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hey guys it's medicosa's perfect snail
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is where medicine makes perfect sense
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continuing our Nephrology playlist we're
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talking about kidney diseases we have
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finished discussing the nephrotic
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syndromes and the nephritic syndromes we
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started talking about acute kidney
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failure in the previous videos today
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we'll learn how to diagnose and manage
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acute kidney failure or acute renal
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azotemia or acute renal insufficiency or
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acute kidney injury when my kidney is
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toast my kidney is unable to get rid of
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the waste products in the urine so all
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of that waste is gonna pile up in my
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blood giving me this pale color uremia
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will lead to skin frosting and itching
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big time also fatigue anorexia nausea
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vomiting and cognitive decline if I
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develop kidney failure I'll be unable to
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concentrate on task and pay attention
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let's get started please watch the
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videos in this technology playlist in
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order a good kidney should get rid of
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urea and creatinine in the urine but if
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I have kidney failure I cannot do that
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so all of the area will end up in my
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blood uremia a good kidney should get
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rid of Bon and creatinine in the urine
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the ratio should be greater than 15 for
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reasons that we discussed before a good
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kidney should not excrete too much
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sodium because sodium is precious to the
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body so the fractional excretion of
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sodium should be less than one percent a
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good kidney should be capable of
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concentrating therein which means High
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urine osmolality relatively speaking and
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the normal urine volume is one to two
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liters per day why do you call it acute
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kidney injury because the deterioration
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is rapid injury it is reversible unlike
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end stage kidney disease which is
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irreversible when my kidney cannot get
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rid of waste products in the urine
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what's gonna happen they will end up
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accumulating in my blood now nitrogenous
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wastes in the blood azotemia so I have
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acute kidney failure which means lots of
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urea in the blood uremia uremic acidosis
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azotemia renal failure GFR and urine
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volume are decreased serum built-in and
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creatinine are high don't forget that
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acute or chronic cranial failure will
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give me high anion gap metabolic
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acidosis but renal tubular acidosis will
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give me normal anion gap metabolic
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acidosis acute kidney injury has three
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types pre-renal interenal postrenal and
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three stages we talked about all of this
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in great detail in previous videos in
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this Nephrology playlist pre-renal the
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problem is before the kidney such as
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decreased kidney perfusion how about
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post renal the problem is after the
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kidney in the outflow about interenal
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the problem started inside the kidney in
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pre-renal azotemia do not blame the
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kidney the problem is before the kidney
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so so far it's a good kidney the ratio
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is greater than 15 which is good F Ena
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is less than one percent which is good
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even osmology is greater than 500 which
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is also good but if the problem is in
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the kidney the kidney is toast you get
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the exact opposite low ratio bad Fe and
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a more than two percent bad and the
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kidney is unable to concentrate the
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urine also bad how about post renal well
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early on it's not the kidney's fault so
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so far we have a good kid just like here
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however later it becomes a bad kidney
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just like here what are the signs and
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symptoms of acute kidney failure fatigue
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anorexia nausea vomiting and itching
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mental status changes and cognitive
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problems are common symptoms of volume
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depletion include I feel dirt in my eyes
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I feel thirsty dizzy I faint especially
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when I stand up Suddenly signs include
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dry skin sunken fontanels in neonates
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pore skin turgor hypotension tachycardia
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orthosis stasis in kidney failure GFR
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goes down Bon and creatinine in the
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blood go up and I have less urine volume
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oligaria in pre-renal it's a good kidney
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usually due to hypoperfusion so how do I
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treat it give the patient fluid like
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normal saline which is 0.9 percent
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sodium chloride solution when everything
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hits the fan dialysis how about
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intrarenal azotemia signs and symptoms
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are very similar although they will be
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more severe than pre-renal azotemia
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foreshore especially the uremia skin
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frosting or the chalky white deposits
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uremic faces which are pale and
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sometimes called toxic it's a very
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characteristic look of the kidney
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disease patient it's very difficult to
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describe in words that's why does
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doctors call it toxic look but once you
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see it many times you will be able to
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recognize a patient with kidney failure
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from a distance just like how a nurse
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with experience can recognize your
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cephalic Vein from two miles apart my
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kidney is being hammered by a toxin a
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contrast dye heavy metal or a drug what
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should I do stop the offending agent
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treat the underlying cause hit me with
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dialysis remember the three stages
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initiation maintenance recovery in the
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maintenance phase we get hyperkalemia
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but in the recovery phase we can get
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some hypokalemia hypophosphatemia Etc so
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be very careful because that will
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determine how you can treat your
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patients GFR is very important to
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diagnose acute or chronic renal failure
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so look at this in pre-renal GFR is
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starting to decrease initiation even
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worse extension maintenance that's the
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lowest GFR that you will get after this
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recovery
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urine volume will increase the patient
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will literally flood the hospital and
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the doctor will be so happy about it
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because the kidney function is getting
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better instead of oligaria we get
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polyurea both foreign
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is usually due to an obstruction so try
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to treat the underlying obstruction how
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can we diagnose acute kidney failure
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let's take acute tubular necrosis or
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intra-renal exotemia as an example we
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need some urine tests don't forget the
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GFR of course and we need some blood
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tests can you tell me what should we
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expect that they are in volume B in this
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case how about during osmology high or
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low specific gravity urine cast please
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pause and try to answer all of these
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yourselves are you ready urine volume
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should go down because it's called
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oliguria urine osmolarity should go down
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the kidney is unable to concentrate the
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urine it's also unable to produce urine
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urine specific gravity is low the kidney
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is unable to concentrate the urine urine
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casts are muddy Brown granular or
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pigmented casts fena is high not good
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urine sodium is high not good but in the
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blood high creatinine High We Are
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integrating in the ratio the low which
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means the kidney is unable to reabsorb
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bun so the numerator goes down and
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therefore the entire ratio goes down
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below 15. let's do arterial blood gases
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pH low because all of that waste that's
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accumulating in my blood includes
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sulfuric acid phosphoric acid lactic
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acid uric acid all kinds of acids and
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these acids will lead to acidosis is it
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the kidneys fault or the lung's fault
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kidneys fault so what you call
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respiratory or metabolic acidosis
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metabolic acidosis bicarbonate is low
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when you have too many acids in the
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blood you will consume your base you
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will consume your buffer system one of
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the most important equations in
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acid-base disturbance is here pH is
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proportional to bicarbonate on top and
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carbon dioxide at the bottom what
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happened to bicarbonate here bicarbonate
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went down therefore what's going to
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happen to the pH it went down this is
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what you call me metabolic acidosis what
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should be the compensation from your
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normal lungs do unto others what you
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want them do unto you I should lower the
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denominator just like how the numerator
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went down so that we can bring the pH
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back to normal so if your lungs are
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healthy they will compensate by getting
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rid of carbon dioxide through
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hyperventilation respiratory alkalosis
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is the compensation of the metabolic
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acidosis the accumulation of the uric
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acid sulfuric acid Etc all of these are
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unmeasured anions which will increase
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the anion gap above 12. we call this
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High anion gap metabolic acidosis here
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is acidosis here is metabolic and here
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is high anion gap anytime you have too
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many protons in the blood I.E acidosis
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you will trade with your cell the
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hydrogen ion will hide in the cell to
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decrease the acidosis in the blood in x
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change well if a positive wind in a
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positive has to go out of the cell and
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this positive is potassium that's why
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most cases of acidosis are associated
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with hyperkalemia too much potassium in
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the blood what's the normal urine
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osmolarity it could be anywhere between
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50 and 1200 let's say 600 or 700 is a
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good number a good kidney should be able
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to concentrate there and giving me a
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high number but kidney failure you'll
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get a lower number urine specific
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gravity is very similar to urine
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osmolality but less accurate for reasons
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that we discussed before in my videos in
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the labs playlist I have a video on
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urine osmolality and another video on
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urine specific gravity what kind of
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casts do we see in cases of acute
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tibular necrosis muddy Brown granular
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course casts Brown so they are pigmented
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we get too much creatinine in the blood
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what's creatinine creatinine is a
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metabolic end product of creatin
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phosphate metabolism which is present in
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muscle so if I see high serum creatinine
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it could be kidney disease or it could
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be strenuous exercise Rhabdomyolysis
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excessive protein intake Etc how about
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the story of urea urea is the metabolic
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end product of proteins amino acids and
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pyrimidines high bun in the blood could
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be a sign of kidney disease or it could
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be because of excessive protein intake
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and increased protein catabolism the
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difference between serum buen and serum
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creatinine was discussed before in my
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labs playlist please pause and review
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what is the fractional excretion of
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sodium basically it's a crazy equation
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that we have discussed before but the
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moral of the story is a good kidney
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should not waste too much sodium in the
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urine a good kidney should reabsorb more
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than 99 percent of that sodium back to
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the blood that's a good kidney because
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it's wasting less sodium that's a bad
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kidney because it's wasting too much
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sodium and in my previous video on the
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fractional excretion of sodium I've told
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you about this dilemma and how to solve
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it clinically to learn more about this
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please check out my video called
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fractional excretion of sodium in my
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labs playlist and another video titled
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fractional excretion of urea also in the
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labs playlist next how can we manage
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acute renal failure please don't forget
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the 3DS diet drugs and dialysis but
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before we talk about any of these you
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stop the offending agent if it's lead
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poisoning stop the exposure mercury
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poisoning stop the exposure remove the
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patient from the bad toxic environment
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if the blood pressure is too high we
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treat it of course volume depletion give
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fluids volume overload give diuretics
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hyperkalemia this can stop your heart
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protect the heart with calcium gluconate
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calcium chloride
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Etc give insulin with glucose give
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diuretics anything except the potassium
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sparing diuretics like spironolactone
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because this will worsen the
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hyperkalemia you can give beta agonists
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to treat hyperkalemia and you can give
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the potassium binding resin known as
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kayexalate which will take the K
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potassium and dumps it in the stool diet
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well this kidney is fragile right now we
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have acute kidney injury so be very
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gentle on the kidney do not drink too
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much fluid because who do you think
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should excrete all of that fluid that
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you're drinking your kidney do not
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overwhelm the kidney for the time being
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also do not overwhelm your kidney with
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too much protein or too much salt or too
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much potassium because it's the kidney's
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job to get rid of all of these so be
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very gentle on the kidney same thing
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goes for phosphate limit the phosphate
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intake so decrease meat intake
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especially beef decrease day Dairy
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intake no milk no ice cream no yogurt
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Etc because of the fat no because they
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have sugar also no because they have
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phosphate and phosphate is dangerous for
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the failed kidney and when everything
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hits the fan hit me with dialysis as you
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know we have peritoneal dialysis and
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hemodialysis can we take a moment to
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review the treatment of hyperkalemia
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first order of business protect the
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heart who cares about the potassium
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level just protect the heart otherwise
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they will die how do you stabilize the
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cardiac membrane calcium calcium
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stabilizes the membrane if you want to
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know why or how check out my nerve
00:13:42
physiology Series in my physiology
00:13:44
playlist and remember that calcium is
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Contra excitability that's why in tetany
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when you have low calcium what happens
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to your nerve excitability High nerve
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excitability that's why you get carpal
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spasms pedal spasms laryngeal spasms all
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kinds of spasms positive choistic sign
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and Russo sign next give insulin with
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glucose insulin will push the potassium
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and the glucose together into the cell
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leaving less potassium in the blood
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which decreases the hyperkalemia why not
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give insulin alone without glucose if
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you give insulin alone without giving
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glucose insulin will push glucose into
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the cell leaving less glucose in the
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blood and you will develop
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hypoglycemia well done doctor you give
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the insulin with the glucose and then
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diuretics except potassium-spiring
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diuretics can I use Loop Derek's
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furosemide yeah can I use thiazide
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diuretics also yeah next beta agonists
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why because they stimulate the sodium
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potassium 80 phase and if you recall the
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sodium potassium 80 paste pump will pump
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sodium out of the cell but pump
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potassium into the cell leaving less
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potassium in the bloodstream treating
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the hyperkalemia next let's bind that
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potassium in the stool to prevent its
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absorption to decrease the level of
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potassium in the blood when everything
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hits the fan you hit me with dialysis
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man if you want to learn more about
00:15:18
kidney physiology the proximal to build
00:15:20
the loop of Henley the distal tibial the
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collecting ducts that titratable acidity
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and much more download my renal
00:15:27
physiology course at
00:15:29
miracostessperfectsnellis.com to learn
00:15:31
about anion gap metabolic acidosis High
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versus normal the serum anion cap versus
00:15:37
the urine anion gap if you want to learn
00:15:40
about the serum a smaller Gap and the
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stool a smaller Gap base excess base
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deficit compensated versus uncompensated
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Etc download my acid-base imbalance
00:15:51
course at
00:15:52
medicosasperfectsnellis.com if you do
00:15:54
not want to download my courses and
00:15:56
would rather watch them right here on
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YouTube click click the join button and
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subscribe to the highest tier hit the
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00:16:12
medicosa's perfect analysis where
00:16:14
medicine makes perfect sense
