006 Mark Klimek

Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Anything beyond these five is really enough to know. It's not really need-to-know territory. You do need to know these five, though. I would really suggest that just a little bit of memory work. But it's a good payoff for it. Because you understand, this is a test for nurse safety. And one of the biggest ways you can be unsafe is to not know drug toxic effects. You see how that could result in real patient harm. So that's an area they like to test is toxic reactions to drugs, drug toxicity. So let's talk about these five. Lithium. Lithium, of course, is the famous anti-mania drug. It's used for bipolar, but it's not used for the depression. It's used for the mania. Its therapeutic level in the middle column there, you should write 0.6 to 1.2. Now, the toxic level is greater than or equal to 2. Now, immediately, you should see that there is a gray area there, where you're higher than 1.2 but under 2.0. You see that gray area? That is a gray area where no books agree on exactly what's going on with lithium at those levels. From 0.6 to 1.2, everyone agrees that it is therapeutic. Everyone agrees that two and over is toxic. But in between, you just pick your book and they're going to say different things. One of the things that you guys don't know about me, or maybe you do know about me, that's probably good for you to know about me and help you understand why I say what I do and how I say what I do, is that for years I was an NCLEX RN item test writer. I wrote questions on the NCLEX. The questions that were on there, I've written some of those questions. So I've been through the whole training protocol on how they want you to write questions for them. When I tell you the questions are written this way, that's because I've been through the in-service education on it. I've been trained as their item writer. In 2003, I think it was, maybe it was 2002, somewhere right around in there, NCSDN made a rule that you cannot be an item writer and be a NCLEX reviewer at the same time. Which makes sense. You can't write the questions and then go teach people how to pass the test. It's not ethically correct. So at that time, I had to sit between writing questions and reviewing, and I picked reviewing, and so I stopped writing questions. And so I haven't written a question since 2003, roughly. But if they only change 5% every year, there's still loads of questions on there that I've written. Now I say that to tell you that when I give you ranges, the ranges I give you may not be the ones you learned. But they are the ones that you use when you write questions. Do you see what I'm saying? And most of the time, my ranges are wider than what, most of the times, than what you learn. Because the instructions are, to every item writer on the board, is when you write a test question where you use a lab value or a range, a value in a range, a number, go to at least five different books published by five different publishers, and see what they say. The range is, then make your range wide enough to fit all of those. Do you see what I'm saying? So the book 1 says 1 to 2, book 2 says 1 to 2.3, book 3 says .8 to 1.9. Well, you've got to go from .8 to 2.3 as your range. That way, it's a fair question no matter what book the student's used. So you're going to see my ranges are different, but my ranges are made to fit the NCLEX. Do you understand that? And not necessarily a particular book. So you may use my ranges and my numbers, and you may go take the, like the Saunders Review Book with questions, or the Exam Cram with questions, or the NCLEX Gold with questions, and using my ranges, you may miss the question. Why? Because they went by their ranges. What ranges? The ranges in the MedSurg book that that company publishes. Only one book, not five. Now, Kaplan does what I do. Anybody that's a national reviewer does what I do, which is a wider range than normal, okay? So here's the deal. Ford's would never give you a lithium of 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9. Why? It's in that gray area where books don't agree, and item writers have to get it to where all the books agree. So I teach you two and greater, because every book agrees that that is toxic, all right? So don't worry about that when you see these ranges. Okay, Lenoxin. Lenoxin, what's the other name for it? I told you you have to know this. DIG. This is used to treat basically two things. DIG is used to treat AFib and congestive heart failure. Atrial fib and congestive heart failure. How should you have already known that it treats atrial fib? DIG. In what context did we talk about DIG yesterday? Adena, beta, calcium, DIG. Oh, so DIG is the D of the ABCDs of atrial treatment, so atrial fib, yes, and then congestive heart failure is the other big one that it treats. Well, what is the therapeutic level of DIG? One to two. And you notice I'm not giving you units, correct? Because what did I tell you about units? Don't worry about it. They're not going to ask you. They're going to say, how many milligrams per deciliter of, and you just say the number. Its toxic level is greater than or equal to two. So what do you notice about two? It could be therapeutic and it could be toxic. So what do you call it when they give you a value of two? Toxic line. It's safer to call something toxic when it may not be than to say it's therapeutic when it might not be. So always err on that safe side. What do you notice about lithium and linoxin toxicity? They're the same at two and greater. Aminoflin. Aminoflin is an airway antispasmodic. It relieves spasms in your airway. It is technically not a bronchodilator. What do I mean by that? It is technically not a bronchodilator. What does it not do? It doesn't stimulate your beta-2 agonist cell to bronchodilate. It just relaxes a spasm. Now, when you're in a spasm, your airway is what? Narrow or wide? Narrow. And when I relax the spasm, what happens to the airway? It gets what? Wider. So it actually looks like it's a bronchodilator, but it's not really a bronchodilator. Epinephrine is a bronchodilator. Ipetropium is a bronchodilator. Alupent, albuterol are bronchodilators. Tributeline is a bronchodilator. This is a muscle spasm relaxer. I'm sort of just going off the side here on these things just to see if you can apply some stuff. Have you ever seen anybody come in or heard of anyone coming in in an acute asthmatic attack and the bronchodilators aren't working? That happens on occasion. It's probably what's happening. How are the bronchodilators working? Okay. I really can't hear anything. Okay, there's the inflammation, but there's a bigger reason. They're in a spasm. They're in an acute, locked-down spasm. And the bronchodilator isn't going to work because the spasm is in the way. So what do you have to give them first? Some aminophilin to do what to the spasm? Relieve the spasm. Then you can come in with a bronchodilator and it will work. So just remember, when a bronchodilator doesn't work in an acute airway problem, give them a theophilin, give them an aminophilin, and that will melt the spasm, and then the bronchodilator will work. Yes? Do they have post-op when they get the anti-asthmatic first? Yeah. A lot of times when little kids come in with acute reactive airway disease, they'll slap them on an aminophilin drip and then start giving them breathing treatments with betas. And they may have 20 of them. And the first 19 may not work until that aminophilin kicks in and then the 19th one works. You see? So I've seen little kids. What's the most breathing treatments you've seen in an airway? Anybody ever, any work ER in children? No? Nobody? Okay. Well, that's a dumb question. But I have seen up to 20 breathing treatments being given in a row in these little kids. It's really just phenomenal. Okay. No, that's not typical. That's the extreme. All right. What's the therapeutic level? 10 to 20. There again, don't worry about units. 10 to 20. Any aminophilin under 10 is what? If you get an aminophilin level of 8, what does that mean? So they need to take more. Or are they taking it? Okay. If it's 21, what's it mean? Toxic. But anything in between 10 and 20 is therapeutic. What if it's 20? You get 20 toxicity is greater than or equal to 20 on this one. So 20 could be either way so you call it toxic. If you have to. So aminophilin toxic is greater than or equal to 20. Dilantin. What is this used for? Does anybody know what dilantin or phenytoin? Seizure. Seizure. Yeah. It's therapeutic level is 10 to 20. And it's toxicity is greater than or equal to 20. So what do you call 20? Although it may be therapeutic. Bilirubin. Bilirubin is not a drug. It's a waste product from the breakdown of red blood cells. When boards test bilirubin they will only test it in newborns. They will never test it in adults. Does anybody know what the normal adult bilirubin is? It's like 1 to 2. You know, 1.4 to 2.3. Something like that. It's really low. But in newborns, newborns have high bilirubins all the time. Why? What are they doing? Breaking down. Which red blood cells? The mom. Babies will run bilirubins of 5, 6, 7, 8, 9. And that's fine. Now, if I had an 8 bilirubin right now, they'd have my rear end in a bed over there finding out what's wrong with me. But a newborn with an 8 is no big deal. So what I want you to do with this bilirubin is you see where it says therapeutic level, the middle column? In the box for bilirubin I want you to write the word elevated level. Elevated level. So what is the elevated range for bilirubin in a newborn? 10 to 20. So what does it mean when a bilirubin in a newborn is 9.9 and less? It's normal, but it's... It's high for an adult, but it's normal. So we don't even get concerned about newborn bilirubins until it hits what number? 10. Which is 10 times... 5 to 10 times more than what an adult should have. So what is the bilirubin toxicity? Greater than or equal to 20. So when do you suppose a child... A child with what bilirubin and above do you think needs to come into the hospital? Certainly before... What about before 10? No. And even at 10, 11, and 12, what are they? Is it elevated? But you can manage it at home with sunlight, drinking a lot, flushing that bilirubin out. It's usually right about 14 to 15 that docs start thinking about hospitalizing these kids. About 14 or 15. Because once you hit 15, where are you in the scheme of things overall? You're halfway to what? You're halfway to toxic. And once you hit toxic, they can die. So you don't want it to be 18 or 17 or 19. That's way too close. You just don't like that. So... But most docs will not bring in a 12 or a 13. They usually wait until 14. Some docs wait until 15. I don't see any docs that wait until 16. Just typically not. Okay, so halfway through the elevated range, they start to hospitalize. Now, what do you notice about those toxic levels? What pattern do you see? 2s and 20s. 2s and 20s. Which ones are the 2s? Lithium and lead oxide, which start with one letter. So you pick the lower number than the ones without. So lithium and lead oxide go low. 2s. Bilirubin, aminophen, dilantin go high. Go 20. So you're usually picking between 2 and 20. And those are the major ones that they talk about. Alright, what about kernitrus and opisthotonus? Do you see those words right there? You need to know these words, these vocabulary words. What does kernitrus mean? Does anyone know what kernitrus means? Bilirubin in the brain. When your bilirubin crosses your blood-brain barrier, and it's in your cerebral spinal fluid, it's in your brain, it's in your meninges, you have kernitrus. So kernitrus... Okay, what's jaundice? It's a yellow color due to... Bilirubin in the skin. What's kernitrus? Bilirubin in the brain. Do you see what I'm saying? So jaundice is bilirubin in the skin, kernitrus is bilirubin in the brain. Both are due to bilirubin, it's just where is it? Kernitrus usually occurs when you get up around 20. When your bilirubin gets around 20, you start going kernitrus. Do you see why it's so dangerous? Because bilirubin, when it gets into your brain, it causes what we call aseptic. What does that mean? Aseptic. A means what? Without sepsis means infection. So aseptic means no germs. It causes aseptic meningitis, aseptic encephalitis, which means a sterile encephalitis due to the irritation of the bilirubin. You don't have to know all that, just know that when your bilirubin gets to be 20, you go kernitric and you could die. The baby could. Now, opisthotonos, does anybody know what that is? I told you we'd learn a lot of vocabulary this week. What's opisthotonos? Okay, it's a position the baby assumes when they have bilirubin on the brain. It's a position. Kernitrus is a condition, opisthotonos is a position. And what they do is they hyperextend. These babies hyperextend due to the irritation of the meninges with the bilirubin. So these babies hyperextend. Now what do you know about the flexibility of a newborn? No flexibility or unbelievable flexibility. Unbelievable. So when they extend, literally their heels will come up and touch their ears. They will be like in a back walkover. You know, they'll be completely, and they'll be very rigid in that. They'll hyperextend. They almost look like they're decerebrating, if you've ever heard of decerebration. They look, they're real hyperextended. When you see that, when you see a little kid who's bilirubin is 15, okay, he came in bilirubin 15, and he starts extending his neck, what do you think? Is that something that needs to follow up right away, immediately, medical emergency? Yes, because he could be going into epistatonos because he's kernicteric. And you want to catch it right away. Now the question that often is asked on boards and other standardized tests is, what, in what position do you place an opisthotonic child? So think about it. If they're hyperextending like this, what's a good position to put them in? On their side. You can't put them on their back. You can't put them on their abdomen. You have to put them on their side. Okay, that's it on drug toxicities. Just remember your 2s and your 20s. Yes? Do you know what else they'll cut based on how many hours the woman or the population needs on boards? Well, the only thing boards will do there is they'll talk about pathologic jaundice versus physiologic jaundice. And physiologic jaundice, the bilirubin is high, and the kid is yellow at birth. With pathologic jaundice, don't reverse that. Pathologic is high at birth and the kid's yellow at birth. Physiologic jaundice, the kid's bilirubin is low at birth, not low, normal at birth, and over the next 2 to 3 days goes high on bilirubin. So here's the deal. If they come out yellow, something's wrong. It's pathologic. If they come out yellow. If they turn yellow over the next few days, that's typical. They're just going to ask about whether it's present at birth or develops on day 2 and day 3 and which one's pathologic, which one's physiologic. And they won't get any more specific than that. Which is in the blue book, so you've got to remember that blue book, too. Okay, dumping syndrome versus high-aim hernia. These are very commonly tested things on boards, particularly dumping syndrome. They really like to talk about dumping syndrome. It shows up a lot. Definition. What is high-aim hernia? Well, I like to talk about these two together because they're both gastric emptying problems. And they're kind of opposites. And I like to remember opposites together. Why? Memorize one and you got the other. That's why diabetes, insipidus, and SIADH, I'm only going with one, figuring the other one out. Well, let's talk about what high-aim hernia is. High-aim hernia is regurgitation of acid, meaning acid comes back up, into your esophagus, where it's not supposed to be, because the upper part of your stomach permeates upward through the diaphragm. You're not supposed to have... Your stomach is supposed to be 100% in your abdominal cavity, right? With high-aim hernia, you have a two-chambered stomach. You're like a calf. You got two stomachs. Typically, this is your thorax here. Okay, and here's your diaphragm, separating your abdominal cavity below from your thoracic cavity above. Esophagus comes down like this, and then the stomach's there. It's supposed to be all below this diaphragm. In high-aim hernia, what happens is, part of it goes up like this. And you've got a two-chambered stomach with a band around the middle. And what happens when you eat, it sort of sits right here and then comes right back up. That's the problem with high-aim hernia. Now, below the line there, did you see where it says gastric contents move? Gastric contents move in the right or wrong direction. Wrong direction at the correct rate. In other words, does the stomach empty faster or slower or at a normal rate? Well, it empties at a normal rate. The rate's not the problem. With high-aim hernia, the rate is not the problem. It is the direction that is the problem. It's moving in the wrong direction at the correct rate. Now, let's compare that with something called dumping syndrome. Dumping syndrome, again, is a gastric problem. It usually follows gastric surgery in which the gastric contents dump too quickly into the duodenum. Now, are your gastric contents supposed to go into your duodenum? Yes. So, what's the problem? Too fast. So, in this case, the gastric contents move in the right direction at the wrong rate. So, you see where they're opposite? One is correct rate, wrong direction. The other is wrong rate, correct direction. You know, they flip-flop. So, if these were speeding tickets that you... It's not speeding. If these were traffic violations you got, if these were traffic violations, what would you be cited for in hiatal hernia? Going the wrong way on a one-way street. Correct? What would you be cited for with dumping syndrome? Speeding. So, one's a speed issue, one's a direction issue. Alright, what are the signs and symptoms? Well, hiatal hernia is real easy. The signs and symptoms of hiatal hernia are just plain GERD. G-E-R-D. Gastroesophageal Reflux Disease. In other words, heartburn and indigestion to state it simply. So, when you see GERD, don't freak out. It's just heartburn and indigestion. No biggie. So, let me tell you something. Hiatal hernia is a specific case here. You can have GERD for a hundred different reasons. One of which is hiatal hernia. What makes GERD hiatal hernia is this. Hiatal hernia is GERD if you lie down after you eat. If you have indigestion and heartburn, it doesn't mean you have hiatal hernia. You could have it, but it doesn't mean you do have it. I'm going to give you two examples. You tell me which one has GERD and which one has hiatal hernia. Alright? A nurse gets up in the morning, skips breakfast, goes to work, passes a whole floor of meds, does a bunch of treatments, and at 11 o'clock gets epigastric burning pain, burping, indigestion, and it really, really hurts and they've got to drink some milk or something. They say, oh, it hurts. Do they have GERD? Yes. Do they have hiatal hernia? Why not? You aren't lying down and you didn't eat. Okay, but what about this patient? Nurse gets up at 7 p.m., goes home, eats dinner at 8 o'clock. Sits down, watches TV. Half hour later, eats a bowl of cereal. 20 minutes later, eats a bag of chips. 20 minutes later, eats, you know, ice cream and chocolate syrup. Then they get tired and 10 minutes later, they go to bed. Half hour later, they wake up with burning, epigastric pain, indigestion, and they go, oh, it hurts. Same sub-symptoms that the other nurse had. Could this person have hiatal hernia? Why? They lay down right after they ate. You cannot have hiatal hernia unless your symptoms occur when you're lying down after you eat. If you have GERD at a random time, you don't have hiatal hernia. Hiatal hernia is dependent upon position and meal time. That's hiatal hernia. It's just indigestion and heartburn when you lie down after you eat. Okay, dumping syndrome, and they like to test dumping syndrome and it's a huge list of signs. The easiest way I know to remember all the things that happen in dumping syndrome is to take what I already know and combine it to equal dumping syndrome. So what do I want you to take? First off, if you want to know what a person looks like with dumping syndrome, the first thing is talk about drunk. Okay, what's a drunk person look like? Staggering gaze? Slurred speech? Impaired? Judgment delayed? Reaction time? Emotional? What's the fancy word? Labile emotion? Well, all that can be dumping syndrome because with dumping syndrome you do have cerebral impairment. There's a decreased blood flow to the brain because all the blood's going to the gut because it jumped into the duodenum. Then you also get shock. Signs of shock, which are what? Hypotension? Tachycardia? Tachypnea? What's the skin? Pale? Cold? Clammy? Cold because you don't have any blood there? Vasoconstricting? So pale, cold, clammy. Alright, so drunk plus shock. What does that equal? What did I teach you that drunk plus shock equals? Hypoglycemia. Well, to get dumping syndrome you add to that acute abdominal distress. And what belongs on the list of acute abdominal distress signs and symptoms? When someone has acute abdominal distress, describe it for me. Cramping, pain, doubling over, guarding, protecting, what else? What would you hear with a stethoscope? Borborygmi, thank you. Yes, I cracked about those but they won't say that. They'll say borborygmi. What kind of bowel elimination pattern would you have? Diarrhea? So you get cramping, abdominal pain, diarrhea, borborygmi, guarding, bloating, distension, tenderness. That all goes with dumping syndrome. So if you get a dumping syndrome question and they ask you for signs and symptoms, how do you learn them? Drunk, shock, acute abdominal distress. So here's what I, hopefully you're, see I want you guys to start violent things I want you guys to start violent things better, more efficiently. They do test alcohol intoxication, which is drunk, right? So drunk is drunk, right? You know that. Okay, shock, they'll test that too. Shock looks like shock. You understand that? Now, if you take drunk and shock and you put them together, what do you have the signs and symptoms of? Hypoglycemia, low blood sugar. If you throw in some acute abdominal distress with that, what do you get? Dumping syndrome. So I'm trying to link four of the major things they test. Shock, low blood sugar, dumping syndrome, alcohol intoxication. They all can be learned together. So what's the protocol? Drunk is? Drunk. Shock is? Shock. Drunk plus shock is? Hypoglycemia. That plus acute abdominal distress is? Dumping syndrome. And you just see what I'm trying to do is keep it adding rather than memorizing four separately. Okay, drunk is drunk, shock is shock, drunk plus shock is hypoglycemia, drunk plus shock plus acute abdominal distress is dumping syndrome. Okay, number three, what's the treatment for a hiatal hernia and dumping syndrome? They're going to be opposite. Because think about this, with hiatal hernia, you want the stomach to empty faster. Why do you want the stomach to empty faster with hiatal hernia? Because if it's empty, it won't what? Reflux. However, with dumping syndrome, we want the stomach to empty slower. You see it's the opposite? So you just remember one, remember the other's opposite. So what are you going to do to affect stomach emptying time? Well, there are three things you can do. To change the way the stomach empties, you can play around with the head of the bed, you can play around with the water content of the meal, and you can play around with the carbohydrate content of the meal. Alright, so let's go through this. In hiatal hernia, what do we want to do with the head of the bed during and after meals? We want it in high position. Why high? That makes gravity empty it faster. Okay, go down the column. What do we want to do with the amount of fluids we give with the meal? With a liquidy meal or a solid meal, which one will go through the stomach faster? Liquid. So we want the stomach to go through faster with this, so we want the amount of fluids to be high or low. So high fluid. And carbs go through you really fast. Carbs go through your stomach fast. So if you have a high carb, will it empty faster or slower? Fast. So here again, you want the carbohydrate content to be high or low. High. Now, the dumping syndrome is opposite of that. So how should the dumping syndrome eat their meal? In low position. Head flat. In other words, how would they eat? How should they eat? Yes. Head of the bed is what? Flat. They're turning to their side and they're eating on the side with the head down. They're eating on the back with the head down. That would be stupid. Right? But on the side with the head down. So low head of bed. What about the fluids with the meals? High or low? Low. So when would they get their fluids? Not with the meals. They'd get it, what, an hour or two before meals or an hour or two after meals, but they would never get it with the meals. And what about carbohydrate content? Low. Because when it's the stomach too empty, slow. When everything is low, the stomach goes slow. You hear that? When everything is low, the stomach empties slow. In high atal hernia, you want everything to be what? High. In high atal hernia, everything needs to be high. So when you see high atal hernia, you should say everything needs to be high. What needs to be high? Head, fluids, carbs. And if you want the stomach to go slow, take everything low. Head low, fluids low, carbs low. Now be careful. What if they throw you a curve and they talk about protein in the diet? For these two. What do you think? Yeah. Low protein in high atal hernia, high protein in stomach syndrome. Because if you're low carb, you're going to be high protein. You understand that? So whatever carbs is, protein is the opposite. Any questions about stomach syndrome and high atal hernia? It's pretty clear. This is a review. Sometimes people say, Mark, I know most of what you're teaching me. And I say, good. This is called a review. So don't get upset when there's a lot of stuff you know. Get upset when it's all a news flash. Electrolyte. How many of you in here can give me 15 signs and symptoms of hyperkalemia, hypokalemia, hypocalemia, hypercalcemia, hypocalcemia, hypomagnesemia, hypomagnesemia, hyperdietremia, and hypoendotremia with 80% accuracy? How many can do that? When you raise your hand, everybody's nodding. I'm not there. How many can do it with 50% accuracy? No? You probably wouldn't even be able to get 50% with your approach. Okay, I went about 5% accuracy. Yeah, I got takers on that. Okay, I'm going to ask you that same question in 15 minutes and I'm going to see what you say in 15 minutes. Alright? So let's talk about electrolytes. To know your signs and symptoms of electrolyte disorders, you need to memorize three sentences. The first sentence you memorize is Collenias. Do you see where we're at? Number one here. Collenias. What are we talking about? Collenias. Potassium. Collenias do the same act. Same act. Same act goes in the blank. Same act. Same act. The prefix except for heart rate and urine output. Potassium imbalances do the same as the prefix except for heart rate and urine output. You memorize that. Collenias do the same act. The prefix. So what I'm telling you is when you get a Collenia just look at the prefix. There are only two options. Hyper and hypo. Hyper means everything is what? High. And hypo means it's low. And your symptoms will go high with hyper and low with hypo. They'll go high with hyper and low with hypo because it's doing the what? Same as the prefix except for the heart rate and the urine output which will go what? Opposite of the prefix. So with hyper urine output and heart rate go down and with hypo urine output and heart rate go up. Yes. So in your box there give me some signs and symptoms of hypercollenia. Hyper. Start with the brain. Give me some hyper signs in the brain. Surely you can you know what I'm talking about right? You're not I know it's the post-lunch flow but cerebrally it's hypercollenia. Collenia is due to what? Same. Same as the prefix. The prefix is hyper so everything in the brain is going to go up because it does the same in hyper. So if you talk about the brain what symptoms are hyper signs in the brain? Give me some hyper signs in the brain. Agitation restlessness irritability aggression obnoxiousness decreased inhibitions loud hoarse breath right? Those all go with hypercollenia. Alright well let's talk about the lungs. What are you going to see there? Tachypnea. What are you going to see in the heart? Low heart rate because there's the exception but the T waves will be peak, tall the STs will be elevated See the only thing that goes up is the heart rate. Everything else about the heart goes with the prefix. Okay what will you see in the bowels? Diarrhea Borborygmi What will you see in the muscle? Staticity increased tone What will you see in the reflexes? Plus three, plus four And all those signs what do they have in common? They're all up. Why are they all up? Because you have hyper collenia. And in collenia they do the same as whatever the prefix says they are except for the heart rate and urine output which goes opposite. So what would you list for hypo collenia? Lethargy Lethargy Tachycardia Tachycardia you said it would go opposite there. Tachycardia and polyuria What? Bradypnea Bradypnea Bowels are going to be what? Slow down to what might you have? Ilias Constipation All of that What are you going to see in your muscles? Placidity What are you going to see in reflexes? Do I want you to memorize these lists that we're generating? No Because you can get those lists from the thing that says what? Collenias do the same as the prefix except for heart rate and urine output. Are you seeing where I'm going with this? Okay Your patient has hypercollenia Select all that apply Adynamic Ilias Obtundism Plus one reflex Clonus Which is Okay U-Wave Depressed ST What do I want to do here? Polyuria Bradycardia Okay I want you to look at it and talk to your buddy partner See if you can come up with use of this list Okay Partner See if you can come up with use of this list Collenias do the same as the prefix except for heart rate and urine output and draw your arrow So you're going to have to draw an arrow and you're also going to have to draw the exception which is the heart rate and urine output Oh that should say hyper It says hyper H-Y-P-E-R And here's the heart rate and urine output Hyper A U-Wave A U-Wave is a wave that goes like this It goes what? Down Down Make sure you get all your arrows right You need to draw a general arrow an arrow for the heart rate and an arrow for the urine output Make sure you get them right It wouldn't be there Okay how many did you select? I selected two Let me see if I'm wrong Okay Because I'm going to write my arrows out first I see hyper and I know Colleen needs to do the what? Same Same So it's going to make everything go up The heart rate's going to go down and urine output's going to go down Okay A Dynamic Without movement Ilias That's down That does not fit Abundant That is down That does not fit Plus one reflex That is down That does not fit Clonus That is irritability There we go That fits UA That goes down That doesn't fit Depressed ST It's going down That doesn't fit Polyuria Oh no It should be oliguria That doesn't fit Heart rate Down Rhetocardia Yeah that fits Now those of you that did three Which one did you add that you shouldn't have added? You forgot to write If you forget to write your arrows you're dead in the water You've got to write your arrows Then go looking Don't look first and then go back and write arrows You know what I'm saying? Know what you're looking for first You know the meaning of the words too Yeah Meaning of the words is helpful Yes The UA The UA is something that starts on the baseline and goes down from the baseline So it's a baseline of cardiac depression And the idea though is if you don't know what something is on a select all of it apply don't dig in Because everybody tends to what? Overselect by one Is that what you guys did? You overselected by one I mean it's like predictable Yes Off-tunded is just a little more comatose than lethargy So you got lethargic and then as you go even more deep into a coma you get off-tunded A lethargic person ask me a question and I'll be lethargic It's actually a question Where do you live? What's your name? Where do you live? Now that's lethargic This is off-tunded What would you do? You're a nurse Do what you would do What's your name? What's your name? This is off-tunded Now what's coma? So off-tunded they pretty much they're you can rouse them and then they go off to la-la land and then you rouse them and they go lethargics will respond that they just it's going to take a while to get off-tunded It's going to take a while to get it off-tunded tundeds will never respond but they're rousable Yes? Is stupor as well as off-tunded? Stupor and off-tunded are often considered to be the same idea stupor is more a generic word off-tunded is more the medical term Usually Now I'm going I won't go that doesn't need to happen Okay, calcium Calcemias do the opposite Calcemias do the opposite of the prefix which means if your calcium goes high everything goes low and if your calcium goes low everything goes high So hypercalcemia what would you have? Bradycardia Bradycardia Bradypnea Bradypnea flaccid muscles hypoactive reflexes lethargy constipation Right? Everything goes down when calcium goes up However when calcium goes down hypocalcemia everything goes up So what do you get with hypocalcemia? Hypocalcemia Agitation Irritability Clonus Plus-4 reflexes Spasm Irritability Seizure Tachycardia All that kind of stuff And you get two other things Shabostek's sign and Trousseau's sign which Heather loves Trousseau's and Shabostek's Shabostek's starts with what two letters? CH And what do you do to elicit it? You tap the cheek So just think Shabostek's cheek CH CH Shabostek's cheek So when you rub their when you touch their cheek with Shabostek's they go into a spasm in the face their face spasms which shouldn't happen You know, if I touch you on the cheek you should go You know, and you shouldn't go That would be Shabostek's What is its sign of? It's a sign of neuromuscular irritability associated with a low calcium It is a sign of neuromuscular irritability associated with a low calcium Why does that sentence make sense? Irritability low calcium Why does that make sense? Because calciums do the opposite so irritability would have to be low calcium The other sign is Trousseau's Trousseau's is when you put a cup blood pressure cup on their arm you pump it up and they go into a spasm in the hand It's a hand spasm when you put a blood pressure cup on So Shabostek's you do what? Cheek Trousseau's you do blood pressure cup and look for that Stupid way I remember this Really dumb but it works for me Trousseau sounds like a French name So when I see Trousseau on a test I think of an effeminate Frenchman and you think I'm too sad So you know I'm sorry that that's too sad So I don't see what you know it may stick Okay Bohr's Hesse's test Those of you that are going to take Hesse's they will test Shabostek's and Trousseau's so the cows can hold on that They'll love it Alright Hey by the way What if I changed this to hyper calcemia Would it change the answer? Yeah Cause now you're looking for what? Calcems do the opposite this says hyper so it's going to down so you're going to see this and this and this and not that and that and that and that and not this Oh you will see that Yeah you will see You will see that I'm sorry I got a little pen happy You see so it's You put it on polyurethane Yeah you want some polyurethane It's really good when you guys are better than me at this That's what we do cause I'm not taking the test It really is more manageable Now if they ask you which set of these like for the hypercalemia If they ask you which one of those was most likely You'd have narrowed it down to two Which two? Clonus and Rhetacardia But because it was potassium you'd give the edge to the heart If they're talking calcium you'd have all these things but you'd give the edge to the muscles and the muscles and the nerves You see what I'm saying? So there is that little but make sure it's the right thing first before you do it you know what I mean but if you're between a couple of signs for potassium that are correct and they're asking you to pick between them for potassium pick the heart sign but make sure it's going the right way for the precepts correct and when you're picking the skeletal muscle and nerve make sure it's going the correct way Alright let's talk about magnesium Number 3 Magnesemia is due the opposite of the precepts Now some review books out there say that hypomagnesemia is not associated with hypertension because it doesn't want magnesium to do the opposite of the precepts so hypomag would result in high blood pressure but some books say that's not true check it out go investigate and you'll find that most magnesium is associated with hypertension ok so some of these books get a little sloppy in their answers who had that zig zam tram book yesterday yeah a lot of times they'll say that when you retain sodium magnesium sometimes gets retained so they say that high magnesium is associated with hypertension but no it's really a function of the high sodium not the magnesium if you just talk about magnesium itself the low magnesium has the high pressure it is kind of related but it is not a symptom they won't even go there because that doesn't tell them anything significant about you it just tells you on what side of the debate are you on that kind of thing just a little thing about people have asked me about using multiple choice books to study for boards you know those multiple choice books what have I told you about them already one out of five answers is bogus in those books 100% of the question in those books are wrong they are wrong and when you do them you think they are all what 100% right and when and you start to doubt yourself when you're the one that knows what's right and the book is wrong so you have to be real careful when you do those books do I want you to do them yeah but how do I want you to do them if you answer an answer and you know it's wrong what should you say what do I want you to say it's bogus I am not having my confidence destroyed I do know what I'm talking about the book is wrong I mean there was a classic one on the exam the other day that you showed me which patient needs a private room and there was a patient with Cushing's syndrome in there well Cushing's people are immunosuppressed they should be in the room the other patient was hyperthyroid and they said a hyperthyroid should be in the room because they don't sleep well because they're hyperthyroid and if they had a roommate they wouldn't be able to sleep for a while well my opinion is between somebody that isn't sleeping and somebody that's immunosuppressed there's no any nurse you ask would say you need to get hypokalemia in one of the chapters it said that hypokalemia is not seen with Cushing's absolutely it is with Cushing's you've got a lot of what L-dosterone which makes you retain sodium and water well to retain sodium in a loop of Henle what do you have to kick out potassium so you do get hypokalemia and then in chapter 8 you get hypokalemia with Cushing's so in chapter 3 they say you don't and in chapter 8 they say you do that's the state of the art of those books you see what I'm saying so when you go do these books and you know your stuff and you're ready to go and it's telling you no you're wrong you're wrong you're wrong you're probably what you're right you're right you're right well they just don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't they don't 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