Latest / Pearls and Prep / Board Bomb 💣: Would You Miss This Depakote Red Flag?

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Board Bomb 💣: Would You Miss This Depakote Red Flag? · Pearls and Prep

• 0:00
  Foreign.
• 0:06
  Welcome
• 0:06
  back
• 0:06
  my
• 0:07
  friends
• 0:07
  to
• 0:07
  another
• 0:07
  episode
• 0:08
  of
• 0:08
  Pearls
• 0:09
  and
• 0:09
  Prep.
• 0:09
  This
• 0:09
  is
• 0:09
  NPC
• 0:10
  here,
• 0:11
  your
• 0:11
  preceptor
• 0:12
  in
• 0:12
  your
• 0:12
  pocket,
• 0:12
  your
• 0:13
  go
• 0:13
  to
• 0:13
  place
• 0:13
  for
• 0:14
  pearls
• 0:14
  that
• 0:14
  prep
• 0:15
  you
• 0:15
  to
• 0:15
  practice.
• 0:16
  We
• 0:16
  have
• 0:16
  a
• 0:17
  board
• 0:17
  bombs
• 0:18
  doozy
• 0:18
  for
• 0:18
  you
• 0:19
  today.
• 0:19
  These
• 0:20
  have
• 0:20
  been
• 0:20
  really
• 0:20
  popular.
• 0:21
  Appreciate
• 0:22
  you
• 0:22
  guys
• 0:22
  sharing
• 0:22
  these
• 0:23
  with
• 0:23
  your
• 0:23
  peers,
• 0:24
  your
• 0:24
  professors,
• 0:25
  your
• 0:26
  colleagues.
• 0:27
  Just
• 0:27
  a
• 0:27
  quick
• 0:27
  way
• 0:27
  to
• 0:27
  keep
• 0:28
  us
• 0:28
  on
• 0:28
  our
• 0:28
  toes,
• 0:29
  see
• 0:29
  if
• 0:29
  we're
• 0:30
  at
• 0:30
  the
• 0:30
  top
• 0:31
  of
• 0:31
  our
• 0:31
  game
• 0:31
  getting
• 0:32
  the
• 0:32
  answers
• 0:32
  right.
• 0:33
  And
• 0:33
  this
• 0:33
  is
• 0:33
  a
• 0:33
  fun
• 0:34
  board
• 0:34
  style
• 0:34
  question
• 0:35
  that
• 0:35
  I
• 0:35
  think
• 0:35
  is
• 0:35
  pretty
• 0:35
  high
• 0:36
  yield
• 0:36
  and
• 0:36
  gets
• 0:36
  us
• 0:37
  appreciating
• 0:38
  a
• 0:38
  lot
• 0:38
  of
• 0:38
  the
• 0:38
  pharmacokinetics
• 0:40
  that
• 0:40
  are
• 0:40
  so
• 0:41
  integral
• 0:41
  in
• 0:41
  our
• 0:42
  field.
• 0:42
  So
• 0:42
  without
• 0:42
  further
• 0:43
  ado,
• 0:43
  here
• 0:43
  we
• 0:43
  go.
• 0:43
  You
• 0:44
  have
• 0:44
  a
• 0:44
  38
• 0:45
  year
• 0:45
  old
• 0:45
  woman
• 0:46
  with
• 0:46
  bipolar
• 0:47
  one
• 0:47
  disorder.
• 0:48
  We're
• 0:48
  going
• 0:48
  to
• 0:49
  call
• 0:49
  her
• 0:49
  Desiree.
• 0:50
  She's
• 0:50
  fake.
• 0:51
  Um,
• 0:51
  I
• 0:51
  mean
• 0:52
  that
• 0:52
  as
• 0:52
  she's
• 0:52
  not
• 0:52
  a
• 0:52
  real
• 0:53
  patient.
• 0:53
  I
• 0:53
  don't
• 0:53
  mean
• 0:53
  she's
• 0:53
  a
• 0:54
  fake
• 0:54
  person.
• 0:54
  She's
• 0:54
  just
• 0:54
  not
• 0:55
  a
• 0:55
  real
• 0:55
  patient.
• 0:57
  Okay.
• 0:57
  Bipolar
• 0:58
  1
• 0:58
  disorder,
• 0:59
  alcohol
• 0:59
  related
• 1:00
  liver
• 1:00
  cirrhosis.
• 1:01
  Her
• 1:01
  albumin
• 1:01
  level
• 1:02
  is
• 1:02
  2.6.
• 1:04
  Okay.
• 1:05
  Grams
• 1:05
  per
• 1:05
  deciliter.
• 1:06
  She
• 1:07
  started
• 1:07
  on
• 1:07
  Depakote
• 1:08
  ER
• 1:08
  for
• 1:08
  acute
• 1:09
  mania
• 1:09
  on
• 1:09
  day
• 1:10
  5.
• 1:10
  Her
• 1:11
  total
• 1:11
  Depakote
• 1:12
  level
• 1:12
  is
• 1:12
  78
• 1:13
  micrograms
• 1:14
  per
• 1:14
  milliliter.
• 1:15
  Okay.
• 1:16
  And
• 1:16
  that
• 1:16
  is
• 1:16
  within
• 1:16
  the
• 1:16
  therapeutic
• 1:17
  range,
• 1:17
  which
• 1:17
  is
• 1:17
  50
• 1:18
  to
• 1:18
  125.
• 1:19
  So.
• 1:19
  So
• 1:20
  she's
• 1:20
  getting
• 1:20
  increasingly
• 1:21
  sedated
• 1:21
  and
• 1:21
  she
• 1:22
  has
• 1:22
  a
• 1:22
  new
• 1:22
  tremor
• 1:22
  and
• 1:23
  the
• 1:23
  question
• 1:23
  is
• 1:24
  what
• 1:24
  the
• 1:24
  heck
• 1:24
  do
• 1:24
  you
• 1:24
  do
• 1:25
  next?
• 1:25
  Okay.
• 1:26
  Do
• 1:26
  you
• 1:26
  a,
• 1:27
  increase
• 1:27
  the
• 1:28
  dose
• 1:28
  because
• 1:29
  she's
• 1:29
  only
• 1:29
  mid
• 1:29
  range
• 1:30
  and
• 1:30
  needs
• 1:30
  better
• 1:30
  symptom
• 1:31
  control?
• 1:32
  Do
• 1:32
  you
• 1:32
  b,
• 1:32
  reassure
• 1:33
  the
• 1:33
  team
• 1:33
  the
• 1:34
  level's
• 1:34
  therapeutic
• 1:35
  and
• 1:35
  symptoms
• 1:35
  are
• 1:35
  likely
• 1:36
  from
• 1:36
  mania?
• 1:37
  Do
• 1:37
  you
• 1:37
  c
• 1:38
  order
• 1:38
  a
• 1:38
  free.
• 1:39
  That's
• 1:40
  an
• 1:40
  unbound
• 1:41
  Depakote
• 1:41
  level.
• 1:42
  Do
• 1:42
  you
• 1:42
  d,
• 1:43
  discontinue
• 1:43
  Depakote
• 1:44
  and
• 1:44
  start
• 1:44
  calling
• 1:45
  carbamazepine
• 1:47
  or
• 1:47
  do
• 1:47
  you
• 1:47
  e
• 1:48
  at
• 1:49
  a
• 1:49
  benzodiazepine
• 1:50
  for
• 1:50
  the
• 1:50
  tremor?
• 1:51
  Go
• 1:51
  ahead
• 1:51
  and
• 1:52
  pause
• 1:52
  this
• 1:52
  if
• 1:52
  you'd
• 1:52
  like.
• 1:53
  Discuss
• 1:53
  it
• 1:54
  in
• 1:54
  your
• 1:54
  zoom
• 1:54
  breakout
• 1:55
  groups.
• 1:56
  Ask
• 1:57
  your
• 1:57
  professor
• 1:57
  for
• 1:58
  help.
• 1:58
  Ask
• 1:59
  your
• 1:59
  preceptor.
• 2:00
  Take
• 2:00
  a
• 2:01
  moment.
• 2:04
  All
• 2:04
  right,
• 2:04
  my
• 2:04
  friends,
• 2:06
  so
• 2:08
  this
• 2:08
  is
• 2:08
  a
• 2:08
  tricky
• 2:09
  one.
• 2:09
  And
• 2:09
  what
• 2:10
  it's
• 2:10
  trying
• 2:10
  to
• 2:11
  sniff
• 2:11
  out
• 2:11
  here
• 2:12
  is,
• 2:12
  is
• 2:12
  whether
• 2:12
  or
• 2:13
  not
• 2:13
  we
• 2:13
  appreciate
• 2:14
  the
• 2:14
  fact
• 2:15
  that
• 2:17
  valproate
• 2:18
  or
• 2:18
  depakote
• 2:19
  is
• 2:19
  protein
• 2:19
  bound.
• 2:20
  It
• 2:20
  is
• 2:20
  actually
• 2:20
  90%
• 2:21
  protein
• 2:22
  bound.
• 2:22
  And
• 2:23
  so
• 2:23
  the
• 2:24
  siren
• 2:24
  should
• 2:25
  go
• 2:25
  off
• 2:25
  in
• 2:25
  your,
• 2:26
  in
• 2:26
  your
• 2:26
  mind
• 2:27
  when
• 2:27
  you
• 2:27
  see
• 2:27
  a
• 2:28
  medication
• 2:28
  is
• 2:28
  highly
• 2:29
  protein
• 2:29
  bound.
• 2:30
  We,
• 2:30
  we
• 2:30
  talked
• 2:31
  about
• 2:31
  how
• 2:31
  Cymbalta
• 2:32
  is
• 2:32
  highly
• 2:32
  protein
• 2:32
  bound
• 2:33
  in
• 2:33
  a
• 2:33
  previous
• 2:33
  episode.
• 2:34
  Highly
• 2:35
  recommend
• 2:35
  you
• 2:35
  look
• 2:35
  at
• 2:35
  that.
• 2:36
  The
• 2:37
  Depakote
• 2:37
  is
• 2:38
  also
• 2:38
  highly
• 2:38
  protein
• 2:39
  bound.
• 2:39
  Okay.
• 2:40
  Well,
• 2:40
  that's
• 2:40
  an
• 2:40
  issue
• 2:41
  if
• 2:41
  you
• 2:41
  have
• 2:42
  an
• 2:42
  albumin
• 2:42
  level
• 2:43
  of
• 2:43
  2.6,
• 2:44
  because
• 2:44
  that's
• 2:45
  the
• 2:45
  most
• 2:45
  abundant
• 2:45
  protein
• 2:46
  in
• 2:46
  your
• 2:46
  body,
• 2:46
  manufactured
• 2:47
  by
• 2:47
  the
• 2:48
  liver.
• 2:48
  And
• 2:49
  so
• 2:49
  if
• 2:49
  you
• 2:49
  don't
• 2:49
  have
• 2:49
  enough
• 2:50
  protein
• 2:50
  circulating
• 2:51
  around,
• 2:52
  well,
• 2:53
  guess
• 2:53
  what?
• 2:53
  You're
• 2:54
  gonna
• 2:54
  give
• 2:54
  someone
• 2:55
  Depakote,
• 2:56
  and
• 2:56
  there's
• 2:56
  going
• 2:56
  to
• 2:57
  be
• 2:57
  too
• 2:58
  much
• 2:58
  free
• 2:58
  Depakote,
• 2:59
  which
• 2:59
  means
• 2:59
  you
• 3:00
  can
• 3:00
  have
• 3:00
  toxic
• 3:00
  levels
• 3:01
  of
• 3:01
  Depakote.
• 3:02
  That's
• 3:02
  a
• 3:02
  huge
• 3:03
  problem.
• 3:03
  Right?
• 3:03
  That's
• 3:04
  a
• 3:04
  huge
• 3:04
  problem.
• 3:04
  And
• 3:05
  we'll
• 3:05
  talk
• 3:05
  about
• 3:05
  why.
• 3:06
  But
• 3:06
  remember
• 3:07
  that
• 3:07
  the
• 3:07
  whole
• 3:07
  idea
• 3:08
  here
• 3:08
  is
• 3:08
  when
• 3:09
  medications
• 3:09
  are
• 3:09
  protein
• 3:10
  bound,
• 3:10
  typically,
• 3:11
  you
• 3:11
  know,
• 3:12
  they
• 3:12
  bind
• 3:12
  to
• 3:12
  the
• 3:12
  protein
• 3:13
  after
• 3:13
  you
• 3:14
  take
• 3:14
  your
• 3:14
  medication.
• 3:15
  Okay?
• 3:15
  And
• 3:16
  that
• 3:16
  controls
• 3:16
  the
• 3:16
  response.
• 3:17
  When
• 3:17
  it's
• 3:17
  bound
• 3:17
  to
• 3:18
  a
• 3:18
  protein,
• 3:18
  it's
• 3:18
  not
• 3:18
  exerting
• 3:19
  its
• 3:20
  therapeutic
• 3:20
  effects
• 3:21
  just
• 3:21
  yet.
• 3:21
  It's
• 3:21
  bound
• 3:22
  to
• 3:22
  the
• 3:22
  protein
• 3:22
  and
• 3:22
  it
• 3:22
  gets
• 3:23
  kind
• 3:23
  of
• 3:23
  slowly
• 3:24
  shipped
• 3:24
  over,
• 3:24
  crosses
• 3:25
  the
• 3:25
  blood,
• 3:25
  brain
• 3:25
  barrier,
• 3:26
  and
• 3:26
  exerts
• 3:26
  an
• 3:27
  effect.
• 3:27
  Okay,
• 3:28
  but
• 3:28
  in
• 3:28
  this
• 3:28
  case,
• 3:29
  your
• 3:29
  patient
• 3:29
  has
• 3:29
  a
• 3:29
  low
• 3:29
  albumin
• 3:30
  level
• 3:30
  of
• 3:30
  2.6,
• 3:32
  clearly
• 3:32
  has
• 3:32
  liver
• 3:33
  issues.
• 3:33
  Right.
• 3:33
  Alcohol
• 3:34
  related
• 3:34
  liver
• 3:34
  cirrhosis.
• 3:36
  So
• 3:37
  you
• 3:37
  might
• 3:37
  have
• 3:37
  a
• 3:37
  therapeutic
• 3:38
  blood
• 3:39
  level
• 3:39
  that's
• 3:40
  in
• 3:40
  the
• 3:40
  middle
• 3:40
  of
• 3:40
  the
• 3:41
  50
• 3:41
  to
• 3:41
  125
• 3:42
  micrograms
• 3:42
  per
• 3:42
  milliliter
• 3:43
  of
• 3:43
  Depakote,
• 3:44
  but
• 3:45
  it
• 3:45
  may
• 3:46
  not
• 3:46
  be
• 3:46
  reflecting
• 3:47
  the
• 3:47
  actual
• 3:48
  free
• 3:49
  level
• 3:49
  of
• 3:49
  Depakote
• 3:50
  because
• 3:50
  she
• 3:51
  has
• 3:51
  a
• 3:51
  liver
• 3:51
  issue.
• 3:52
  And
• 3:53
  sure
• 3:53
  enough,
• 3:53
  she
• 3:53
  is
• 3:54
  definitely
• 3:54
  exhibiting
• 3:55
  signs
• 3:56
  of
• 3:56
  toxicity,
• 3:57
  the
• 3:57
  sedation
• 3:58
  and
• 3:58
  the
• 3:58
  new
• 3:59
  tremor.
• 4:00
  So
• 4:00
  although
• 4:00
  you
• 4:01
  may
• 4:01
  be
• 4:01
  inclined
• 4:02
  to
• 4:02
  add
• 4:02
  a
• 4:02
  benzodiazepine
• 4:04
  for
• 4:04
  the
• 4:04
  tremor,
• 4:05
  you
• 4:05
  are
• 4:05
  treating
• 4:06
  the
• 4:06
  symptom
• 4:06
  and
• 4:06
  not
• 4:07
  the
• 4:07
  cause.
• 4:07
  And
• 4:07
  you're
• 4:08
  also
• 4:08
  adding
• 4:08
  a
• 4:08
  CNS
• 4:09
  depressant
• 4:09
  to
• 4:09
  a
• 4:09
  patient
• 4:10
  who
• 4:10
  is
• 4:10
  already
• 4:11
  over
• 4:11
  sedated
• 4:12
  from
• 4:12
  drug
• 4:12
  toxicity,
• 4:13
  and
• 4:13
  that
• 4:13
  is
• 4:13
  dangerous.
• 4:15
  So
• 4:15
  option
• 4:16
  E,
• 4:16
  adding
• 4:17
  a
• 4:17
  benzo
• 4:17
  is
• 4:18
  wrong.
• 4:19
  Okay,
• 4:19
  let's
• 4:20
  get
• 4:20
  that.
• 4:20
  Let's
• 4:20
  just.
• 4:21
  Let's
• 4:21
  just
• 4:23
  make
• 4:23
  that
• 4:23
  very
• 4:24
  clear
• 4:24
  right
• 4:24
  now,
• 4:25
  okay?
• 4:27
  You're
• 4:28
  not
• 4:28
  going
• 4:28
  to
• 4:28
  be
• 4:29
  spanked
• 4:29
  with
• 4:29
  a
• 4:29
  ruler.
• 4:31
  You
• 4:31
  know,
• 4:31
  they're
• 4:32
  not
• 4:32
  going
• 4:32
  to
• 4:32
  do
• 4:32
  like
• 4:32
  they
• 4:32
  used
• 4:32
  to
• 4:33
  do
• 4:33
  to
• 4:33
  my
• 4:33
  dad
• 4:33
  in
• 4:33
  Italy
• 4:34
  and
• 4:34
  like,
• 4:34
  twist
• 4:34
  your
• 4:35
  ear.
• 4:35
  This
• 4:35
  is.
• 4:35
  This
• 4:35
  is
• 4:36
  a
• 4:36
  very
• 4:36
  safe
• 4:36
  place.
• 4:37
  There's
• 4:37
  no
• 4:37
  corporal
• 4:37
  punishment
• 4:38
  here.
• 4:39
  I
• 4:39
  couldn't
• 4:39
  do
• 4:39
  that
• 4:39
  if
• 4:40
  I
• 4:40
  tried.
• 4:40
  But
• 4:40
  this
• 4:41
  is.
• 4:41
  This
• 4:41
  is
• 4:42
  a
• 4:42
  podcast,
• 4:42
  so.
• 4:43
  Okay,
• 4:44
  now,
• 4:45
  do
• 4:45
  we
• 4:45
  discontinue
• 4:46
  Depakote?
• 4:47
  Is
• 4:47
  that
• 4:47
  the
• 4:47
  answer?
• 4:48
  We
• 4:48
  just
• 4:48
  quit?
• 4:49
  Are
• 4:49
  we
• 4:49
  quitters?
• 4:50
  And
• 4:51
  do
• 4:51
  we
• 4:51
  just
• 4:51
  start
• 4:52
  Carbamazepine?
• 4:54
  Well,
• 4:54
  that
• 4:54
  doesn't
• 4:55
  really
• 4:55
  help
• 4:55
  us
• 4:55
  because
• 4:56
  carbamazepine
• 4:57
  is
• 4:57
  also
• 4:57
  heavily
• 4:59
  hepatically
• 5:00
  metabolized.
• 5:01
  It
• 5:01
  has
• 5:01
  its
• 5:02
  own
• 5:02
  black
• 5:02
  box
• 5:02
  warnings.
• 5:03
  Stevens
• 5:04
  Johnson
• 5:04
  syndrome.
• 5:05
  Right,
• 5:06
  that,
• 5:06
  you
• 5:07
  know,
• 5:07
  that's
• 5:07
  probably
• 5:08
  not
• 5:08
  a
• 5:08
  good
• 5:08
  idea
• 5:09
  because
• 5:10
  the
• 5:10
  patient
• 5:10
  is
• 5:10
  a,
• 5:11
  is
• 5:11
  cirrhotic.
• 5:11
  So
• 5:12
  it's
• 5:12
  not
• 5:12
  going
• 5:12
  to
• 5:12
  solve
• 5:12
  our
• 5:12
  problems.
• 5:13
  That's
• 5:13
  not
• 5:13
  going
• 5:14
  to
• 5:14
  fix
• 5:14
  our
• 5:14
  issue
• 5:14
  here.
• 5:15
  We
• 5:15
  want
• 5:15
  to,
• 5:15
  we
• 5:16
  want
• 5:16
  to
• 5:16
  gravitate
• 5:16
  away
• 5:17
  towards
• 5:17
  the
• 5:18
  hepatotoxic
• 5:19
  medications.
• 5:20
  Now
• 5:20
  do
• 5:20
  we
• 5:21
  reassure
• 5:22
  the
• 5:22
  team
• 5:23
  that
• 5:23
  the
• 5:24
  level
• 5:24
  is
• 5:24
  therapeutic
• 5:25
  and
• 5:25
  symptoms
• 5:25
  are
• 5:25
  likely
• 5:26
  from
• 5:26
  mania?
• 5:27
  Well,
• 5:27
  you
• 5:27
  could
• 5:28
  probably
• 5:28
  tell.
• 5:28
  This
• 5:29
  is
• 5:29
  one
• 5:29
  of
• 5:29
  the
• 5:29
  multiple
• 5:29
  choice
• 5:30
  questions.
• 5:31
  One
• 5:31
  of
• 5:32
  the
• 5:32
  possible
• 5:32
  answers
• 5:32
  that
• 5:33
  is
• 5:33
  really
• 5:33
  not
• 5:33
  very
• 5:34
  comforting.
• 5:35
  I
• 5:35
  don't
• 5:35
  really
• 5:36
  know
• 5:36
  of
• 5:36
  any
• 5:37
  intervention
• 5:38
  that
• 5:38
  ever
• 5:38
  worked.
• 5:39
  When
• 5:40
  you
• 5:40
  just
• 5:40
  go
• 5:40
  ahead
• 5:40
  and
• 5:40
  reassure
• 5:41
  people
• 5:41
  when
• 5:41
  something's
• 5:42
  clearly
• 5:42
  not
• 5:42
  right.
• 5:43
  It's
• 5:43
  like
• 5:43
  if,
• 5:44
  if
• 5:44
  you're,
• 5:44
  if,
• 5:44
  if
• 5:45
  all
• 5:45
  three
• 5:45
  of
• 5:45
  your
• 5:45
  tires
• 5:46
  blow
• 5:46
  out
• 5:46
  on
• 5:46
  the
• 5:46
  interstate
• 5:47
  and
• 5:48
  someone
• 5:48
  pulls
• 5:49
  over
• 5:49
  and
• 5:49
  just
• 5:49
  like
• 5:50
  reassures
• 5:50
  you
• 5:50
  that
• 5:51
  you're
• 5:51
  gonna
• 5:51
  be
• 5:51
  okay,
• 5:52
  I
• 5:52
  mean
• 5:52
  that
• 5:53
  might
• 5:53
  be
• 5:53
  great,
• 5:53
  but
• 5:53
  you
• 5:53
  have
• 5:54
  like
• 5:54
  three
• 5:54
  tires
• 5:54
  that
• 5:55
  are
• 5:55
  blown
• 5:55
  out
• 5:55
  and
• 5:56
  your
• 5:56
  engine's
• 5:56
  on
• 5:56
  fire.
• 5:57
  Yeah,
• 5:58
  chances
• 5:58
  are
• 5:58
  when
• 5:59
  somebody,
• 5:59
  when
• 5:59
  the,
• 6:00
  when
• 6:00
  one
• 6:00
  of
• 6:00
  the
• 6:00
  answers
• 6:01
  is
• 6:01
  reassure,
• 6:02
  probably
• 6:03
  not.
• 6:03
  And
• 6:04
  last
• 6:04
  I
• 6:04
  checked,
• 6:05
  sedation
• 6:05
  and
• 6:06
  tremor
• 6:06
  is
• 6:06
  like
• 6:06
  not
• 6:07
  a,
• 6:07
  not
• 6:08
  really
• 6:08
  a
• 6:09
  symptom
• 6:09
  of
• 6:09
  mania.
• 6:10
  You
• 6:10
  know,
• 6:10
  we're
• 6:10
  talking
• 6:10
  like
• 6:11
  symptoms
• 6:11
  of
• 6:11
  mania
• 6:11
  in
• 6:12
  the
• 6:12
  DSM
• 6:12
  5
• 6:13
  are
• 6:13
  like
• 6:13
  grandiosity,
• 6:14
  goal
• 6:14
  directed
• 6:15
  behavior.
• 6:16
  Right?
• 6:17
  Decreased
• 6:18
  need
• 6:18
  for
• 6:18
  sleep.
• 6:20
  So
• 6:20
  I,
• 6:21
  I
• 6:21
  don't
• 6:21
  know
• 6:21
  where
• 6:21
  sedation
• 6:22
  is.
• 6:22
  In
• 6:22
  fact,
• 6:22
  like
• 6:23
  if
• 6:23
  anything,
• 6:23
  they're
• 6:23
  more
• 6:24
  energized.
• 6:24
  So
• 6:24
  that,
• 6:25
  that's,
• 6:25
  that's
• 6:25
  just
• 6:25
  not
• 6:26
  a
• 6:26
  good
• 6:26
  answer.
• 6:27
  Now
• 6:27
  do
• 6:27
  we
• 6:27
  increase
• 6:27
  the
• 6:28
  dose?
• 6:28
  Well,
• 6:29
  that
• 6:29
  would
• 6:30
  be
• 6:30
  very
• 6:31
  dumb.
• 6:31
  That
• 6:31
  would
• 6:32
  be
• 6:32
  a
• 6:32
  dumb,
• 6:33
  bad
• 6:33
  thing
• 6:33
  to
• 6:33
  do
• 6:34
  to
• 6:34
  increase
• 6:35
  the
• 6:35
  dose.
• 6:36
  She's
• 6:36
  already
• 6:36
  toxic.
• 6:37
  She
• 6:37
  has
• 6:37
  elevated
• 6:37
  free
• 6:38
  drug.
• 6:38
  Increasing
• 6:38
  the
• 6:39
  dose
• 6:39
  would
• 6:39
  just
• 6:39
  push
• 6:40
  her
• 6:40
  into
• 6:40
  severe
• 6:40
  toxicity
• 6:41
  or
• 6:41
  liver
• 6:41
  failure.
• 6:42
  That's
• 6:42
  not
• 6:42
  a
• 6:43
  good
• 6:43
  idea.
• 6:44
  So
• 6:44
  that
• 6:44
  leaves
• 6:45
  us
• 6:45
  with
• 6:45
  one
• 6:45
  option,
• 6:45
  my
• 6:45
  friends,
• 6:46
  and
• 6:46
  that
• 6:46
  would
• 6:46
  be
• 6:46
  to
• 6:46
  order
• 6:47
  a
• 6:47
  free
• 6:47
  unbound
• 6:48
  Depakote
• 6:49
  level.
• 6:49
  Okay?
• 6:50
  Cause
• 6:50
  again
• 6:50
  with
• 6:51
  patients
• 6:51
  who
• 6:51
  have
• 6:51
  low
• 6:52
  albumin
• 6:52
  or
• 6:52
  liver
• 6:53
  disease,
• 6:53
  the
• 6:53
  total
• 6:54
  levels
• 6:54
  are
• 6:54
  misleading
• 6:55
  because
• 6:56
  of
• 6:56
  how
• 6:56
  protein
• 6:57
  bound
• 6:57
  Depakote
• 6:58
  is.
• 6:59
  So
• 6:59
  with
• 6:59
  fewer
• 6:59
  albumin
• 7:00
  binding
• 7:01
  sites,
• 7:01
  cause
• 7:01
  her
• 7:01
  albumin
• 7:02
  is
• 7:02
  only
• 7:02
  2.6.
• 7:03
  The
• 7:03
  actual
• 7:04
  free
• 7:04
  or
• 7:05
  active
• 7:05
  fraction
• 7:05
  of
• 7:05
  the
• 7:06
  Depakote
• 7:06
  in
• 7:06
  her
• 7:06
  system
• 7:07
  could
• 7:07
  be
• 7:07
  like
• 7:07
  two
• 7:07
  to
• 7:07
  three
• 7:08
  times
• 7:08
  higher
• 7:08
  than
• 7:08
  expected.
• 7:09
  And
• 7:10
  so
• 7:10
  her
• 7:10
  sedation
• 7:11
  and
• 7:11
  tremor
• 7:11
  are
• 7:11
  red
• 7:12
  flags
• 7:12
  that
• 7:12
  something
• 7:12
  isn't
• 7:13
  right
• 7:14
  and
• 7:14
  we
• 7:14
  have
• 7:14
  to
• 7:14
  question
• 7:15
  the
• 7:15
  level
• 7:15
  that
• 7:15
  we
• 7:16
  got.
• 7:16
  And
• 7:17
  sure
• 7:17
  enough,
• 7:17
  that's
• 7:18
  what
• 7:18
  happened
• 7:18
  here.
• 7:19
  Okay?
• 7:21
  So
• 7:21
  I
• 7:22
  hope
• 7:22
  you
• 7:22
  guys
• 7:22
  appreciated
• 7:23
  this.
• 7:23
  It
• 7:23
  was
• 7:23
  a
• 7:23
  fun
• 7:24
  one,
• 7:24
  it
• 7:24
  was
• 7:24
  a
• 7:24
  high
• 7:24
  yield
• 7:25
  one,
• 7:25
  it
• 7:25
  was
• 7:25
  an
• 7:25
  interesting
• 7:25
  one.
• 7:26
  I
• 7:26
  hope
• 7:26
  it
• 7:26
  keeps
• 7:26
  you
• 7:26
  on
• 7:27
  your
• 7:27
  toes.
• 7:28
  And
• 7:28
  yeah,
• 7:28
  I
• 7:28
  loved
• 7:29
  it.
• 7:29
  And
• 7:29
  if
• 7:30
  you
• 7:30
  want
• 7:30
  more
• 7:30
  of
• 7:30
  this.
• 7:31
  If
• 7:31
  you
• 7:31
  want
• 7:31
  to
• 7:32
  be
• 7:32
  at
• 7:32
  the
• 7:32
  top
• 7:32
  of
• 7:32
  your
• 7:32
  game,
• 7:32
  if
• 7:33
  you
• 7:33
  want
• 7:33
  to
• 7:33
  separate
• 7:33
  yourself
• 7:34
  from
• 7:35
  the
• 7:35
  fray
• 7:36
  and
• 7:36
  really
• 7:36
  understand
• 7:36
  the
• 7:37
  how
• 7:37
  and
• 7:37
  why
• 7:37
  of
• 7:38
  what
• 7:38
  you're
• 7:38
  prescribing
• 7:38
  and
• 7:39
  diagnosing,
• 7:39
  then
• 7:39
  I
• 7:39
  highly
• 7:40
  recommend
• 7:41
  you
• 7:41
  go
• 7:41
  to
• 7:41
  our
• 7:41
  Show
• 7:42
  Notes
• 7:42
  by
• 7:42
  the
• 7:42
  end
• 7:42
  of
• 7:42
  the
• 7:43
  day
• 7:43
  and
• 7:44
  you
• 7:44
  become
• 7:44
  a
• 7:44
  Patreon
• 7:45
  member
• 7:45
  because
• 7:45
  that's
• 7:46
  where
• 7:46
  all
• 7:46
  the
• 7:46
  fun
• 7:46
  is.
• 7:46
  We
• 7:47
  have
• 7:47
  a
• 7:47
  huge
• 7:47
  clinical
• 7:48
  library
• 7:48
  and
• 7:49
  it's
• 7:49
  going
• 7:49
  to
• 7:49
  keep
• 7:49
  you
• 7:49
  at
• 7:49
  the
• 7:49
  top
• 7:50
  of
• 7:50
  your
• 7:50
  game
• 7:50
  and
• 7:50
  patients
• 7:51
  smell
• 7:51
  it
• 7:51
  a
• 7:51
  mile
• 7:51
  away
• 7:52
  when
• 7:52
  you
• 7:52
  know
• 7:52
  what
• 7:52
  the
• 7:52
  heck
• 7:53
  you're
• 7:53
  doing
• 7:53
  and
• 7:53
  the
• 7:54
  why
• 7:54
  behind
• 7:54
  what
• 7:54
  you're
• 7:54
  doing.
• 7:55
  So
• 7:55
  I
• 7:56
  highly
• 7:56
  recommend
• 7:56
  it.
• 7:56
  I
• 7:56
  built
• 7:57
  this
• 7:57
  library
• 7:57
  because
• 7:57
  I
• 7:58
  wanted
• 7:58
  this
• 7:58
  library
• 7:59
  when
• 7:59
  I
• 7:59
  was
• 7:59
  in
• 7:59
  school,
• 8:00
  when
• 8:00
  I
• 8:00
  started
• 8:00
  practicing
• 8:01
  because
• 8:01
  it
• 8:01
  really
• 8:02
  just
• 8:02
  cuts
• 8:03
  to
• 8:03
  the
• 8:03
  chase
• 8:04
  in
• 8:04
  a
• 8:04
  beautiful
• 8:04
  fun
• 8:05
  way
• 8:05
  and
• 8:06
  it
• 8:06
  keeps
• 8:06
  you
• 8:06
  at
• 8:06
  the
• 8:06
  top
• 8:07
  of
• 8:07
  your
• 8:07
  game.
• 8:07
  So
• 8:07
  definitely
• 8:08
  go
• 8:08
  over
• 8:08
  to
• 8:08
  the
• 8:08
  Show
• 8:08
  Notes,
• 8:09
  click
• 8:09
  that
• 8:09
  bad
• 8:09
  boy,
• 8:10
  become
• 8:10
  Patreon
• 8:10
  member,
• 8:11
  say
• 8:11
  hi
• 8:12
  and
• 8:12
  we
• 8:12
  will
• 8:12
  see
• 8:12
  you
• 8:13
  next
• 8:13
  time
• 8:13
  here
• 8:13
  on
• 8:13
  Pearls
• 8:14
  and
• 8:14
  Prep.
• 8:14
  Thank
• 8:15
  you.