anion gap?
487
01:07:35.350 –> 01:07:46.900
SMED 175 Podium: So 1, 46, minus 1, 15. So you have a gap of what? 2021,
488
01:07:47.050 –> 01:07:48.140
SMED 175 Podium: something like that?
489
01:07:48.920 –> 01:07:50.030
SMED 175 Podium: 25.
490
01:07:50.310 –> 01:07:59.230
SMED 175 Podium: No gaps, 31. Right? Yeah. Okay, so any gaps 31. So high. Anion gap. Guy drank something.
491
01:07:59.510 –> 01:08:03.230
SMED 175 Podium: His delta gap is very high.
492
01:08:03.670 –> 01:08:08.490
SMED 175 Podium: And then do you remember how to calculate the plasma. Osmolality.
493
01:08:09.050 –> 01:08:17.750
SMED 175 Podium: Okay, because they’ll ask you about that. So plasma osmolality is 2 times the sodium plus glucose over 18,
494
01:08:18.160 –> 01:08:26.680
SMED 175 Podium: plus the bun over 2.8. So the key thing to know is plasma. Osmolality is just sodium bun and glucose
495
01:08:26.950 –> 01:08:27.740
SMED 175 Podium: time.
496
01:08:30.040 –> 01:08:42.479
SMED 175 Podium: So if you do the numbers 2 times the sodium glucose over 18 bun over 2.8. You come out with 296, and then they gave us in here that the guy’s serum. Osmolality is 3, 79.
497
01:08:42.600 –> 01:08:43.710
SMED 175 Podium: So
498
01:08:43.819 –> 01:08:52.740
SMED 175 Podium: it’s going to be 379, minus 2, 96 is a big number 83 normal Osmolar Gap is less than 10,
499
01:08:52.939 –> 01:08:55.910
SMED 175 Podium: so this person has a high Osmolar gap.
500
01:08:56.450 –> 01:09:00.609
SMED 175 Podium: and they have an anion gap. So it boils down to 2 choices
501
01:09:00.779 –> 01:09:02.710
SMED 175 Podium: right. So what are those 2 choices?
502
01:09:03.859 –> 01:09:05.920
SMED 175 Podium: Methanol or
503
01:09:06.149 –> 01:09:22.089
SMED 175 Podium: ethylene? Glycol? Okay, that’s how that shows up. So then the next question is, Oh, what do you do about it. Well, how do you treat ethylene, glycol, or methanol ingestion? You know dialysis is one choice, but if you want to keep the
504
01:09:22.240 –> 01:09:31.790
SMED 175 Podium: the parent compounds are not so bad themselves. It’s just when alcohol dehydrogenase gets a hold of it, it turns it into bad stuff.
505
01:09:31.960 –> 01:09:35.089
SMED 175 Podium: So ethylene glycol is fairly inert.
506
01:09:35.390 –> 01:09:52.360
SMED 175 Podium: but when alcohol dehydrogenase gets a hold of it, you make oxalic acid, which is horrible, and that’s what you like. Strip the biofilm off of boats with, you know, and then methanol turns into formaldehyde formic acid.
507
01:09:52.479 –> 01:10:07.910
SMED 175 Podium: So you can embalm yourself as you’re doing that. So so the other for your purposes is going to be blocking alcohol, dehydrogenase. So what are the answer? Options here? Methylene, blue ethanol.
508
01:10:08.600 –> 01:10:16.119
SMED 175 Podium: tylenol and acetylcysteine fulmeprazole naloxone and flumazenil okay, so do you guys remember fulmeprazole
509
01:10:16.420 –> 01:10:29.629
SMED 175 Podium: in this case. So for no omeprazole formprazole is a drug that blocks alcohol, dehydrogenase. So does ethanol ethanol competitively inhibits alcohol dehydrogenase
510
01:10:29.800 –> 01:10:35.870
SMED 175 Podium: but phomeprazole is a drug and you know ethanol is, hospitals don’t carry it too much anymore. But they used to.
511
01:10:37.510 –> 01:10:43.900
SMED 175 Podium: So this is a how do I mess with an ingestion question. So methylene blue
512
01:10:44.610 –> 01:10:52.009
SMED 175 Podium: is inert, but we use it for cyanide toxicity. Okay? So that’s 1 option
513
01:10:52.690 –> 01:10:56.990
SMED 175 Podium: and acetylcysteine. We give to reconstitute
514
01:10:58.392 –> 01:11:03.879
SMED 175 Podium: what what you’ll call it the the sulfide stuff.
515
01:11:07.150 –> 01:11:36.160
SMED 175 Podium: yeah, that’s right. Glutathione. Thank you. So n-acetylcysteine you give for Tylenol overdoses fomeprazole you give for ethylene glycol and methanol ingestions. Naloxone. Right? That’s an antagonist for opiates. And then Flumazonil is the antagonist for benzodiazepines. So those are worth knowing about. So now I’m hoping you guys get a question that has Fulmeprazole on there.
516
01:11:37.336 –> 01:11:43.133
SMED 175 Podium: Okay. 61 year old, 2 week history of fatigue and muscle weakness.
517
01:11:44.070 –> 01:11:48.840
SMED 175 Podium: no fever chills. One month ago was treated with Amoxicillin for uti
518
01:11:48.960 –> 01:12:00.889
SMED 175 Podium: history of type 2 diabetes, hypertension, chronic, low back pain. Okay. Medicines are insulin and allopryl and Tylenol doesn’t smoke or drink. No illicit drug use.
519
01:12:01.375 –> 01:12:07.929
SMED 175 Podium: Okay, let’s just go to the labs here. So hemoglobin a 1 c is 9% 9.1. So it’s high. Right?
520
01:12:10.880 –> 01:12:19.320
SMED 175 Podium: what are? What is our question here? Okay? So which of the following is causing this stuff? So sodium is 136, potassium is high.
521
01:12:19.870 –> 01:12:22.120
SMED 175 Podium: Bicarb is low.
522
01:12:23.220 –> 01:12:25.299
SMED 175 Podium: Creatinine is up a little bit.
523
01:12:25.970 –> 01:12:29.999
SMED 175 Podium: Your analysis is maybe a little bit on the
524
01:12:31.560 –> 01:12:33.480
SMED 175 Podium: a little bit on the acid side.
525
01:12:33.830 –> 01:12:35.340
SMED 175 Podium: No blood.
526
01:12:35.530 –> 01:12:46.710
SMED 175 Podium: So what does this person have? Adrenal insufficiency, prerenal analgesic stuff, hyperosmolar, hyperglycemic state, fanconi, syndrome or an rta
527
01:12:47.130 –> 01:12:50.568
SMED 175 Podium: okay, so if you go through these
528
01:12:51.230 –> 01:12:56.380
SMED 175 Podium: what are diabetic patients at risk for? Especially if they’re on an ace. Inhibitor?
529
01:12:58.590 –> 01:13:01.480
SMED 175 Podium: Okay? So this comes back to the Ras system.
530
01:13:01.840 –> 01:13:12.980
SMED 175 Podium: So diabetic patients. And especially if you’re on on an ace. Inhibitor will cause ace inhibitors do what? To your aldosterone activity?
531
01:13:15.430 –> 01:13:27.229
SMED 175 Podium: Right? So if you reduce at 2 activity, then what happens to your Aldo activity goes down. So if your Aldo activity is down, what happens to your serum potassium level.
532
01:13:29.890 –> 01:13:36.910
SMED 175 Podium: it’s going to go up right, because that’s what Aldo does. It helps us get not only hold on to sodium, but we get rid of potassium with that.
533
01:13:37.040 –> 01:13:42.870
SMED 175 Podium: So this person has. Oh, look! They have a little bit of a metabolic acidosis.
534
01:13:43.000 –> 01:13:50.350
SMED 175 Podium: So I guess we should do our numbers. So we’ll do the anion gap. Okay, so 1, 36, minus
535
01:13:50.630 –> 01:13:53.400
SMED 175 Podium: 1, 28 is 8.
536
01:13:53.670 –> 01:13:56.160
SMED 175 Podium: Oh, that’s a pretty low Anion gap
537
01:13:56.570 –> 01:14:05.570
SMED 175 Podium: that’s going to be one of the used cars things. But Henry said, just know about diarrhea and rtas. Okay? So this person has a non
538
01:14:05.880 –> 01:14:07.460
SMED 175 Podium: anion gap.
539
01:14:07.620 –> 01:14:15.950
SMED 175 Podium: Metabolic acidosis. It’s mild, but it’s there. So what’s the rule with non metabolic acidosis
540
01:14:17.650 –> 01:14:20.200
SMED 175 Podium: what? What’s the next test? You look at
541
01:14:21.700 –> 01:14:26.530
SMED 175 Podium: the potassium level. And then what’s the question you ask about the potassium level?
542
01:14:27.560 –> 01:14:30.350
SMED 175 Podium: Is it high, normal, or low?
543
01:14:30.500 –> 01:14:34.210
SMED 175 Podium: And 5.9 is Hi.
544
01:14:34.400 –> 01:14:42.680
SMED 175 Podium: So this person has a what a type! 4
545
01:14:43.160 –> 01:14:49.190
SMED 175 Podium: renal tubular acidosis. Yep, there’s your answer. So the answer here is, they have a
546
01:14:49.290 –> 01:14:53.919
SMED 175 Podium: renal tubular acidosis, but just appreciating that. And that’s where that’s coming from.
547
01:14:54.340 –> 01:15:07.760
SMED 175 Podium: So here I mentioned, you know, it’s putting it all together. What’s the acid base status. What’s the Anion gap? It’s normal. What’s the K level? It’s high. What does diabetes do? So the other thing that diabetes does is
548
01:15:07.900 –> 01:15:20.859
SMED 175 Podium: long-term diabetes will trash your juxtaglomerular apparatus. So you don’t make as much renin. So diabetic kidney disease by definition patients develop hyporeninemic
549
01:15:21.520 –> 01:15:23.570
SMED 175 Podium: hypoaldosteronism.
550
01:15:23.970 –> 01:15:28.239
SMED 175 Podium: And that’s just a baseline and then when you throw an ace or an arb in there.
551
01:15:28.880 –> 01:15:44.289
SMED 175 Podium: you make them hypo hypo hypoaldo, because you’re like pickling their Aldo from doing anything, so they’re going to retain potassium, and you’ll see that a lot, Ben. Yes, on this last case, if the potassium is low, would it also have been?
552
01:15:44.750 –> 01:15:52.810
SMED 175 Podium: Yep, precisely so. If they gave you the same question, and the K. Was 2.1, you’d say, oh, that’s low, that’s a type one.
553
01:15:53.000 –> 01:16:00.140
SMED 175 Podium: and then you move on, or it would be a type. 2, yeah, yeah.
554
01:16:00.710 –> 01:16:11.089
SMED 175 Podium: So that’s the that’s the. And yeah. And then the only other thing I can think about them asking about Rtas is type 2
555
01:16:11.640 –> 01:16:19.839
SMED 175 Podium: is the proximal tubule. You’re dumping bicarb. So that’s a bicarb losing event type one and type 4
556
01:16:20.110 –> 01:16:24.700
SMED 175 Podium: are proton retaining events. So type one
557
01:16:25.200 –> 01:16:29.890
SMED 175 Podium: is a screwed up intercalated cell and type 4 is a screwed up principal cell.
558
01:16:30.130 –> 01:16:34.940
SMED 175 Podium: and that’s kind of the way to look at those, if that if that helps you. So
559
01:16:36.920 –> 01:16:46.562
SMED 175 Podium: okay, there’s all my thoughts on that one. So we’re back to this diagram again. So so here, I even put out there. Type 4 Rta is
560
01:16:49.440 –> 01:17:10.340
SMED 175 Podium: right is out here because the K is high. And then to Ben’s point of the K was low, it’d be a type, one rta, and it’s going to be this cell versus that cell where those things are happening. Okay. But, Rtas, I mean, if you, they’re so straight they really are pretty straightforward. If you just get them down, you’ll you’ll nail the questions guaranteed. Okay.
561
01:17:15.790 –> 01:17:19.020
SMED 175 Podium: okay, let’s see, what else can we do now 3 month old.
562
01:17:20.440 –> 01:17:22.430
SMED 175 Podium: Oh, look! The potassium is low.
563
01:17:22.580 –> 01:17:40.180
SMED 175 Podium: Okay. 3 month old. Brought in for feeding a poor feeding, irritability, vomiting born at term, uncomplicated pregnancy, not very big for age. Well, normal pulse for a 3 month old. So here
564
01:17:40.300 –> 01:17:41.510
SMED 175 Podium: the
565
01:17:42.600 –> 01:17:51.029
SMED 175 Podium: see, where’s our bicarb? They give us on our blood gas here right? So 7.2 8 is a metabolic or ph is
566
01:17:51.310 –> 01:17:56.269
SMED 175 Podium: acidemic. Pco 2 is we don’t have one.
567
01:17:56.780 –> 01:18:01.349
SMED 175 Podium: Bicarb is 12. 0, wow! That’s a metabolic
568
01:18:01.960 –> 01:18:05.020
SMED 175 Podium: acidosis. What’s the 1st thing I want to calculate
569
01:18:05.720 –> 01:18:14.599
SMED 175 Podium: anion gap? So I’ll do. My sodium is 138, and I’ll subtract 115, plus 12 is 127. So I have a gap of.
570
01:18:14.780 –> 01:18:20.800
SMED 175 Podium: okay, it’s 11 fine. So it’s still normal. Okay, so it’s not very high.
571
01:18:20.910 –> 01:18:29.119
SMED 175 Podium: So we have a gap that’s not very impressive. Which of the following is the problem. So is it.
572
01:18:29.350 –> 01:18:40.959
SMED 175 Podium: 21 beta hydroxylase problem, branch chain amino acids, loop of Henle Mesmesta, proximal tubules, not reabsorbing bicarb, cystic fibrosis, gene
573
01:18:41.400 –> 01:18:49.860
SMED 175 Podium: inability of the distal tubule to secrete protons and deficiency of ornithine transcarbamylase
574
01:18:50.070 –> 01:18:51.660
SMED 175 Podium: don’t ask me about that one.
575
01:18:52.210 –> 01:19:04.470
SMED 175 Podium: So which is so to your point, Ben. Right? This is this question was made just for you. So we have a non-gap acidosis with a low potassium. So we have a
576
01:19:06.600 –> 01:19:13.459
SMED 175 Podium: type one rta, exactly right? So the K is low and all that. So where do type ones happen at?
577
01:19:13.630 –> 01:19:19.049
SMED 175 Podium: They happen in the distal tubule with an inability to secrete protons. Right?
578
01:19:19.390 –> 01:19:21.270
SMED 175 Podium: So that’s your answer. There.
579
01:19:21.430 –> 01:19:29.270
SMED 175 Podium: So what are these other things? 21 beta hydroxylase that goes along with congenital adrenal hyperplasia.
580
01:19:29.920 –> 01:19:37.800
SMED 175 Podium: branched chain amino acids that’s maple syrup urine disease. If they ever ask you that one barter’s is a messed up
581
01:19:38.560 –> 01:19:43.529
SMED 175 Podium: is a messed up loop of Henley Channel, or it could be a or it could be a loop diuretic.
582
01:19:43.700 –> 01:19:54.839
SMED 175 Podium: It’s not this proximal tubular one, because the potassium level is normal. And we’re not really losing bicarb. This is the holding on to protons and peeing off
583
01:19:57.260 –> 01:19:59.449
SMED 175 Podium: potassium. With that. Okay.
584
01:19:59.640 –> 01:20:04.650
SMED 175 Podium: does that? Does that help trying to parse those out? Because it’s really important to do that part.
585
01:20:06.570 –> 01:20:08.740
SMED 175 Podium: Okay, any any acid based stuff.
586
01:20:09.380 –> 01:20:23.579
SMED 175 Podium: I think the acid-based stuff, from what I understand, is really pretty straightforward. So if you know the definitions, and you know the clinical clues like anxiety, pulmonary embolism, tachypnea versus Copd benzos opiates all that stuff
587
01:20:23.680 –> 01:20:25.720
SMED 175 Podium: that that can really be helpful.
588
01:20:26.680 –> 01:20:34.480
SMED 175 Podium: And then don’t forget that part of the respiratory drive is hypoxia, right? So if somebody’s hypoxic, if they have
589
01:20:34.790 –> 01:20:51.189
SMED 175 Podium: pneumonia, or something like that, or even a pulmonary embolism can make you hypoxic. That’s another reason to increase your respiratory drive. So your your body’s trying to get more oxygen. But you’re blowing off Pco 2 in the process. Right?
590
01:20:51.490 –> 01:21:02.430
SMED 175 Podium: Okay? Aki, remember prerenal intrarenal post-renal. Okay, that’s always remember those 3
591
01:21:02.750 –> 01:21:23.520
SMED 175 Podium: pay attention to what they’re giving you for clues. So if they’re giving you any stuff in there about ras activity, that’s probably a pre-renal risk, right? So hypotension, tachycardia, vomiting diarrhea, blood loss, that kind of stuff and intact
592
01:21:24.220 –> 01:21:35.729
SMED 175 Podium: proximal tubule will reabsorb all kinds of sodium and everything else, and if your and so your urine sodium should be
593
01:21:36.490 –> 01:21:42.839
SMED 175 Podium: low, and if your Ras activity is really high, Aldo is going to reabsorb what
594
01:21:44.090 –> 01:21:49.769
SMED 175 Podium: sodium! So your urine sodium is still going to be low. So if you’re pre-renal.
595
01:21:50.070 –> 01:21:52.480
SMED 175 Podium: you’re going to have a low urine sodium.
596
01:21:52.600 –> 01:22:13.789
SMED 175 Podium: Okay, if you have a high urine sodium, then you need to. But low urine sodium goes along with pre-renal. If it’s higher than that, if it’s not less than 10 or some low number, then something else is going on. So then start looking for other things like the following. So if your fina
597
01:22:14.190 –> 01:22:20.410
SMED 175 Podium: remember that fractional excretion of sodium thing, so if your fina is less than 1%
598
01:22:21.440 –> 01:22:34.540
SMED 175 Podium: that tells you that your tubule’s intact and you’re hanging on to sodium. So your Ras system is intact. Aldo is working, and the proximal tubule’s working. But if your fiend is high, greater than 2%.
599
01:22:35.480 –> 01:22:44.170
SMED 175 Podium: Then the kidneys are inappropriately dumping sodium for some reason, and a lot of that has to do with proximal tubular injury.
600
01:22:44.460 –> 01:22:48.440
SMED 175 Podium: Okay? And so what do we call it when the proximal tubule is injured?
601
01:22:50.820 –> 01:22:59.410
SMED 175 Podium: If you make the proximal tubule mad, and it can’t reabsorb everything like it wants to, and it starts dumping everything that’s acute.
602
01:23:00.060 –> 01:23:24.490
SMED 175 Podium: Tubular necrosis. So Atn is a disease of the proximal tubule, and there’s 2 ways to get atn. It can either be ischemic, like crummy blood flow, or it could be nephrotoxic. So famous drugs are aminoglycosides like gentamicin. Okay, so those are going to be the 2 big risks you’ll see in there if the proximal tubule is damaged
603
01:23:24.630 –> 01:23:49.950
SMED 175 Podium: and it’s necrosing right. Then you’ll get proximal tubular dandruff starts showing up in the urine, and that shows up as muddy brown casts. So if you see muddy brown casts, that’s pathognemonic for atn, and that’s what it is. It’s just a bunch of gummed up proximal tubular cells. If you see Rbc casts, what part of the nephron is the problem?
604
01:23:51.880 –> 01:23:53.940
SMED 175 Podium: Where do Rbc casts come from
605
01:23:54.964 –> 01:23:58.360
SMED 175 Podium: like glomerulonephritis, right? So like a nephritic syndrome.
606
01:23:59.580 –> 01:24:01.730
SMED 175 Podium: if you get eosinophils in there
607
01:24:02.070 –> 01:24:29.729
SMED 175 Podium: that can go along with allergic interstitial nephritis right so that’s more of a parenchymal part of things, and then look for reasons for people to be obstructed for the post renal. So somebody who’s had a kidney stone, maybe they had pelvic surgery or gynecologic surgery in this, you know, the gynecologist accidentally tied off the ureter or something. I mean, there’s things like that that they might throw in there. Bph, in an older patient in an older guy.
608
01:24:30.140 –> 01:24:37.159
SMED 175 Podium: So just know about these features. And so for Prerenal.
609
01:24:40.060 –> 01:24:49.720
SMED 175 Podium: If you see these numbers, then you just have to take them for what they’re worth a prerenal. If your urine sodium is less than 10, or your fiend is less than 1%,
610
01:24:50.020 –> 01:24:54.670
SMED 175 Podium: you are prerenal, and they’ll give you those numbers. You don’t have to calculate them.
611
01:24:55.207 –> 01:25:11.230
SMED 175 Podium: If you have muddy brown casts and so forth. Then that tells you that the proximal tubule is unhappy, and the casts are forming in here, and that’s what. So this is a muddy green cast. Okay, so. But that’s what would show up in the urine later on.
612
01:25:11.500 –> 01:25:14.790
SMED 175 Podium: And so, Atn.
613
01:25:16.100 –> 01:25:23.029
SMED 175 Podium: you’re going to have a high urine sodium. You’re going to have a high fina. Usually it’s greater than 2%
614
01:25:23.130 –> 01:25:33.159
SMED 175 Podium: for what it’s worth. So just know about that. And and those are kind of absolutes. Right? If you have muddy brown cast that’s atn path for that
615
01:25:33.400 –> 01:25:42.720
SMED 175 Podium: low urine sodium low fina is prerenal. And look for all those clues about hypotension, diarrhea, and whatever
616
01:25:43.870 –> 01:25:45.910
SMED 175 Podium: other things they can throw in there.
617
01:25:46.440 –> 01:26:08.790
SMED 175 Podium: So okay, so let’s do a case on this. 1 68 year olds in the Icu. Had a big aneurysmal surgery, got a bunch of blood because he was hemorrhaging 24 h later. He’s only passed a tiny bit of urine. Has some heart failure symptoms. He’s on an ace inhibitor. He’s on Spernolactone. So just think about where those work.
618
01:26:08.850 –> 01:26:20.019
SMED 175 Podium: Pulse rate’s 110. Blood pressure is 110 dry mucous membranes, flat neck. Okay, so dry. Mucous membranes, flat neck veins.
619
01:26:20.230 –> 01:26:25.270
SMED 175 Podium: Remainder of the exam shows no other abnormalities.
620
01:26:25.710 –> 01:26:28.739
SMED 175 Podium: Okay, creatinine is 2.
621
01:26:29.160 –> 01:26:30.840
SMED 175 Podium: Bun is 48.
622
01:26:31.810 –> 01:26:36.040
SMED 175 Podium: His bun and creatinine on admission were 1.2 and 18.
623
01:26:36.240 –> 01:26:40.919
SMED 175 Podium: Okay, so which of the following features is this person going to have?
624
01:26:41.330 –> 01:26:48.760
SMED 175 Podium: And so there’s some real big clues here. Okay? So this person has
625
01:26:51.468 –> 01:26:57.140
SMED 175 Podium: let’s see, they got blood. So they had a prerenal risk, right? They got transfused.
626
01:26:57.620 –> 01:27:04.780
SMED 175 Podium: Now they’ve got dry mucous membranes, flat neck veins. So when they tell you that this person’s intravascular volume is
627
01:27:05.370 –> 01:27:09.650
SMED 175 Podium: low. Okay? So that’s a risk factor for what
628
01:27:11.550 –> 01:27:16.290
SMED 175 Podium: pre-renal, at least, right? Okay, so we have that then?
629
01:27:16.540 –> 01:27:21.010
SMED 175 Podium: Oh, look! They gave me some numbers here. What’s give me a 2, and they gave me a 48.
630
01:27:21.830 –> 01:27:25.670
SMED 175 Podium: What’s another tip off that somebody’s pre-renal.
631
01:27:27.570 –> 01:27:35.629
SMED 175 Podium: It’s that bun to creatinine ratio. So do you remember that one? If not know it? Okay, so if it’s greater than
632
01:27:36.680 –> 01:27:40.890
SMED 175 Podium: 20 to one, then they’re prerenal.
633
01:27:41.000 –> 01:27:56.750
SMED 175 Podium: So in this case this is 24 to one, right? So 48, divided by 2 is 24, it’s greater than 20 to one. So there’s another reason that this person’s pre-renal. And so which of the following features would we expect to find
634
01:27:57.070 –> 01:28:07.129
SMED 175 Podium: decrease? Urine, osmolality? No, that’s Adh is going to tell us if that’s happening or not, leukocyte cast would be ain
635
01:28:07.590 –> 01:28:09.880
SMED 175 Podium: and ain’s always going to be a drug.
636
01:28:10.000 –> 01:28:22.700
SMED 175 Podium: Hey? There, I can give you a drug. It’s usually a drug. So some kind of antibiotic hematuria. We don’t really have a story for glomerulonephritis. Right? So probably not that low urine sodium.
637
01:28:23.290 –> 01:28:45.849
SMED 175 Podium: Yep. And then what’s the other? One? Proteinuria? Again, no risk factor for a nephrotic thing. So this one’s going to be pre-renal. Okay? So the answer is low urine sodium. So here’s all the features, flat neck pains, dry mucous membranes. b, 1 to creatinine ratio greater than 20. So this is a pre-renal picture. So if you see that, don’t overthink it. That’s your answer. Okay?
638
01:28:49.980 –> 01:28:52.180
SMED 175 Podium: Questions on that one. Okay.
639
01:28:52.650 –> 01:29:07.809
SMED 175 Podium: all right. So 9 days after being treated for a gastric ulcer 78 year old, decreased. Urine output has an emergent laparotomy in the icu. For sepsis. Blood cultures grow pseudomonas on ceftazidime and gentamicin
640
01:29:08.200 –> 01:29:17.600
SMED 175 Podium: think think about that diabetes hypertension, osteoarthritis of the hips, insulin ace inhibitor, and an nsaid
641
01:29:18.980 –> 01:29:32.950
SMED 175 Podium: pulse rates. Normal blood pressure is normal. Exam shows a well, healing. Surgical incision and here’s what we get so decreased. Urine output after this big mess and sepsis for a perforated gastric ulcer.
642
01:29:33.070 –> 01:29:36.030
SMED 175 Podium: So what do we have here?
643
01:29:39.940 –> 01:29:41.939
SMED 175 Podium: Creatinine is 4.2.
644
01:29:42.250 –> 01:29:43.660
SMED 175 Podium: Hi, right?
645
01:29:44.290 –> 01:29:52.890
SMED 175 Podium: So this person has acute kidney injury, presumably right? So this is a kidney injury question, as it says, on the top.
646
01:29:53.911 –> 01:30:00.089
SMED 175 Podium: Bun to creatinine ratio is 6, so it’s probably not pre-renal
647
01:30:00.380 –> 01:30:06.160
SMED 175 Podium: blood pressure is normal. Pulse rates normal. Probably still not pre-renal.
648
01:30:06.758 –> 01:30:17.270
SMED 175 Podium: This person was in the icu before for sepsis, so presumably they were hypotensive. And then the what else are they giving us here?
649
01:30:17.860 –> 01:30:25.019
SMED 175 Podium: Fractional excretion of sodiums? 2.1%. So what does this person have?
650
01:30:27.100 –> 01:30:28.659
SMED 175 Podium: So Hi, fina!
651
01:30:29.480 –> 01:30:32.579
SMED 175 Podium: So they’re dumping sodium inappropriately.
652
01:30:33.140 –> 01:30:40.100
SMED 175 Podium: And they were septic, and they were on gentamicin.
653
01:30:40.440 –> 01:30:47.410
SMED 175 Podium: So they have an ischemic risk for something, and they have a nephrotoxic risk for something. So what is that something?
654
01:30:48.830 –> 01:31:09.449
SMED 175 Podium: Yeah, you’re making the proximal tubule mad. Right? So in the proximal tubule is so finicky because it remember, we earlier on, we talked about how much energy the proximal tubule chews up well, when it doesn’t get that energy it revolts, and then it necroses. So that’s what Atn is. So this person has a high fina.
655
01:31:09.540 –> 01:31:30.480
SMED 175 Podium: a risk for atn, which included septic shock. It sounds like. And then also this exposure to gentamicin. And then oh, the ibuprofen and the Ramipril really didn’t help the Gfr. Either, to be honest so and this is kind of like a real life case. So I mean, this would be something you’d see. So what would you expect to see with Atn?
656
01:31:32.000 –> 01:31:49.599
SMED 175 Podium: We see Wbc. Cast. Fatty cast muddy brown cast Rbc casts muddy brown casts. Okay, so that’s the answer to that one. So what are the big risk factors here? Aminolycoside exposure, so on and so forth. Eosinophils they gave us were low. So it’s not going to be ain.
657
01:31:49.810 –> 01:31:57.150
SMED 175 Podium: So, anyway. So know these features. If you know these fundamental features. You’re gonna
658
01:31:57.340 –> 01:31:59.950
SMED 175 Podium: good question should not be a problem. Okay?
659
01:32:01.770 –> 01:32:04.859
SMED 175 Podium: Okay. 57 year old. ER.
660
01:32:04.960 –> 01:32:09.120
SMED 175 Podium: Pain in the sides of the abdomen with blood-tinged urine.
661
01:32:09.400 –> 01:32:22.429
SMED 175 Podium: progressive malaise, myalgias, itchy, rash reflux disease didn’t respond well to Zantac or Ranitidine, but got better since I got put on pantoprazole drug
662
01:32:22.580 –> 01:32:30.249
SMED 175 Podium: takes occasional acetaminophen diffuse maculopapular, rash.
663
01:32:30.920 –> 01:32:36.220
SMED 175 Podium: And now this person’s creatinine is oh, wow! It’s 4 that’s not normal. That’s high right?
664
01:32:36.440 –> 01:32:44.019
SMED 175 Podium: So presumably acute kidney injury. They have a rash.
665
01:32:44.620 –> 01:32:47.990
SMED 175 Podium: They got started on a proton pump. Inhibitor.
666
01:32:48.870 –> 01:32:51.810
SMED 175 Podium: What kind of findings? What do you think this person has?
667
01:32:57.100 –> 01:33:02.480
SMED 175 Podium: Yes, perfect. So ain okay, so acute interstitial nephritis.
668
01:33:02.720 –> 01:33:17.719
SMED 175 Podium: It’s invariably going to be due to a medication that got started. And then the clue here is this person also has a maculopapular rash. So the rash, the new drug, and all that. And then, when you look at the labs here, let’s see
669
01:33:18.060 –> 01:33:26.999
SMED 175 Podium: nothing really exciting, otherwise, so renal ultrasound showed no, no abnormalities. So what’s our answer going to be for
670
01:33:28.730 –> 01:33:30.829
SMED 175 Podium: acute interstitial nephritis?
671
01:33:34.090 –> 01:33:50.649
SMED 175 Podium: So probably I mean the thing they’re looking for. Here is probably your I’m guessing it’s going to be urine eosinophils, right? Which kind of makes sense with that rash. Okay, so so what does this? The rest of this stuff tell us, Dermal, Iga deposition, that that’s Henox purpura.
672
01:33:50.870 –> 01:34:00.710
SMED 175 Podium: Okay? So that’s going to be like, Ig nephropathy plus your skin involvement nitrites that are positive on a urine dipstick that tells you they have a urinary tract infection.
673
01:34:02.010 –> 01:34:18.699
SMED 175 Podium: urinary crystals. You’re going to think of some kind of calcium oxalate mesangium having Iga deposits is going to be Iga. And then, if you have the crescent shaped stuff that’s going to be like a nephritic syndrome, like anti-gbm or lupus, or
674
01:34:19.160 –> 01:34:20.759
SMED 175 Podium: or an Anka disease.
675
01:34:21.210 –> 01:34:27.579
SMED 175 Podium: So yeah, yeah, yeah. And after starting the car.
676
01:34:28.340 –> 01:34:31.249
SMED 175 Podium: usually within usually a few weeks.
677
01:34:32.410 –> 01:34:37.839
SMED 175 Podium: I mean truthfully, can happen anytime. But usually it’s after they’ve been on it for a few weeks.
678
01:34:39.080 –> 01:34:46.549
SMED 175 Podium: I don’t think they would be that picky about it, but just know that drugs and skin rash and Aki are going to be.
679
01:34:47.050 –> 01:34:51.190
SMED 175 Podium: you know, acute interstitial nephritis until proven. Otherwise. Okay.
680
01:34:51.810 –> 01:35:08.349
SMED 175 Podium: so what are the drugs to remember? Nsaids can do this? Rifampin can do this? Cephalosporins and penicillins can do this and proton pump inhibitors. These are like the big big ones, and the way I can see them playing with all of this stuff is, what condition is rifampin used for a lot?
681
01:35:09.820 –> 01:35:22.899
SMED 175 Podium: Yeah. Tuberculosis, right? So they might do something like, Oh, blah! Blah X-ray miliary pattern. Blah blah, Tb blah blah! They’re on. What’s the therapy for? Tb, a lot of times.
682
01:35:23.400 –> 01:35:36.820
SMED 175 Podium: Isn’t that ripe ripe? The Isoniazid Pyrazinamide ethambutol and the rifampin so the rifampin is part of that. So if they give you a Tb. Patient on ripe therapy with acute kidney injury.
683
01:35:37.380 –> 01:35:39.420
SMED 175 Podium: it’s probably going to be Ralph Hampin
684
01:35:39.540 –> 01:35:41.753
SMED 175 Podium: right? They’ll kind of extend it that way.
685
01:35:42.300 –> 01:35:46.419
SMED 175 Podium: So, and then white cell casts is what you would look for.
686
01:35:46.810 –> 01:35:50.169
SMED 175 Podium: They’ll probably tell you they have white blood cell casts and not
687
01:35:50.400 –> 01:35:52.139
SMED 175 Podium: ask you to pick them out.
688
01:35:53.160 –> 01:35:54.590
SMED 175 Podium: You guys ready for another one.
689
01:35:54.800 –> 01:35:55.780
SMED 175 Podium: Okay?
690
01:35:55.890 –> 01:36:10.060
SMED 175 Podium: 48 year old er three-day history of confusion and lethargy, abdominal pain hospitalized for pyelonephritis treated with ceftriaxone history of chronic hep. C. No medicines. What’s hep? Ca. Risk for
691
01:36:12.130 –> 01:36:18.830
SMED 175 Podium: Mpgn. Okay? Just so. Memor no proliferative. Gn so
692
01:36:19.180 –> 01:36:30.560
SMED 175 Podium: let’s see, physical exam shows icterus jaundice. So the presumably have liver disease pitting edema, distended abdomen with a positive fluid waves. What do they have
693
01:36:31.100 –> 01:36:37.460
SMED 175 Podium: ascites right. So here’s the lab stuff. Creatinine’s 3.5.
694
01:36:37.640 –> 01:36:48.329
SMED 175 Podium: Transaminases are high. Presumably that’s coming from the liver. Bun is in the 70 70. Hemoglobin is 10. Okay, Urinalysis.
695
01:36:48.570 –> 01:36:51.280
SMED 175 Podium: fina, less than 1%.
696
01:36:51.430 –> 01:36:52.720
SMED 175 Podium: What’s your answer?
697
01:36:53.850 –> 01:37:05.239
SMED 175 Podium: Prerenal? Right? Exactly. So. I mean, if they give you that, that’s going to be, that’s an absolute piece of objective data. So everything else gets kind of put by the wayside once you have
698
01:37:05.700 –> 01:37:20.719
SMED 175 Podium: info like that. Which of the following is the most likely cause of kidney dysfunction. So is it going to be interstitial inflammation, immune, mediated, gn renal vein, thrombosis, decreased renal perfusion.
699
01:37:21.260 –> 01:37:29.459
SMED 175 Podium: renal tubular injury, ie atn or throm by like hemolytic, uremic syndrome, or something like that.
700
01:37:29.870 –> 01:37:36.530
SMED 175 Podium: So what’s the answer? Here, fina? Less than 1% goes along with
701
01:37:38.530 –> 01:37:57.529
SMED 175 Podium: decreased renal perfusion. Okay, so all right, so decreased renal perfusion. So that’s what we’re after. What are the Hep C related things, Mpgn. But then that person’s going to have enough glomerular disease. Right? So you’re going to have hematuria proteinuria as part of that. So they give you that.
702
01:37:57.630 –> 01:38:00.210
SMED 175 Podium: Then that’s the the other stuff.
703
01:38:02.070 –> 01:38:12.360
SMED 175 Podium: okay, Pth stuff. Just know the chart that we go over. If you understand that chart, you’re golden. So here’s a person 46 year old.
704
01:38:12.980 –> 01:38:16.680
SMED 175 Podium: Mild flank, pain, blood pressure is 1, 32.
705
01:38:16.980 –> 01:38:26.599
SMED 175 Podium: Okay, so sodium is 141 calcium is 11. Phosphorus is 2. I’ll just tell you right now, calcium is high, phosphorus is low.
706
01:38:27.190 –> 01:38:30.779
SMED 175 Podium: Okay? And the kidney function is normal.
707
01:38:32.460 –> 01:38:33.590
SMED 175 Podium: So
708
01:38:34.450 –> 01:38:42.830
SMED 175 Podium: now they’re going to do these studies repeat calcium. Still, in the 11 range, it’s high. Pth level is 890. That’s very high
709
01:38:43.360 –> 01:38:51.360
SMED 175 Podium: and normal is like 80 to a hundred vitamin d level is fine. It’s 48
710
01:38:51.520 –> 01:39:00.809
SMED 175 Podium: 24 h. Urine calcium excretion is elevated. Abdominal ultrasound shows small calculi in both kidneys. So presumably there’s stones there.
711
01:39:01.511 –> 01:39:04.639
SMED 175 Podium: So what’s the what does this person have?
712
01:39:06.960 –> 01:39:12.970
SMED 175 Podium: So this person is hypercalcemic and hypophosphatemic.
713
01:39:13.630 –> 01:39:18.579
SMED 175 Podium: So, and they have a really high Pth level. Right? So what what are the
714
01:39:18.690 –> 01:39:23.860
SMED 175 Podium: what are the electrolyte effects of parathyroid hormone. If everything’s working normally.
715
01:39:25.880 –> 01:39:36.500
SMED 175 Podium: Pth goes to the kidneys and basically tells it to hold on. So go to bones. Tells it to release calcium goes to kidneys tells it to hold on to calcium.
716
01:39:36.730 –> 01:39:38.252
SMED 175 Podium: and then it
717
01:39:38.880 –> 01:39:42.589
SMED 175 Podium: How’s the kidneys get rid of phosphorus?
718
01:39:42.750 –> 01:39:56.500
SMED 175 Podium: So as long as your kidneys are intact, that’s what will happen? Calcium goes up, phosphate goes down, and the creatinine here is 0 point 9. So it’s normal. So what does this person have? Where’s the Pth coming from
719
01:39:57.720 –> 01:40:05.069
SMED 175 Podium: parathyroid gland. Right? We know that. But what’s causing the parathyroid gland to spew out all this Pth.
720
01:40:06.800 –> 01:40:12.110
SMED 175 Podium: so is it. Kidney failure? No, because the creatinine is 0 point 9.
721
01:40:12.300 –> 01:40:15.930
SMED 175 Podium: So what does this person have? They have a parathyroid
722
01:40:16.460 –> 01:40:31.230
SMED 175 Podium: tumor. They have an adenoma. So this is primary hyperparathyroidism. So the pattern to know, for all of this stuff is as follows, if you have a primary hyperparathyroidism.
723
01:40:31.500 –> 01:40:35.479
SMED 175 Podium: you’re making too much pth in unregulated fashion.
724
01:40:35.690 –> 01:41:00.819
SMED 175 Podium: but you have to have intact kidney function which this person has so calcium is high. Phosphorus is low vitamin D levels normal. So this person has a primary hyperparathyroidism. And so here it would be. Have the surgeon remove the tumor. Okay, that’s the answer. How does that compare otherwise? The 1st thing, if you ever get these Pth questions.
725
01:41:01.140 –> 01:41:03.159
SMED 175 Podium: 1st thing to look at is the creatinine.
726
01:41:03.460 –> 01:41:15.259
SMED 175 Podium: Okay, if the creatinine’s high, and it looks like they have chronic kidney disease, then, you know, it’s secondary hyperparathyroidism. And that’s because in that setting you cannot make as much calcitriol
727
01:41:15.580 –> 01:41:23.489
SMED 175 Podium: as your body wants so low vitamin d low calcitriol level is the problem. And then because of that
728
01:41:25.250 –> 01:41:27.489
SMED 175 Podium: the eth goes up.
729
01:41:27.920 –> 01:41:45.480
SMED 175 Podium: but then the calcium goes down, and the mainly the phosphorus goes up because the kidneys can’t pee it off. So chronic kidney disease is a phosphate retaining condition, and then the high phosphate will chelate some of the calcium which makes your calcium level drop down.
730
01:41:45.880 –> 01:41:52.255
SMED 175 Podium: So know that pattern between primary and secondary when the arrows guaranteed, that’ll be on your thing.
731
01:41:52.830 –> 01:42:14.530
SMED 175 Podium: so know that pattern. And then, if you ever see anything else? Pth related. Think multiple endocrine neoplasia. Just as a 3rd thing to think about. Think about men’s syndrome. So men one and 2, a, I think are the ones. So those are the ones that have parathyroid stuff in there.
732
01:42:14.770 –> 01:42:24.079
SMED 175 Podium: So here, what’s our answer on this one? Well, we just oh, let’s see, 68 year old, comes to the physician’s office type, 2 diabetes, hypertension, chronic kidney disease.
733
01:42:24.310 –> 01:42:26.610
SMED 175 Podium: Okay, creatinine’s 4 and a half.
734
01:42:26.870 –> 01:42:31.319
SMED 175 Podium: Which of the following is the answer.
735
01:42:31.520 –> 01:42:35.600
SMED 175 Podium: Okay, so with chronic kidney disease, what’s the major problem?
736
01:42:36.490 –> 01:42:37.290
SMED 175 Podium: Hmm.
737
01:42:37.530 –> 01:42:44.560
SMED 175 Podium: can’t make calcitriol right? So we’re going to go and go straight to the vitamin D, and we’re going to look for the look. Most of them are decreased.
738
01:42:45.170 –> 01:42:53.379
SMED 175 Podium: Okay, so parathyroid hormone is going to be increased. So we’re down to BC and D,
739
01:42:53.770 –> 01:42:58.620
SMED 175 Podium: and then which one? Then remember chronic kidney disease. What can you not get rid of?
740
01:42:59.170 –> 01:43:02.100
SMED 175 Podium: Phosphorus? So phosphorus level is going to be
741
01:43:02.510 –> 01:43:07.490
SMED 175 Podium: high, and there’s only one there. So it should be. B, right? I think
742
01:43:07.790 –> 01:43:11.249
SMED 175 Podium: so. Yeah, so it’s going to be B, so know that pattern.
743
01:43:11.660 –> 01:43:15.629
SMED 175 Podium: and that’s worth spending at least a little bit of time on, because
744
01:43:16.260 –> 01:43:18.039
SMED 175 Podium: you’ll be happy when you see that
745
01:43:19.890 –> 01:43:33.759
SMED 175 Podium: you want to go on some more. Okay, I’ll be fast here. So the glomerular filtration barrier just know that know the main parts to it. So you have vascular endothelium, glomerular basement membrane and podocytes on the outside.
746
01:43:34.620 –> 01:43:47.100
SMED 175 Podium: So if you’re going to approach these nephrotic nephritic things, I cannot emphasize enough knowing the red line here, right? The red line differentiates between
747
01:43:47.290 –> 01:43:51.090
SMED 175 Podium: nephritic and nephrotic. What’s the difference between nephritic and nephrotic
748
01:43:51.710 –> 01:43:56.280
SMED 175 Podium: nephritic you’re going to is a vascular endothelial side of the
749
01:43:56.670 –> 01:44:00.960
SMED 175 Podium: barrier that’s the problem. So you’re going to have blood
750
01:44:01.760 –> 01:44:26.620
SMED 175 Podium: if you don’t have blood, and you have protein, only you’re on the other side of the filtration barrier, and that’s going to be the nephrotic syndromes. So what are those? You guys know these pretty well now but minimal change? Fsgs, membranous, post-infectious, and then diabetes and amyloid. And then so a lot of times you can include, exclude your answer choices
751
01:44:26.750 –> 01:44:37.569
SMED 175 Podium: based on what the Urinalysis tells you. So if the Ua has blood in there, then you can get rid of all your nephrotic diagnoses, because those are going to be purely proteinuria driven.
752
01:44:39.605 –> 01:44:40.609
SMED 175 Podium: So
753
01:44:41.930 –> 01:44:56.880
SMED 175 Podium: you should have this in your notes from before. But I mainly just put this in here because here we go. Here’s all the stuff that’s associated with it. So just know, like minimal change is going to be children steroid responsive.
754
01:44:56.960 –> 01:45:12.010
SMED 175 Podium: It’s associated with non-hodgkin’s lymphoma or with Hodgkin’s lymphoma. Excuse me, Fsgs is the main thing you see with HIV nephropathy so if you had a question about an HIV patient
755
01:45:12.120 –> 01:45:28.059
SMED 175 Podium: that that’ll be the clue membranous is going to be cancer. Pla 2 R receptor antibody. And it’s 1 of the versions of lupus, but just, you know, know, kind of these associations with all of these.
756
01:45:28.420 –> 01:45:30.760
SMED 175 Podium: And then for the nephritic ones
757
01:45:31.010 –> 01:45:39.020
SMED 175 Podium: you’re going to have, you know, there’s not that many left Mpgn, Rpgn and Iga. I think I gave you this case of alports that we had last week, didn’t I?
758
01:45:39.280 –> 01:46:06.629
SMED 175 Podium: Didn’t I send something on slack. Okay? So anyway. So alport syndrome is going to show up as a glomerular disorder that looks nephritic. And then, iga, what’s important about Iga? Most common worldwide. It’s very common in Asia, very common after an upper respiratory tract infection. So remember, Iga is kind of a mucosal antibody. It’s a dimer, and it’s very quick to form. So if you have a
759
01:46:06.650 –> 01:46:12.250
SMED 175 Podium: sore throat, viral gastroenteritis, any of that kind of stuff the
760
01:46:13.140 –> 01:46:17.479
SMED 175 Podium: the hematuria is going to show up like a day or 2 later.
761
01:46:17.840 –> 01:46:38.559
SMED 175 Podium: because the Iga levels get really high and then cause all this inflammation in the glomeruli as opposed to the other infection related, one which is post-infectious gn, which can also be associated with uris and sore throats, and all of that. And that’s going to happen. So with post-infectious gn.
762
01:46:38.790 –> 01:46:45.780
SMED 175 Podium: what is the culprit that causes it? What’s like the fundamental thing going on in the glomerular line?
763
01:46:47.340 –> 01:46:58.709
SMED 175 Podium: You’re getting immune complexes that are forming and depositing. And so the the reason post-infectious Gn mainly shows up is, you get these nephritogenic strains of strep
764
01:46:59.030 –> 01:47:04.739
SMED 175 Podium: and the surface proteins on the strip look a lot like the Gbm.
765
01:47:05.430 –> 01:47:23.760
SMED 175 Podium: And so you wind up with antibodies directed against the strep. But the antibodies don’t know the difference between the strep and the glomerular basement membrane, and so you’ll get immune complexes depositing in there and then. Those are the lumpy, bumpy, irregular ones that you get with the electron microscopy.
766
01:47:23.820 –> 01:47:37.610
SMED 175 Podium: And then anything that has an immune complex associated with it is going to look granular. So who’s going to look granular on here? Mpgn will look granular, post-infectious. Gn. Looks granular
767
01:47:38.060 –> 01:47:47.190
SMED 175 Podium: membranous might look granular because you get immune complexes with that as well. Lupus will look granular. Okay, Iga
768
01:47:47.580 –> 01:47:49.659
SMED 175 Podium: is going to be in the mesangium
769
01:47:49.830 –> 01:47:57.829
SMED 175 Podium: right? You’ll kind of see it in a Mesangio pad, and they have to tell you that it’s Iga in the mesangium. Okay? Membranous.
770
01:47:58.170 –> 01:48:11.550
SMED 175 Podium: You get these immune complexes that form between the podocytes. So you get this very regular spiky looking thing. So you get a very regular looking deposits on the em with that.
771
01:48:11.900 –> 01:48:21.519
SMED 175 Podium: and then minimal change in fsgs. Remember the podocytes get effaced or stripped off of there. So if they say anything about podocyte effacement.
772
01:48:21.630 –> 01:48:24.619
SMED 175 Podium: they’re either talking about minimal change or Fsgs.
773
01:48:26.105 –> 01:48:27.080
SMED 175 Podium: Diabetes.
774
01:48:27.800 –> 01:48:30.269
SMED 175 Podium: What’s the buzzword for? Diabetes
775
01:48:30.630 –> 01:48:47.220
SMED 175 Podium: get like these big red nodules in the glomeruli? Those are those Kimmel-steel Wilson nodules okay, that’s classic for that. And then amyloid is a family of problems. So amyloid is either a bone marrow problem which is kappa or lambda light chains.
776
01:48:47.250 –> 01:49:13.140
SMED 175 Podium: or it’s a chronic, inflammatory problem, like osteomyelitis or rheumatoid arthritis or inflammatory bowel disease like Crohn’s, and stuff like that. And so you’ll get serum amyloid a deposits as opposed to Kappa lambda, light chains with primary amyloid, but the buzzword they always look for is amyloid protein stains. How
777
01:49:15.990 –> 01:49:21.169
SMED 175 Podium: yeah. Apple green biorefringence on Congo red staining right.
778
01:49:21.610 –> 01:49:37.979
SMED 175 Podium: So that’s if you see those words. That’s amyloid. Okay? So anyway, so know this chart. I mean, this chart has almost everything you need to know. But the test taking strategies. You’ve got to look at the Urinalysis, and it’ll tell you which side you’re on. You’re on the top or on the bottom
779
01:49:39.320 –> 01:49:41.970
SMED 175 Podium: oops. Let’s see, what are we doing here?
780
01:49:44.520 –> 01:49:54.281
SMED 175 Podium: Okay, so we’ll try this one. So without even doing anything more, 66 year old has these labs. Okay?
781
01:49:55.460 –> 01:49:58.449
SMED 175 Podium: Oh, look at the urine! There’s no blood.
782
01:49:59.090 –> 01:50:05.070
SMED 175 Podium: There’s 4 plus protein, nephritic or nephrotic, nephrotic
783
01:50:05.740 –> 01:50:08.850
SMED 175 Podium: X-ray shows a right upper lobe tumor
784
01:50:10.670 –> 01:50:14.330
SMED 175 Podium: hmm which nephrotic syndrome is associated with cancer.
785
01:50:15.700 –> 01:50:17.729
SMED 175 Podium: Wait, what was that snowman again?
786
01:50:20.010 –> 01:50:23.170
SMED 175 Podium: Oh, here we go. Membranous carcinomas.
787
01:50:23.480 –> 01:50:35.209
SMED 175 Podium: Okay, so no. So that’s the malignancy related one. Aside from minimal change which is associated with Hodgkin’s right. But that’s so. If you had a question about a lung tumor and and
788
01:50:36.590 –> 01:50:43.070
SMED 175 Podium: and proteinuria, the answer is going to be membranous. Okay, so just know that as you’re doing your studies.
789
01:50:43.250 –> 01:50:44.930
SMED 175 Podium: Know these charts.
790
01:50:46.450 –> 01:50:59.750
SMED 175 Podium: Okay? Next 1, 10 day, history of fatigue and lower leg swelling lost weight. Bronchitis. Use an inhaler. Used to smoke drinks occasionally. Thin
791
01:50:59.850 –> 01:51:04.110
SMED 175 Podium: 2 plus pre-tibial edema. So he’s got swelling.
792
01:51:04.330 –> 01:51:09.680
SMED 175 Podium: and let’s look at our stuff here. Oh, look the urine. No blood.
793
01:51:09.940 –> 01:51:13.359
SMED 175 Podium: 4 plus protein. Oh, wait. We just did this one. Right? Sorry.
794
01:51:14.020 –> 01:51:20.660
SMED 175 Podium: Okay, so yeah. So here is my explanation for that one. So no nephritic problem.
795
01:51:20.790 –> 01:51:22.570
SMED 175 Podium: and it’s going to be membranous.
796
01:51:22.750 –> 01:51:24.439
SMED 175 Podium: Any questions on that one.
797
01:51:24.940 –> 01:51:27.110
SMED 175 Podium: So just as you go through those kind of
798
01:51:28.310 –> 01:51:37.109
SMED 175 Podium: think about that, I don’t know what I did to my, here we go. Okay, 43 year old, swelling around the eyes. Decreased. Urine.
799
01:51:37.360 –> 01:51:46.280
SMED 175 Podium: urinalysis, 3 plus blood, one plus protein top or bottom bottom. Okay, so
800
01:51:47.630 –> 01:51:50.180
SMED 175 Podium: what’s most likely to be seen?
801
01:51:50.560 –> 01:52:03.510
SMED 175 Podium: Rhomboid crystals, achuric acid, low albumin inflammation, red cell casts detached renal, tubular epithelial cells is describing what
802
01:52:04.470 –> 01:52:11.290
SMED 175 Podium: atn right? So this. So this isn’t really an atn question, because there’s no muddy brown cast on there. So
803
01:52:13.470 –> 01:52:17.799
SMED 175 Podium: red blood cell casts right? So red cell casts are pathognomonic for
804
01:52:18.390 –> 01:52:30.070
SMED 175 Podium: nephritic glomerulonephritis. If there’s going to be bleeding coming from that, we don’t know exactly which version of gn this person has we’d have to look into that more. But
805
01:52:30.650 –> 01:52:34.700
SMED 175 Podium: anyway, so this this is where you get these Gn questions.
806
01:52:35.390 –> 01:52:40.019
SMED 175 Podium: Look at the Urinalysis, and then take the clues.
807
01:52:40.140 –> 01:52:57.500
SMED 175 Podium: The clues are not endless. Look at the clues they put on the snowman. Because if you just kind of get those down for the you know the major things on there. You’re going to nail these questions because the other really helpful part is, if they give you this
808
01:52:59.050 –> 01:53:03.499
SMED 175 Podium: this thing here where you’ve got 3 plus blood and one plus protein.
809
01:53:03.840 –> 01:53:08.749
SMED 175 Podium: If they give you minimal change, disease as an option. No.
810
01:53:08.890 –> 01:53:21.209
SMED 175 Podium: Is it amyloid? No. Is it membranous? No. Is it? Fsgs? No right? So you can kind of get rid of a lot of choices as much as anything else. So
811
01:53:21.850 –> 01:53:32.739
SMED 175 Podium: the snowman is. I think it’s like everything you need to know. Aside from, I think the only failing I had in the class is because we just don’t have enough. Time is just to do all the histopathology.
812
01:53:32.890 –> 01:53:40.569
SMED 175 Podium: So you know, know what the Ems look like know the immunofluorescent stuff. So, for example.
813
01:53:41.740 –> 01:53:44.680
SMED 175 Podium: if we go here to this filtration barrier
814
01:53:50.790 –> 01:53:53.329
SMED 175 Podium: if you have what conditions
815
01:53:56.900 –> 01:53:59.480
SMED 175 Podium: mess with the glomerular basement membrane.
816
01:54:00.450 –> 01:54:08.570
SMED 175 Podium: If you hear. Gbm, what conditions? Mess with the glomerular basement of membrane, there’s really 2 main ones.
817
01:54:09.880 –> 01:54:13.680
SMED 175 Podium: good pastures and elkwards. Okay, what’s the difference?
818
01:54:15.540 –> 01:54:18.600
SMED 175 Podium: Yeah. Yeah. Good pastures is anti Gbm.
819
01:54:20.380 –> 01:54:27.980
SMED 175 Podium: and the other ones just screwed up. Type 4 collagen. Right? So that. That’s the problem. And so remember, type 4. Collagen is
820
01:54:28.760 –> 01:54:42.930
SMED 175 Podium: what largely makes up the Gbm. And they have an abnormal alpha chain blah blah with all of that. But just know that it’s an abnormal type. 4. Collagen with L ports. What else is L ports associated with
821
01:54:44.460 –> 01:54:45.490
SMED 175 Podium: what?
822
01:54:46.050 –> 01:54:47.190
SMED 175 Podium: What
823
01:54:48.100 –> 01:55:06.909
SMED 175 Podium: you get? Sensory neural hearing loss right? So hearing loss. Hematuria blah! Blah! What’s the problem? Type? 4 collagens messed up in the Gbm. That’s why they have the this is where the hematuria is coming from okay, as opposed to the lupus person
824
01:55:07.040 –> 01:55:21.830
SMED 175 Podium: or the post-infectious person who is depositing. Well, Lupus is going to be on this side. You’re depositing immune complexes right? And then what do you call that? Again? When immune complexes are.
825
01:55:22.490 –> 01:55:25.909
SMED 175 Podium: they’re they consume complement right?
826
01:55:26.020 –> 01:55:37.430
SMED 175 Podium: So you’ll get hypocomplementemia with immune complex kidney disease. So that type of stuff and then membranous is
827
01:55:38.840 –> 01:55:41.479
SMED 175 Podium: happening here. And in fact, the
828
01:55:41.970 –> 01:55:47.819
SMED 175 Podium: the deposits are kind of between the podo sites, and they’re very regular.
829
01:55:48.440 –> 01:55:51.549
SMED 175 Podium: And so this is the they call this the spike.
830
01:55:54.030 –> 01:56:00.843
SMED 175 Podium: I think it’s like Spike and Dome, or something like that, whatever name they give it. So that’s membranous when you see that
831
01:56:01.870 –> 01:56:08.680
SMED 175 Podium: and you know any of the nephrotic ones, right as you’re messing with your
832
01:56:09.700 –> 01:56:13.619
SMED 175 Podium: glomerular epithelial cells or your podocytes are getting stripped off
833
01:56:13.820 –> 01:56:18.700
SMED 175 Podium: right? That’s minimal change in Fsgs. Yeah. Question. It’s also like Trampo.
834
01:56:19.380 –> 01:56:26.660
SMED 175 Podium: Oh, tram tracking. Yes, yes, you get a splitting of the Gbm, that’s a good one. I didn’t think about that. You guys know which one that is.
835
01:56:27.260 –> 01:56:29.810
SMED 175 Podium: So if you start splitting the Gbm.
836
01:56:31.950 –> 01:56:35.829
SMED 175 Podium: okay, that goes along with MP.
837
01:56:36.360 –> 01:56:37.600
SMED 175 Podium: G.
838
01:56:38.000 –> 01:56:38.840
SMED 175 Podium: Admin.
839
01:56:39.440 –> 01:56:51.550
SMED 175 Podium: So membranoproliferative. Gn, so what do you need to know about Mpgn tram tracking railroad tracks is what it basically is trying to describe. So railroad tracks and hepatitis. C,
840
01:56:51.930 –> 01:56:53.580
SMED 175 Podium: that’s what you’re going to want to know.
841
01:56:54.210 –> 01:56:58.859
SMED 175 Podium: And it’s also friends with Rpgn.
842
01:56:58.960 –> 01:57:00.579
SMED 175 Podium: So you can get.
843
01:57:01.930 –> 01:57:07.949
SMED 175 Podium: Remember the who lives down there. Here’s Mpgn, Rpgn iga.
844
01:57:08.820 –> 01:57:11.289
SMED 175 Podium: And this right here is a crescent.
845
01:57:13.840 –> 01:57:19.050
SMED 175 Podium: Okay? So if you get a chryscentic glomerulonephritis, it’s gonna be
846
01:57:23.710 –> 01:57:25.970
SMED 175 Podium: see if I can move this up.
847
01:57:28.940 –> 01:57:42.649
SMED 175 Podium: Okay, if you get a chryscentic gloryonephritis, it’s going to be one of these guys. So it’s going to be lupus iga vasculitis. Anti. I doubt they do iga vasculitis, but the other name for ige vasculitis is heenox Chron line purpura.
848
01:57:42.770 –> 01:57:52.259
SMED 175 Podium: So if they threw that term out there. But they’re kind of getting away from eponyms, but for what it’s worth. So antigbm, ancovasculitis.
849
01:57:52.570 –> 01:57:55.440
SMED 175 Podium: What about ankovasculitis? What are clues
850
01:57:55.740 –> 01:58:01.429
SMED 175 Podium: for that? So chryscentic gloryonephritis can happen
851
01:58:01.650 –> 01:58:30.079
SMED 175 Podium: so you get acute kidney injury, get hematuria, proteinuria, and then anka diseases are, you know, the old term was waggoners. Now, it’s granulomatosis or microscopic polyangitis. With granulomas. Okay? So you get so. But those are pulmonary renal syndromes. So you get sinus disease and lung disease. And it’s because of
852
01:58:30.380 –> 01:58:54.929
SMED 175 Podium: anka likes to nail cartilage, so you’ll wind up with the cartilage rings and the trachea get nailed. You can get sinus bowl destruction, because all the cartilage is being ruined, and then you can also get granulomas forming all over the place. So those are so Anka disease is going to the big tip off is going to be. There’s going to be some kind of lung involvement. Okay, so know about that.
853
01:58:55.130 –> 01:59:03.139
SMED 175 Podium: So Anca lungs. The other one is Cherg Strauss. So that’s microscopic polyangitis with Eosinophils
854
01:59:03.550 –> 01:59:07.300
SMED 175 Podium: that’s more of an asthma, but still pulmonary type stuff.
855
01:59:07.480 –> 01:59:11.450
SMED 175 Podium: So just remember, ankas will give you kidneys and lungs so
856
01:59:12.110 –> 01:59:21.570
SMED 175 Podium: renal pulmonary syndrome pulmonary renal syndrome whatever you want to call it. So they’re going to give you those clues. So just a matter of putting those together.
857
01:59:22.645 –> 01:59:25.560
SMED 175 Podium: Any other questions on this? Yeah.
858
01:59:25.880 –> 01:59:34.049
SMED 175 Podium: So posse immune means you have a chryscentic glomerulonephritis.
859
01:59:34.830 –> 01:59:37.170
SMED 175 Podium: but all of your markers are negative.
860
01:59:37.880 –> 01:59:44.310
SMED 175 Podium: So we that would never get asked for your purposes. But posse immune means.
861
01:59:44.690 –> 01:59:53.949
SMED 175 Podium: Everything looks like they have glomerulonephritis, they have hematuria, they have proteinuria. We do a biopsy. They have crescents. We do all these studies. And they’re all negative.
862
01:59:54.180 –> 01:59:58.189
SMED 175 Podium: that’s posse immune. So then the next question is, Well.
863
01:59:58.420 –> 02:00:09.250
SMED 175 Podium: how do you treat those? Exactly the same as the Ancas and the Ancas and the lupus and all of that. So they get treated the same way. But you would need to know that
864
02:00:09.490 –> 02:00:10.719
SMED 175 Podium: good question.
865
02:00:12.510 –> 02:00:13.840
SMED 175 Podium: Does this help?
866
02:00:14.650 –> 02:00:15.469
SMED 175 Podium: Okay?
867
02:00:16.760 –> 02:00:32.479
SMED 175 Podium: I just can’t tell you enough. I mean, take the clues they give you in the labs, because those are kind of the absolute things, and there’s so many red herrings that they throw into the stems. You know, smoker, not smoker, drinker, not drinker, that may or may not have anything to do with what’s going on.
868
02:00:32.860 –> 02:00:49.619
SMED 175 Podium: So look at the labs, because that’s where the objective findings are. And then you really can’t argue with those that’s kind of the key thing on all of these. But, boy, I’ll tell you if you get anything that looks even remotely like a gn question.
869
02:00:49.850 –> 02:00:58.179
SMED 175 Podium: Look at the PP. Look for blood and protein, and that’s going to give you your answer just about every single time. Okay.
870
02:01:00.700 –> 02:01:04.650
SMED 175 Podium: anything else. You want to go over everything.
871
02:01:05.600 –> 02:01:09.450
SMED 175 Podium: Let’s do some neurology. No, I don’t think I could.
- This page was last updated on March 14, 2025.