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00:00:03
Hello everyone, how are you, we're00:00:06
here for another day, hey, you're here00:00:09
firm and strong on our third day of00:00:12
immersion in a medical clinic, I'm happy to00:00:15
see you, I'm happy for everyone watching00:00:17
afterwards too, but I'm super happy to00:00:19
have you here live so that we00:00:21
can talk, right? After all, our00:00:24
proposal here is to present content and00:00:26
then have a chat here with you, right?00:00:29
So being here live makes this00:00:31
much easier, right?00:00:36
every00:00:39
day Sandrinha Sandrinha will already win00:00:42
a chair in Every Thursday00:00:45
of all events you are Super welcome00:00:48
K A K2 to Camille to Kelly Hi Kelly00:00:53
how are you to Ana Camila to Paola to00:00:56
Emily to Simone to Priscila some of00:00:59
I'm already recognizing here the00:01:01
names we've been talking about in00:01:03
Direct on WhatsApp too, right? It's really cool to00:01:06
have you here, good afternoon, Abdala and Lu,00:01:09
I'm talking about a beautiful accent, right? Abdala, I00:01:12
think Bia is chic. Good afternoon, everyone, it's00:01:17
one of the most wonderful things. That's what the00:01:19
online universe gives us, right00:01:21
? We meet people that maybe in00:01:24
our face-to-face life we would never00:01:26
meet, so it's really nice to see00:01:28
you here, Aninha and Carol. Good afternoon00:01:32
to all of you, I hope you00:01:35
're not listening to me twice but I00:01:38
think I turned off the feedback here00:01:39
so I think everything is ok here with00:01:41
our life right and so excited for00:01:45
us to talk about diabetes, you know00:01:47
when we went to choose, right, João and I00:01:48
when we sat down to decide00:01:50
which ones they would be the themes of immersion we00:01:53
based a lot on what00:01:57
we received throughout 2023 as suggestions for themes00:01:59
from you, right, so either in our00:02:01
Stories feed content or in00:02:03
our lives and these themes that we00:02:06
addressed here are very recurrent00:02:08
because in fact, right people, when we00:02:10
talk about dermatological problems,00:02:13
what is our flagship in our routine,00:02:16
man, is itching, there is no way to escape that, right?00:02:19
What we actually see in our00:02:22
daily lives is a dog, most of our00:02:24
patients with itching when we00:02:27
talk about the urinary system, it opens up a lot of things, right00:02:30
? We receive a lot of requests for00:02:32
chronic kidney disease and acute kidney injury,00:02:34
which, actually, on a routine basis, few people00:02:38
have been able to diagnose00:02:41
acute kidney injury, especially at the beginning, right,00:02:44
but then it opens up a universe of00:02:46
possibilities in nephrology that we can't00:02:49
immerse in everything, right, that's why00:02:51
we only have the nephrology module there in the mentoring,00:02:53
covering all of this in00:02:56
much more detail for you and then00:02:58
we were very doubtful because00:03:00
there are many legal systems in the00:03:02
clinic all the systems are very00:03:04
cool in the medical clinic, right? And then we00:03:07
were very unsure about the third one and00:03:09
we thought, let's put endocrine00:03:11
because it's really something very common in00:03:15
our routine and within the00:03:17
endocrinopathies of dogs. What do00:03:19
we treat in our day to day00:03:20
hypothyroidism and diabetes merits but00:03:23
diabetes much more, right so let's talk00:03:25
about this inside the possibilities00:03:28
of talking about cardio nephro neuro00:03:31
look how difficult it is to choose do you think it00:03:33
's difficult to sit down and be able to00:03:36
make time in your schedule00:03:38
to watch I know it is, but it's00:03:40
difficult to elaborate on these topics for you00:03:42
too, right, because there are many00:03:45
systems, but what I understand is that00:03:47
there are some systems, folks, that are Taboo, have00:03:49
you already noticed that, there are some00:03:51
people who like endocrine and take it in00:03:54
a very easy way but there is such a00:03:57
great fear when we talk about any00:03:59
diseases, right, and endocrinology Neurology00:04:02
comes into this context because if we00:04:05
manage it wrong, we00:04:06
actually immediately compromise the00:04:09
patient's life, right, so I said let's00:04:11
talk about diabetes because it's something very00:04:13
common and people like it and we're going to show00:04:16
the path to this diabetes so that00:04:19
we can stop messing around with the diagnosis00:04:22
because people, I'm going to talk about the00:04:24
diagnosis here, right? It's so simple to00:04:26
do and we complicate things, right? Throughout00:04:29
2023, in mentoring, we saw several00:04:33
patients with00:04:35
incorrect diagnosis that we brought to the center, oh,00:04:37
this is not diabetes, oh, this is00:04:39
diabetes, right, so we will show you00:04:41
the path to diagnosis and I hope00:04:43
you are with the very open-minded00:04:45
to receive this information and00:04:47
the information I'm going to give you00:04:49
here will be enough for you to make a diagnosis and00:04:51
then the path to therapy, you know, it's00:04:55
long, we have a lot to say,00:04:57
but I've brought here the main points00:04:59
so that we have more security00:05:02
when caring for a diabetic patient, right? I00:05:05
understand people, and sometimes it's even a bit00:05:07
controversial, what I say to you in00:05:08
relation to specialties, right?00:05:11
Specialists, they exist, thank God,00:05:13
And they help us a lot, I have no00:05:16
doubt about that, but When we00:05:18
forward a case to a specialist, now00:05:20
you're going to want to kill me, right, whoever is a00:05:22
specialist will say that for the love00:05:23
of you, but when the Clinician, a good00:05:26
clinician forwards it when it's a system00:05:28
you don't like And then you won't00:05:30
study, for example I'll give you an example00:05:31
in my practice, if I saw00:05:34
a patient yesterday, for example, that I saw,00:05:36
yesterday I told you that I would go00:05:37
at 3 o'clock to see a dog with itching,00:05:40
this dog with itching was a little poodle, it was00:05:42
difficult to see a poodle today, hey, I answered00:05:45
a tiny little pudle,00:05:46
really tiny people and she actually00:05:50
complained of itching, but in my00:05:52
general physical examination, it reminds me of a general physical examination, it's00:05:54
always done. She had a dislocated00:05:57
patella, people, I'm terrified of Orthopedics, I00:06:02
don't like it, I don't even like the feeling of the00:06:04
patella dislocating, I'm already Let me know, so00:06:06
it's a system that I don't want to attend to,00:06:08
so I've already told her, we're going to00:06:10
keep it to ourselves But there's a00:06:11
significant patella dislocation, including a00:06:13
4-year-old TR dog, I'm going to00:06:16
refer you to an orthopedist, look,00:06:18
thank God the orthopedist exists, right, and00:06:20
in the concept of the medical clinic, I think00:06:23
exactly like this, if there is a system that00:06:25
you don't really like, it's good that you00:06:26
have a specialist by your side, but man,00:06:30
if you enjoy studying, if you enjoy00:06:32
attending to that system, you Clinician has00:06:35
Total conditions of solving 90% of your00:06:38
patients When are you going to refer00:06:40
a diabetic to an endocrine in00:06:43
complicated cases where you are not able00:06:44
to make adjustments that suddenly the guy who00:06:47
spent years of his life, you know, two years at00:06:50
least studying it, will find00:06:52
flaws that you Clinician you weren't able to00:06:55
observe, you understand, so the idea here of00:06:58
talking about diabetes is so that you00:07:00
start to have this clarity and this00:07:01
security so that you can walk with your00:07:04
patients, otherwise Guys, what will happen?00:07:09
Let's also value00:07:12
the Ready Clinician I made an initial rant00:07:14
oh and I'm going to make another rant now don't00:07:18
kill me Let's just see who's coming in here00:07:20
and talking to me but I think00:07:22
people are just being very polite and00:07:24
wishing me a good afternoon, right? Re Aninha00:07:26
I already told Carol Safira what a beautiful name00:07:29
daughter Aline Good morning here in Manaus it00:07:32
's still tomorrow because I love tomorrow for me00:07:34
tomorrow could last much longer too, see00:07:36
but I'm already hungry to be honest00:07:39
Lili Rogério Francisca rolls or I don't00:07:42
know how to say this, Evelyn, Mari,00:07:46
our dear mentee, we already have00:07:48
some mentees from 2024 who don't lose the00:07:50
immersion, hey guys, you are so in everything,00:07:53
congratulations and to Mr Mita, I think it's like that,00:07:58
Claudinha, Sandrinha. Exactly that's what00:08:01
I do. Exactly that's what I always forward,00:08:04
I think. what you're talking about exactly in00:08:06
my context, right, Sandrinha, I'll direct you00:08:08
when it's difficult or the path when00:08:10
you don't00:08:11
like it and I'll make another rant00:08:14
here, don't leave, hey, it's an00:08:17
important rant yesterday folks, I arrived here00:08:20
starting our conversation about itching00:08:23
because I had a lot of doubts about00:08:25
mentoring remember that we00:08:27
officially opened registrations on Monday00:08:29
and I dropped this bomb registrations are00:08:31
open guys I'm waiting for you00:08:33
believing what everyone00:08:36
knows that my head knows00:08:38
how mentoring works, right? Yesterday,00:08:41
beauty, I came back here at the beginning of our00:08:43
conversation and explained the00:08:45
mentoring program, but then people wanted to00:08:48
kill me because I didn't say one of the things00:08:51
that people most want to know, so00:08:54
I reserved five questions that were00:08:57
very important, here I apologize for00:09:00
not I said them yesterday and I'm going to00:09:02
answer them now Ok and if you have00:09:05
any questions about the mentoring,00:09:08
feel free to ask here in the chat00:09:10
guys, we're here to answer them in00:09:12
Direct on WhatsApp that you have from00:09:14
our contact in the groups Agreed, so00:09:17
let's go There, a question I was asked00:09:20
here00:09:22
was Ju, you have the lives on Thursday,00:09:25
correct, if you don't know, we00:09:28
have the lives on Thursday,00:09:29
beauty, the mentoring classes, it's a00:09:32
program that you get, the lives on00:09:34
YouTube and playing on a platform00:09:38
has nothing to do with YouTube lives00:09:40
Guys, the mentoring classes are00:09:43
classes made exclusively for that00:09:47
mentoring class Ok so we00:09:49
recycle All the material updates the00:09:52
last year and makes exclusive material00:09:55
you won't see the mentoring class00:09:57
played here on the internet Ok, it's from the00:10:00
student platform and how do we00:10:03
approach this we focus on diagnosis00:10:05
and treatment I told you this00:10:07
yesterday I'm not going to wander about the00:10:09
history of diabetes, right I'm going to tell00:10:12
you My diagnosis is how00:10:14
we're going to start today talking about00:10:16
it and then we're going to break down the00:10:18
treatment of diabetes, right, the last00:10:20
mentorship we had 6 hours of00:10:22
diabetes because we're really00:10:24
focusing on everything, the entire context because it00:10:26
remembers what mine is motto the00:10:30
theoretical knowledge so that later you can just open00:10:33
drawers Ok cool so the classes are00:10:36
focused on the YouTube classes guys, they00:10:39
are modest classes, some of them very cool00:10:41
too but it's like this, every week we00:10:44
cover a content, a point of that00:10:47
content, diabetes itself, we There00:10:49
have already been several lives about her talking00:10:52
about how to take insulin which seems like a00:10:55
silly question but you have your client in00:10:57
front of you the guy doesn't know how to manage it in the00:10:59
cinga, you understand so we're getting00:11:01
points so for you there Ju but I00:11:04
can learn from Live do YouTube Of00:11:07
course, this is our intention here man,00:11:09
if there is one thing that I was born to do00:11:11
in my life and that I love to do, it is to have00:11:13
contact with the veterinarian and student and00:11:15
teach, that is what I am for and that is what00:11:17
we are for YouTube, right, to share00:11:19
content and each time we're going to focus00:11:21
more on this YouTube thing because here00:11:24
we have students who are into00:11:26
real content, right, different from Instagram00:11:28
where you want things faster, right?00:11:30
So we focus on YouTube.00:11:32
likes it too but we bring00:11:35
minced meat, understand in mentoring The idea is00:11:38
to bring the content organized and all the00:11:40
content there so that you don't need to00:11:42
look for other sources of updates00:11:45
Ok so to answer my first00:11:48
question, folks, it's not the YouTube class that00:11:50
There's in the mentoring, the mentoring is00:11:53
something much much better, much more00:11:55
elaborate. Another question they00:11:57
asked me, I thought it was very cute,00:11:59
it was like that Ju, in the immersion, the content was00:12:03
a bit boring because you come and say it's PH,00:12:06
topical dermatitis and so on, but what's up? how do00:12:09
I deal with these things, right? What is the00:12:11
little secret in the midst of these diseases, guys,00:12:13
the immersion is drawn out because you don't even00:12:15
have time to listen to me, do you00:12:18
agree, look at how many people are asking00:12:20
us to extend the access time to the00:12:22
link Because the Life is crazy, right?00:12:26
So the immersion here, the idea is to bring00:12:28
content that's all very straightforward so that your00:12:30
mind starts to open up. Mentoring doesn't have00:12:33
that purpose. Mentoring00:12:34
has the purpose of teaching you all the00:12:37
steps. they are very00:12:39
different, the class doesn't have this desperation00:12:41
that the link will close, you receive the00:12:43
content on the platform every week and00:12:46
that content is yours, you will access it,00:12:48
review it, rewatch it as many times as you00:12:51
want throughout your access,00:12:53
okay, another question was asked by many students,00:12:57
we I'm here guys, I'm going to talk Let's00:12:59
take a pause clap Wow,00:13:02
first second, third year students00:13:05
here asking if they can join the00:13:07
mentoring and our answer is00:13:09
unfortunately we can't, we won't even accept00:13:11
your application, okay, look guys, let's have00:13:15
a chat here, I already I feel super00:13:16
close to you to be able to say what00:13:19
I think, I'm already out of touch, pay00:13:23
attention, I want to have many students in00:13:25
mentoring to have a financial return,00:13:28
of course I also want to have a00:13:30
financial return, but see, I can get a00:13:33
good financial return in My00:13:34
office understands that my focus here in00:13:37
mentoring is to see you, that's what I like to00:13:40
do for a living is to catch my student at the00:13:43
beginning, people who don't have to receive00:13:46
a call to make an appointment and00:13:48
talk. Oh, I don't think I'm going today power00:13:50
because there is that insecurity, that00:13:51
fear or that guy who is doing the00:13:53
same thing to every patient Say man, I00:13:55
want to change I want to be a reference00:13:57
for a Clinician in my region and see the guy00:13:59
do this unfortunately it is not a00:14:02
condition here that I am telling00:14:04
You're despising it, right? But00:14:06
first, second, third, we're not00:14:08
going to achieve this transformation in you00:14:10
at this moment, understand, so we want to00:14:13
prioritize the people who will be able to00:14:15
transform themselves. Ok, so the first,00:14:18
second and third years are not your00:14:20
moment yet, but I'm I'm super happy to00:14:23
have you here because it shows, man, look at00:14:26
your evolution of thought. You're00:14:29
participating in an immersion, maybe you00:14:31
're not understanding anything I'm saying,00:14:32
but you're here and I'm going to say the majority of people00:14:35
here are these people. So00:14:37
congratulations, I I'm very proud to see00:14:40
you here but mentoring isn't00:14:42
for you yet, ok, I'm going to pull this up so00:14:45
who is mentoring for?00:14:54
fifth, you will see routine, you will00:14:57
see practice, you will follow along, shyly00:14:59
for the guy who has just graduated,00:15:01
for the person who has been there for a year, I'm going to give00:15:05
you an example here, it's just a chat, okay guys,00:15:07
I have a student of00:15:09
2023 we are going some I will00:15:12
use as an example I'm sorry Who00:15:14
are the others and I'm not mentioning00:15:16
all of you here we have a great affection00:15:19
for the class of 2023 right it was the group00:15:22
that embraced mentoring it started with00:15:23
us the beauty, one of our students,00:15:26
the girl graduated and went to work on an00:15:29
ICU shift, tell me if the girl does00:15:32
n't already have some courage, say that, and then over the00:15:37
12 months we accompanied him on that00:15:39
ICU shift and see the beautiful woman serving her skin00:15:43
It was something she just wanted to know about00:15:46
neuro when she started mentoring00:15:47
When will the neuro module be, I don't00:15:49
know if she's here and see the evolution of00:15:52
a recent graduate Putz today man she's00:15:54
talking to us about the Clinical case I00:15:56
I'm talking to Bela, who I'm talking to00:15:59
seems like a 60-year-old girl with a degree, she00:16:01
knows maturity, and finally, someone else,00:16:04
too, that we have a lot of People00:16:07
who stayed away from the Clinic, [ __ ], she00:16:09
graduated, she went to work with adults, she00:16:11
got frustrated, she graduated, she went to be a mother, Look at us00:16:14
here I was almost away00:16:17
from the Clinic for three years, you went to be a mother, you moved away and00:16:19
went to the commercial area and want to come back,00:16:22
we have two students from 2024 in this area,00:16:25
they are working in companies and00:16:27
want to return to the medical field. So what do00:16:30
you think, I don't remember Nothing OK,00:16:32
you're on the right track, we00:16:34
even had a student who wanted to00:16:36
do Residency at the end of the year, he's00:16:38
doing it now this month, he studied the00:16:40
entire residency with us, we have students who00:16:43
have, as I told you yesterday, years00:16:45
of training that the Mentoring adds00:16:48
to this person, she will be different,00:16:51
she will be a reference for people who are00:16:54
here with me, someone please tell me00:16:56
that I have been at the clinic for 17 years, man, it's00:17:00
been a while since I was00:17:02
tired of keeping up with crazy schedules, if00:17:05
you do, you don't know Oh, just yesterday I00:17:08
spoke to STC, last week00:17:10
I spoke to STC, one of our00:17:11
mentees, on the way down, she said this, Ju,00:17:13
I can't take it anymore, the end of the day comes,00:17:15
I have a test cake Thank God00:17:17
I have patients, she still said this00:17:19
but I don't even know who Safira is anymore,00:17:21
who Bob is, who is it? I'm00:17:29
sorry, I don't want00:17:31
to be this Clinic, I want to have fewer00:17:33
patients, to know who my patient is, you know, it's00:17:36
just a rant, so this is for00:17:37
who it is. Including, including. Look how00:17:40
cute I made, I prepared myself for00:17:42
you, I even made a graph that00:17:45
We ask PR students to fill out at the00:17:47
end of the mentoring, right now in December00:17:49
so you can see how many students00:17:52
we had in the distribution, we00:17:54
had undergraduate students preparing to00:17:56
start working, they planted00:17:59
in a public agency00:18:01
home care Alright, so that's it That's our00:18:04
other question, well, another question that I00:18:07
received a lot was about the00:18:11
content approach, right? I've already explained more or less00:18:13
here the difference with YouTube, okay,00:18:16
we're going to talk about basic modules,00:18:19
therapy, semiology, fluid, transfusion,00:18:22
antibiotic, anti-inflammatory, all of this00:18:23
in the first module, okay? with a demonstration of00:18:26
how to do a good physical examination, which00:18:28
is the basis of the Clinic, right? How to prepare00:18:31
the prescription, right? And then we go through the00:18:33
systems dermatology, nephrology,00:18:37
neurology, cardiology, pulmonology,00:18:41
I hope I don't forget any00:18:42
gastroenterology and endocrinology, right,00:18:45
over the 12 months ok and this group00:18:49
we have already stamped and validated the mentoring00:18:52
in the first one this brings more Plus we00:18:55
will have guests talking about ophthalmology at00:18:57
home we will have00:18:59
wound management we will have00:19:02
neurologists we will have00:19:05
accessory things personal image I can't wait for00:19:07
this class to arrive,00:19:09
digital marketing, financial management, oh, oh,00:19:12
oh, let's move on to the next point,00:19:16
let me see if you want to say00:19:17
anything Manaus Rogério already00:19:20
says Claudinha Sandrinha said Evelyn, she thinks I'm00:19:23
wonderful, thank you, Evelyn, look I00:19:25
don't have any botox on my00:19:27
face Hi Profe Rafaela Hi Rafa, good afternoon,00:19:32
thanks for the content, Thank you, I'm00:19:35
really happy to be here, really,00:19:37
guys, this is our first00:19:38
immersion, we're going to do several00:19:40
secret rooms with you, we're with you.00:19:42
lots of cool plans with you00:19:45
now we have a group, right we00:19:47
have four groups going on from immersion00:19:49
in WhatsApp are you in any of these00:19:51
four groups there will be lots of00:19:53
cool things for you over the00:19:55
years over the years over the00:19:58
years also, but in the months to Bibi Our00:20:01
eternal dear mentee, madu A00:20:05
Di myself in the third semester, super00:20:07
interested not yet, not yet, not yet,00:20:10
okay, I'm going to pull the gantin,00:20:13
Mia's gantin here to talk about a question00:20:16
that everyone asked me and obviously00:20:18
I forgot to mention yesterday, right? Why was it00:20:20
terrible? What is the value of mentoring?00:20:23
Pay attention to mentoring in Clinics. There00:20:26
is no registration fee. There is no00:20:29
registration fee. Ok, we recommended00:20:33
leaving this class for the second00:20:36
class that starts now, including today00:20:38
we have our first live meeting00:20:40
so I can get to know you so we can talk00:20:42
everything and talk tonight OK but00:20:45
this mentoring00:20:47
so it is about personal investment it is00:20:50
done on00:20:52
monthly fees we don't have a contract00:20:54
ok we do it on monthly fees these monthly00:20:57
fees00:20:58
and in general that He asked me, can it be paid00:21:02
by bank slip, can it be paid by PX00:21:05
or can it be paid by credit card,00:21:08
in that business called00:21:09
smart payment, you know it doesn't compromise your00:21:12
balance, anyway, I don't know. These are the00:21:14
payment methods you choose when00:21:16
you make yours. registration ok the00:21:19
monthly fee guys for this immersion that00:21:22
we started now officially we00:21:24
are putting it at the value of 517 that's the00:21:28
monthly fee okay Oh what00:21:31
else do I have to talk about the values00:21:32
well then you will say that to me Ju00:21:34
eh We already talked about this yesterday, right,00:21:36
if this is a postgraduate course, this is a00:21:38
refresher course No, it's not a00:21:41
postgraduate course, it's not a00:21:42
refresher course, mentoring It brings the00:21:45
difference from these other programs, which00:21:48
is cute updated classes like you00:21:51
would have in any other good course Ok, the00:21:54
difference that establishes it on a00:21:57
higher platform than mentoring is our00:21:59
daily monitoring, ok, which we do00:22:01
in live meetings and in our00:22:03
community also on WhatsApp, ok,00:22:06
there are products with00:22:09
lower prices in the market for sure, right now,00:22:12
a good postgraduate course, you know it's00:22:15
not that value, it's a much higher value00:22:18
Ok, and you also know that in00:22:20
postgraduate studies, no one even knows who00:22:22
you are, what you need or accompany you00:22:23
on the day on a daily basis because there are many students, right,00:22:26
the mentoring or if it is, it's obvious that I'm00:22:29
suspicious to say but the mentoring is00:22:33
wonderful and to prove this to00:22:36
you and we're already going to get into00:22:38
diabetes I just want to show you00:22:40
that I'm one thing I'm talking here, right, I'm00:22:42
saying something else, just our students00:22:45
talking, that is, people who don't have a00:22:48
relationship of wanting to keep inventing00:22:50
things for you, I just want to show00:22:52
a few points, that's what I focus on,00:22:54
Guys, what do I want in the00:22:56
transformation of you with Oria00:22:58
technical knowledge Obviously and what00:23:00
this will generate confidence security00:23:03
security security these are the00:23:05
answers from our mentees from the00:23:07
last year what they achieved with the00:23:09
mentoring So here's proof for you,00:23:12
right? I even left this one on purpose because00:23:15
if you I don't know about you, I don't know about00:23:18
you, but I like attending to00:23:21
a lot of things and a lot of very00:23:23
complex things at the clinic, but man, when I00:23:25
get a shave and I think it's fashionable, I say00:23:28
this to my students, right?00:23:30
It seems like my week is over and it's already00:23:31
won. Look at this person's report, I ask00:23:34
them not to identify themselves, so00:23:35
they can speak openly Anyway,00:23:37
so I don't know if it's a girl or00:23:39
a boy, but I haven't managed to attend00:23:41
even half of the classes yet, but after00:23:43
attending a dermatology class in the first00:23:45
week that I started at work I00:23:46
diagnosed dem modesa in a dog that00:23:49
was being treated for00:23:51
dermatitis dermatitis is not a diagnosis OK so she00:23:54
went there and closed a dem modesa I already00:23:56
thought man if it's me I was already00:23:58
thinking that work will now00:23:59
respect me, right? Why find someone modest?00:24:02
I don't know about you, but I love it when I00:24:04
find someone in a shaved place. Now look, how00:24:06
interesting some of their words are, which00:24:09
I think are super cool, look, I learned to00:24:12
talk to the client and know how to explain00:24:14
what I have to do. be done at every step00:24:16
I understood that the client is the basis for00:24:18
everything to happen and look at this sentence guys I00:24:21
'm here thinking I really am but it's because00:24:24
I have to expose this to you00:24:25
because I have to expose this to the world00:24:27
Look at this I think I could feel like a00:24:30
veterinarian again Man, that has no00:24:32
value, that's not the case, it's the exchange, right?00:24:43
how much this00:24:46
works and that it's not just me here00:24:47
saying Okay, but this is what I want to00:24:50
bring you current content, I00:24:53
want to do what I love to do, right, but00:24:55
for me to love what I like, what I00:24:57
like, doing queer is here teaching If00:24:59
you are following me, I need00:25:01
to form a group for this to happen,00:25:03
right? I know that many of you here00:25:06
may not be in the moment for mentoring,00:25:09
many of you are not interested in00:25:11
what I'm saying, but many of you00:25:13
may not even know that this mentoring00:25:14
exists right, so the idea of me starting00:25:17
here by answering these doubts is to introduce00:25:19
one of you. Maybe it's like Adi, it's not00:25:22
the time now, she's in her third00:25:24
period in the third semester, right?00:25:32
developing virtues00:25:35
is not easy it is not easy throughout our00:25:38
journey and we need it we00:25:40
can do it alone Ju I can be a00:25:43
good Clinician studying alone of course00:25:45
you can do it you have Total capacity00:25:47
to get books and articles and such but do you00:25:49
agree that the path is much more00:25:51
difficult you will take much longer00:25:53
I did this for many years guys but00:25:55
how long did it take me to feel the00:25:57
confidence that I have today, understand00:25:59
so the idea, I'm being very00:26:01
honest here for you, the idea is to00:26:03
do it so that you can evolve along this00:26:05
path faster, I'll show you the00:26:08
path of what I've already learned, right, and from00:26:10
colleagues that we have the opportunity for,00:26:13
our support, in fact, that's it here, there's nothing to00:26:15
discuss, João and I are00:26:17
with you, many times at the same time.00:26:20
we are João responds student I am00:26:22
responding below right we are with00:26:24
you all the time This is going to be very00:26:26
good and then when you talk about the price you00:26:28
say like this Wow Ju R$ 500 is very expensive00:26:31
I'm not saying that R$ 500 is change for a00:26:33
bakery, I know that for many people00:26:36
this is part of a00:26:39
family budget that generates all the repercussions there,00:26:43
R 500, right, per month for 12 months anyway, but00:26:46
understand one thing, you will only get a00:26:50
return, unfortunately, people investing in00:26:52
everything that We do it for all areas00:26:54
of our lives and then I want to show00:26:56
you how much because this has always been00:26:58
a doubt of mine, right at the end I00:27:00
asked the students this, did you think00:27:02
the price was fair because this was the00:27:04
amount that class one paid right and00:27:07
everyone didn't have one person who said it to00:27:08
me Ju I thought it was expensive some were very00:27:11
sincere oh where isn't it here I didn't00:27:14
put it but there was one person who even00:27:16
put it like that Ju it was difficult to pay But00:27:18
it was worth it so you know what I want00:27:21
Also bring is that there were already people Right00:27:23
at the beginning Danilo here, I'm sorry00:27:25
to put your name, right, he eats applying00:27:28
dermatological exams and with a00:27:30
consultation. He paid the monthly fee for the00:27:31
course and once, right, and sees people00:27:35
helping each other, you know, in the community, if giving00:27:38
It's true that everyone is buzzing, man, the00:27:40
right environment really transforms00:27:43
us all Ok, this is our community,00:27:47
just so you can see, these are our00:27:49
WhatsApps, the person goes, we respond, And00:27:51
then we go, we interact there throughout00:27:53
the week, and I have sure00:27:56
sure guys that this is transformative00:27:59
Okay but I understand that it has to be your00:28:02
moment if it's not your moment now if00:28:04
for some reason you don't think it's00:28:06
your moment reflect on why it's not your00:28:08
moment right in the case of day she It's in the00:28:10
third period, it's not going to be00:28:12
her moment, but for other people,00:28:15
reflect on what you're doing, what makes you00:28:17
not take that next step, right?00:28:24
with00:28:26
theoretical knowledge with clarity with00:28:29
your customer's loyalty, these are00:28:31
steps, you know, but anyway, this could be00:28:33
a topic for a live broadcast Wow, this whole00:28:35
philosophy, right, today we're here to00:28:38
talk about what, guys, what is our00:28:40
main focus here and the Let's start with diabetes,00:28:43
so let's just see here00:28:46
on Tuesday what the cost is. I've already answered, I'm in the00:28:49
seventh period, I'm going to have a clinic, oh, oh,00:28:53
let me put on some lipstick here,00:28:55
Safira is starting the clinic, oh,00:28:57
honestly, you're a student we like.00:28:59
already accepted Upon registration Okay, but I would do it00:29:03
in the ninth period, Juliana, okay, I'm just going to00:29:06
tell you why S because in the seventh period00:29:08
you will have a small00:29:10
surgery clinic for small children, probably for00:29:12
big ones, technology for products of00:29:14
animal origin00:29:16
Oh, I don't want just one more student who goes00:29:19
there understands my idea is that you are in the00:29:21
ninth period starting your00:29:23
curricular internship focused on clinical medicine Well,00:29:26
this will00:29:28
direct you, Juan said that00:29:31
this year he wants this00:29:34
mentorship, next year it will be super00:29:36
welcome Juan I just graduated and I00:29:39
feel unprepared Hey, let me00:29:41
tell you something, you are brave to come and00:29:43
say this, but you can contradict me here00:29:47
if you want us to get into a00:29:48
controversy, there is no person who graduates00:29:50
and If you feel safe, that doesn't exist, people,00:29:54
and then I have to work on this mind00:29:56
with you. Graduation doesn't prepare00:29:58
anyone, look at what you do. At graduation,00:30:00
the grid is huge, there's no way to get out.00:30:05
clinical, it's00:30:07
not, it's just a base, understand, so don't00:30:10
worry, this feeling is00:30:12
universal, some just don't recognize it, there are a00:30:16
number of vacancies here, I forgot the name,00:30:18
I think it's Rafa, right, Rafa, we00:30:20
still have vacancies available, okay?00:30:23
There is a very high demand for students00:30:25
and we are even studying the possibility of00:30:27
opening a second class, ok, it00:30:29
depends on whether we will fill the two gaps00:30:32
But there are still vacancies, Madu is in the00:30:34
fifth period, she is having a marathon, what a great00:30:37
seventh period, I still need very00:30:40
much knowledge, right, but it's normal, it's not00:30:43
just you, see, everyone, don't00:30:45
worry, I'm going to the fifth00:30:47
semester Oh, you see how00:30:49
cute you are, everything is, send students here, people,00:30:52
I love it, I love having you here,00:30:54
congratulations on being00:30:56
here Jack Jack is also here, Mari,00:31:01
our new mentee, I myself got into the00:31:03
madness of Motherhood, now I want to go00:31:05
back to Ju, you have inspired me a lot with this Sweet00:31:07
fresh start, thank you, Mari, you are going to00:31:09
fly this year My daughter, we are going to00:31:11
make this mentoring revolutionize your00:31:13
life Malu Cris Biazotti is here Eliane00:31:16
Nanda is in her final year, it's time to00:31:19
join Nanda, more mentoring of 1200:31:22
months of access and 12 months of content00:31:25
and monitoring, yes, there are already00:31:27
students renewing from last year, so00:31:30
you can extend this, oh00:31:32
yeah being so wonderful, imagine00:31:35
modest mentoring aside, imagine00:31:37
those00:31:39
ass Melissa, I've always worked in intensive care00:31:42
Melissa, I already know you, last year I00:31:45
started venturing into the clinic, I was scared to death00:31:47
and I'm still scared, you pass it on to me00:31:51
How cute, there are a number of vacancies, I already told you, right00:31:54
Rafa Next Nanda, do an intensive00:31:56
anesthesia anesthesia, you know that00:31:59
anesthesia was something that00:32:01
last year's people asked Nanda for00:32:03
this class, we put an00:32:04
anesthetist to talk about00:32:06
outpatient anesthesia for us, see, we're going to00:32:08
have that, yes, the mentoring only opens. at the00:32:11
beginning of the year Bia, traditionally00:32:14
we open in January, okay, we can start in the00:32:17
middle of the year, let's see how00:32:20
ours goes, our vuc vuco Bia, we may be able to00:32:23
open a class in the middle of the year, if00:32:26
we can manage the our00:32:29
preference is for the group at the beginning of the year,00:32:31
if we feel that we are00:32:33
able to provide good support, we will00:32:35
open another one if we are very overwhelmed,00:32:37
then we will privilege people at the00:32:39
beginning of the year, there is a teacher who00:32:41
teaches anesthesia00:32:43
Top, I think he's a clinical professor, I do00:32:46
n't know the methodology, but00:32:50
I'm also exploring YouTube,00:32:52
so it could be that you certainly00:32:54
know a lot more than me, right? You00:32:55
're all much more intelligent. You're00:32:59
cheap, you see. I say that it00:33:03
's also cheap and oh, it's not real, it's not really00:33:05
cheap, because what He offers is really cheap, and00:33:07
if I'm not already00:33:10
attending the clinic, I think it's valid, since00:33:13
following the routine to help the00:33:14
student, oh, Bia, we have students who don't00:33:17
they are in the routine for various reasons00:33:19
because they are still on00:33:21
maternity leave they will not return now00:33:23
you understand but the theoretical knowledge that00:33:26
you will have seeing the experiences of other00:33:28
students our contact certainly the00:33:31
mentoring is valid for you right00:33:33
Mentoring is not valid in some for00:33:35
those who are not mentoring guys, it's not00:33:37
for First Second Third year, not00:33:39
fourth year, I don't know, I don't think it's00:33:43
a good move either, and it's not for you,00:33:45
like, Ju, I have money, it's not a00:33:47
problem to pay R500, but I I don't have00:33:50
time so mentoring isn't for you00:33:52
because I didn't tell00:33:54
you about mentoring, I'm sorry, the word here,00:33:56
my passion is teaching, so the person has to00:33:59
be committed to studying if you00:34:02
don't, Ju won't do it, I can't, ah00:34:05
It's been 7 months since a class has been opened, it's not00:34:07
for you either, ok, but for you,00:34:10
Bia, who isn't attending but00:34:12
wants to learn, it's for you,00:34:14
ok, Nanda, he's a master in anesthesia, I00:34:17
think he's great, I'm going to want this00:34:20
mentorship now, how much The cost of00:34:22
mentoring, oh man, I love it Hey, I just got00:34:26
married, we're still a little lost00:34:28
mentoring 12 monthly payments payment card00:34:31
or pics of 517, when is the second class coming today?00:34:40
Gigi Gigi Let's00:34:42
do a YouTube live just about this,00:34:45
people here are like this00:34:47
Where's the diabetes Where's the diabetes Where's the00:34:48
diabetes because it's already 30 minutes Let's00:34:51
do a live just about our00:34:52
feelings as veterinarians, it's super00:34:55
normal vi Gigi is security It's normal until00:34:58
you have clarity there is a vet with00:35:00
30 years of experience who has graduated insecure but doesn't know it00:35:02
's insecurity but it's insecure super00:35:05
normal Zelinda wants to do it you'll be super00:35:08
welcome Zelinda I'll wait for you there in my00:35:10
direct I'm in the sixth semester cute go00:35:13
join me I'm sure you'll soon pay in00:35:16
cash, there's a difference. Wow, Talia threw the00:35:18
check in my face, hey, there's no00:35:20
difference in value, ok, Mi, in this case, if I00:35:23
do it by bank slip, I can set a date00:35:25
that's good, you, you'll00:35:28
register and the bank slip will come with it. so00:35:30
you can register on a date00:35:31
that is good because it is the00:35:33
platform itself that takes care of the finances, okay00:35:34
guys, it's not me, okay,00:35:36
okay, go ask your questions00:35:39
and I'll start talking now about what I00:35:41
want to tell you about diabetes, let's go00:35:44
There, this guy Oops, let me get you out of here, I'm talking about00:35:49
problems related to00:35:52
diabetes, right guys, let's start with the00:35:54
basics, what diabetes is, diabetes is00:35:56
a patient that you care for, pay00:35:59
attention to this, who00:36:01
has persistent hyperglycemia with00:36:05
hard glucose, Dude This is a00:36:07
stupid definition from a book, but it's very00:36:10
important, you know, because I've seen00:36:12
now that we have contact with a lot of00:36:14
people, right? I've seen a lot of00:36:17
misdiagnosis of diabetes,00:36:19
diagnosis of from veterinarians who00:36:21
go there to evaluate a dog, for example, and00:36:23
in the screening of exams, even under00:36:27
the screening of exams, blood glucose is discharged00:36:30
and then we have this, and some00:36:33
connections are natural for us, right? And then00:36:35
when we see00:36:37
hyperglycemia, it is very easy00:36:39
to relate this to diabetes, but pay00:36:41
attention to hyperglycemia.00:36:45
We have already talked here a few00:36:48
times, you know, that hyperglycemia has00:36:49
several causes, diabetes is one of them, but00:36:53
pay attention to diabetes. This00:36:54
hyperglycemia is persistent and it is00:36:58
persistent in such a way that it00:37:00
exceeds the reabsorption capacity00:37:02
of the tubules. Why We want to lose00:37:05
glucose in the pee, no, we don't want to00:37:09
lose it, it's a very important thing for00:37:11
our body, that's why even when00:37:13
it's there in the glomerular filtrate to go00:37:15
away in the pee, there in the nephron, right in the00:37:20
morphofunctional unit, when glucose escapes00:37:22
into the pee, renal tubules reabsorb,00:37:25
that is to say, it takes the pee back into the blood,00:37:27
oh glucose, you don't go away, my00:37:30
dear, it comes back, right?00:37:41
Poor00:37:43
kidneys can't bring it back into00:37:46
circulation, that's why the patient is00:37:49
considered diabetic, when he has00:37:51
hyperglycemia with glycosuria, so00:37:55
there is no such thing as a diabetic dog that you can00:37:57
diagnose that has it Ju, but he has00:37:59
400 glycemia, he has glycosuria, or00:38:02
even I'm going to do it, right? Ju has to do it, so00:38:06
in addition to us having this concept that00:38:10
in the laboratory, diabetics have to00:38:12
have hyperglycemia with glycosuria So00:38:15
let's say here, once again we talk about00:38:17
this on Monday, with the importance of00:38:20
urinalysis, there's no way to diagnose a00:38:22
diabetic without urinalysis since this00:38:24
is an essential laboratory finding for00:38:27
the diagnosis, but not for me to00:38:30
institute therapy and talk about beauty,00:38:32
let's start insulin therapy on this00:38:34
dog so that I can do it00:38:38
in the laboratory, this is the basis that00:38:40
seals my diagnosis, but pay attention to00:38:44
endocrinopathies, I I only treat my00:38:46
patient when he has what00:38:49
clinical signs I'm doing a checkup on the dog00:38:52
he has hyperglycemia let's worry00:38:54
about diabetes No but he has00:38:56
hyperglycemia with glycosuria he will have00:38:59
clinical signs why when he has00:39:01
glycosuria the glucose is osmotic she draws00:39:05
water Ok this dog will have polyuria he00:39:09
will start to eliminate a lot of water in this00:39:11
pee to compensate physiologically he00:39:15
develops polydipsia00:39:18
the lack of use of this glucose right due to the00:39:22
lack of insulin action which is the00:39:24
pathogenesis of diabetes it generates hunger in the00:39:26
satiety center for this patient then00:39:29
he has00:39:30
polyphagia and the catabolism related00:39:33
to the pathogenesis process generates00:39:37
weight loss so guys there are four00:39:40
clinical signs that your patient will00:39:42
have Ju he will have the four signs00:39:45
most of the time it will most of the00:39:47
time look like the dog Diabetic00:39:48
comes to you like this with a00:39:50
little sign on his forehead, I'm diabetic, right?00:39:52
Because most of the time he'll have00:39:54
polyuria polydipsia polyf weight loss00:39:58
But he may have three of these00:39:59
signs, what stage of diabetes is he in?00:40:04
advanced stages with already00:40:07
established cataracts, there are patients at the beginning,00:40:10
clients who begin to notice Wow, I00:40:12
think it's strange, huh, Doctor, Bob is00:40:14
drinking more water, he's peeing more,00:40:16
he's getting hungrier but he's still00:40:18
chubby, you know, so depending on the00:40:21
stage, I'll have the constellation of signs00:40:24
that are the four PS of the devil known00:40:27
there as qu PS But it may be that00:40:30
some of these signs are missing, ok, but the thing here00:40:33
is thinking about diabetes will only make00:40:36
sense, write it down, thinking about the00:40:38
diagnosis of diabetes will only start00:40:41
to enter your head when the patient00:40:43
has at least three of these signs00:40:46
polyuria polydipsia polyphagia and weight loss00:40:48
he has this screening in his head he00:40:52
started opening drawers What are the00:40:55
differences for these clinical signs00:40:57
brought us here slowly about the00:41:00
process right diabetes merits with the00:41:03
four signs is very characteristic, you can00:41:05
confirm Ju, no, you can't, you'll00:41:08
have to do hyperglycemia, you'll have to00:41:10
evaluate hyperglycemia with glycosuria,00:41:12
point, but when it comes in absence or00:41:16
confusion as to whether a sign exists or not,00:41:19
other differential diagnoses may00:41:21
come to your mind and then in dependence00:41:24
Of the signs that are00:41:26
present, we will have some more00:41:29
important ones and I will always focus here00:41:32
for you. Start by thinking about three00:41:35
differences. I brought a little more00:41:37
here because it will change the dynamics a little,00:41:39
for example, there is another00:41:43
endocrine disease well known as00:41:46
hyperadrenocorticism, which Today it has fallen00:41:48
into the name of hypercortisolism or00:41:51
Cushing's syndrome, right, which goes with00:41:54
polyuria, with Polydipsia, with polyphagia,00:41:58
but instead of the patient having00:42:01
that constant weight loss, there are even00:42:04
diabetic dogs that you see,00:42:05
cachectic, right, they have that00:42:09
centralized fat on that abdomen, well pendulums,00:42:13
this is more characteristic of00:42:15
hypercortisolism, oh Ju, every patient00:42:18
I see with that00:42:20
barrel abdomen is Cushing's, no, but it comes in as00:42:23
a differentiator Ok, when we00:42:26
talk about chronic kidney disease It seems like00:42:28
it's00:42:30
very, very easy, eh, how do you say it?00:42:34
in our heads, right, the dog that drinks00:42:36
a lot of water pees a lot and is00:42:39
losing weight, we already have a00:42:41
little plug here with chronic kidney disease,00:42:43
but look, people, chronic kidney disease00:42:46
has four stages, right,00:42:48
when we talk about a patient in the00:42:50
stage three or four is when we00:42:53
have important clinical manifestations And00:42:56
then yes, weight loss enters this range00:42:59
of chronic kidney disease, but00:43:01
Normally when the patient with00:43:03
chronic kidney disease is already in stage four,00:43:06
he is actually losing weight00:43:08
by drinking lots of water, doing a lot of peeing, the00:43:11
guy already has difficulty eating00:43:14
these patients of ours, many times00:43:16
we have to stimulate00:43:17
appetite using palatable food,00:43:20
removing nausea, sometimes introducing00:43:23
feeding tubes, so it doesn't00:43:26
really affect the idea of polyphagia, you know, but00:43:29
suddenly you can take care of a dog00:43:31
only with this sign polyuria poid psí00:43:33
weight loss then chronic kidney disease00:43:35
is on your list of three00:43:38
diabetes is included and chronic kidney disease is00:43:41
also going to be fine with00:43:43
hypercortisolism when this is00:43:46
polyphagia00:43:50
hypoadrenalism hypoadrenocorticism and00:43:53
Adson's syndrome, right, we forget a00:43:56
little bit of this disease and it comes, it's00:43:59
a real masquerade, right, we make00:44:02
several diagnoses And then in the end00:44:04
we discover that it was hypo Adreno from00:44:06
the beginning and one of the very important signs00:44:08
of hypo Adreno is weight loss,00:44:10
polydipsia and polyuria, but normally00:44:14
this patient will start to have a00:44:16
gastroenteric sign, vomiting, diarrhea,00:44:19
so polyphagia would also not be something00:44:21
important for this patient, but I00:44:24
say again, treating a dog with00:44:26
mild polyuria, polyuria, polydipsia and00:44:29
weight loss can also put this on the list00:44:32
of Differential diagnoses, there we00:44:34
have a classic, right?00:44:51
megaesophagus, for example, and00:44:54
chronic liver disease will also lead to00:44:57
polyuria, polydipsia, there will be no00:44:59
polyphagia and there will also be weight loss.00:45:07
the00:45:10
final path, when we have00:45:12
theoretical knowledge of each of these00:45:14
diseases and this is what we00:45:16
reinforce in our knowledge when00:45:19
caring for a patient with sign x and y,00:45:22
we will start to list that this is the00:45:24
path that I cure and that is what I learned00:45:27
to do what I want to teach you to00:45:29
think about differentials based on what00:45:32
since Monday I've been telling00:45:33
you this to focus on the main00:45:36
physical findings of the anamnesis, clinical sign00:45:40
and start even before collecting an00:45:42
exam and thinking about my I have I have to think00:45:44
about three differences first, so00:45:47
if this dog arrives with the four signs00:45:50
polyuria polydipsia polyphagia00:45:53
weight loss there is no doubt that diabetes will be00:45:55
my first three names. In fact,00:45:58
sometimes he arrives with polyuria00:45:59
polydipsia and weight loss then I I have00:46:02
to remember kidney disease I have to00:46:03
remember liver disease I have to remember00:46:12
hypoadrenocorticism00:46:13
Ok I just want to show you that00:46:16
sometimes, for example, yesterday's class was00:46:18
pruritus in dogs I have a signal to00:46:21
work on and this opens my00:46:23
paths but when I'm talking about endocrine,00:46:26
I'm not going to have a dog with polyphagia, I'm00:46:28
going to have a dog with polyphagia with00:46:30
polyuria, so then I'm going to need to00:46:32
connect signals and start working00:46:35
based on the set of these signals. I was able00:46:38
to understand what I want to convey to00:46:39
you, I just want Open00:46:42
your minds that other important diseases in your00:46:44
routine will have similar signs, that's fine,00:46:47
but when we actually focus on00:46:51
diabetes, how do we confirm this00:46:53
diagnosis?00:46:59
highlight text anyway00:47:02
to focus on you it only makes sense00:47:05
write down this sentence it only makes sense for me to00:47:07
think about diabetes when there are00:47:09
clinical signs so polish four PS Ok00:47:13
polyuria compensatory polydipsia00:47:16
polyphagia weight loss then with these00:47:20
signs I will ask my patient00:47:22
to return fasting and I'm going to do a G00:47:26
and he has to have fasting hyperglycemia00:47:29
Furthermore, I have to have00:47:31
glycosuria associated Guys, this slide that's on the00:47:34
screen for you is a diagnosis of00:47:36
diabetes, but sometimes this00:47:38
diagnosis is so simple that00:47:40
we want to complicate it And That's when the00:47:43
clinician's first insecurity in00:47:45
endocrinology begins, but wait a minute, I'm00:47:47
talking about a diabetes disease, it's going to be00:47:50
that simple to close this00:47:51
diagnosis, yes, you're going to correlate00:47:54
these signs with Ju, but he has the sign,00:47:56
these signs aren't with00:48:00
fasting hyperglycemia and with glycosuria, notice that00:48:03
in the slide the hyperglycemia is above00:48:06
120, when I have the dog's blood glucose00:48:09
above this value, we already consider00:48:11
this a high value, but this will not be00:48:13
your diabetic patient because remember that00:48:15
I explained to you that glucose is00:48:17
leaving There it will pass through the kidneys the tubule00:48:21
reabsorbs until it reaches a point where it00:48:24
cannot reabsorb and you will have00:48:26
glycosuria which is what confirms the00:48:28
diagnosis with diabetes but00:48:30
to have glycosuria this blood glucose has00:48:33
to be higher than 180 with a blood glucose level00:48:37
Above 180, the tubules exceed00:48:41
their capacity to reabsorb glucose,00:48:43
so there is glycosuria, so00:48:45
you will diagnose a00:48:48
diabetic patient with a dog's blood glucose above00:48:51
180, right, because he will have a blood glucose00:48:53
high enough to have00:48:56
glycosuria and the set of information00:48:59
will close swear, I have a patient00:49:01
like this who does not have glycosuria, I did00:49:03
a urinalysis and he is not diabetic, look for00:49:06
another disease that has these signs00:49:09
that has hyperglycemia. Maybe00:49:11
hypercortisolism is even a good00:49:13
candidate for this, or any00:49:16
chronic disease that is there with00:49:18
high cortisol that justify the signs because00:49:21
it's diabetes, it's not because there's no00:49:22
glycosuria, that's ok. I understand00:49:25
that, so diagnosing diabetes is00:49:27
very simple, right? And the fasting we00:49:30
're going to do is what.00:49:35
ok we're just going to ask for an00:49:37
8 hour food fast00:49:43
Ok so let's take care of this dog00:49:46
we already know we're already here oh00:49:49
Crack to know that the clinical signs00:49:52
are these here polyuria polydipsia00:49:55
polyphagia and weight loss what in the00:49:58
exam physical I can see nothing in a00:50:00
diabetic patient, he may have a00:50:03
perfect physical examination, he may have00:50:05
a marked weight loss, so you can00:50:08
already classify him nutritionally00:50:10
as a thin or even cachectic patient,00:50:13
he may already have the development of00:50:15
cataracts and he may even have his00:50:18
abdominal palpation has hepatomegaly00:50:21
precisely because of the deposition there, you know,00:50:25
of gluconeogenesis, anyway, we00:50:27
start to observe the distension of the00:50:29
liver tissue, this can happen, but00:50:32
see, he may be in perfect physical examination,00:50:34
but Ju, what if he's diabetic,00:50:37
such a serious disease, he doesn't there's nothing00:50:39
physically It's good that you're getting it at the00:50:40
beginning of the disease You know why I00:50:43
think diabetes Sometimes it's a00:50:46
thorn in the side of the clinician because00:50:49
normally Look how now I made a00:50:51
link here in my head because eh ol Look00:50:55
at lack of clarity again in terms of00:50:57
technical knowledge, you know why Because00:50:59
your client, Bob, the client, or he00:51:03
has obviously heard about diabetes in00:51:05
his life, right, or often he has a00:51:08
relative, he is diabetic So there is00:51:12
often a certain dominance between00:51:15
quotation marks because they also think they know00:51:17
but they don't know [ __ ], you know, sometimes there is00:51:19
a certain mastery of00:51:21
theoretical knowledge about diabetes and this makes00:51:24
the Clinician more insecure.00:51:25
I'm going to talk about a disease that the guy already00:51:27
has, right?00:51:30
Keep your head up, you are the00:51:32
Clinician Ok, let's know the theory and it doesn't00:51:36
even matter if the doctor is an endocrin, if00:51:39
Bob, the client, is an00:51:41
endocrinologist, let's give him a [ __ ], we'll tell00:51:43
him what happens in the00:51:45
veterinary clinic, what he thinks of00:51:47
human medicine he saves it for his patients, ok,00:51:51
so let's go, trust, posture,00:51:53
changing already. I changed my posture here,00:51:56
so fasting has to be food00:51:57
for 8 hours and closes the diagnosis with00:52:00
hyperglycemia, glycosuria, we have doubts about00:52:03
diagnosing diabetes, let's clear up00:52:05
these doubts, now let's go I'll see here in the00:52:07
chat if you have any questions about diagnosing00:52:10
diabetes, we're going to have ophthalmology ah in the00:52:13
mentoring, right, we're going to have a00:52:15
guest, a specialist talking about the00:52:17
approach to ophthalmology, OK. It's because00:52:21
in fact ophthalmology has a lot of things that00:52:23
we didn't have in the Mentoring like this,00:52:25
people missed it a lot, we00:52:26
added it to this class, ok Ah, João00:52:30
explained, João is our team Hey00:52:31
guys, João is our right and00:52:33
left hand man, he said, here we will have a00:52:35
guest specialist who will talk00:52:37
about basic exams that everyone should00:52:39
take right, those are the ones we do on a00:52:42
routine basis, João and I, right, say hi to me, oh00:52:45
well, João, let's go, I'll send João,00:52:48
the fasting for blood glucose 8 hours out of 8 hours,00:52:52
Manu, we don't even extend it much, okay,00:52:55
we're going to do one of 8 hours answered00:52:57
Thank you, Janderson said even if the00:53:00
blood glucose level is above00:53:03
180, even if the blood glucose level is above00:53:06
180, in cases of non-diabetes,00:53:09
glycosuria will occur, that's a very good00:53:11
question, Janderson, if the blood glucose level exceeded00:53:14
180, yes, glycosuria will happen Ju and00:53:17
now I'm confused No, you weren't00:53:19
confused, that's why it can happen in00:53:22
some diseases without clinical signs.00:53:24
Look, we're sure that00:53:26
clinical signs should always be the basis for00:53:29
you to think about diabetics. Ok, and another00:53:31
situation is that these diseases can00:53:35
generate hyperglycemia above 180 with00:53:38
glycosuria it is not persistent that's why it does00:53:42
n't generate clinical signs I don't00:53:44
know if I was Clara why did you00:53:45
say that to me Ju but wait a minute00:53:47
he will have a Clinical sign because he has00:53:49
high hyperglycemia He has glycosuria00:53:51
he will have polyuria and polydipsia this is00:53:53
a correct thought but the other00:53:55
diseases that can cause this00:53:57
Janderson will not be persistent So it00:54:00
will not generate the Clinical signal see if it is00:54:02
understood and we will only00:54:04
think about diabetes in the Clinical signal Ok00:54:08
Roberta said Here for me, the00:54:10
fructosamine dosage helps with this diagnosis R,00:54:12
let's go fructosamine, what is it,00:54:14
let me have my ride here,00:54:16
what is fructosamine, fructosamine is a00:54:18
glycated protein, that is, linked with00:54:20
glucose, right, like our00:54:23
most abundant protein? I said it right, this00:54:25
is abundant, it's Albumin, we use the00:54:29
half-life, the half-life of00:54:31
Albumin represents fructosamine,00:54:33
which I mean, when we donate00:54:35
fructosamine, we have a00:54:38
relative value of what the00:54:41
patient's blood glucose concentration was in the last 14 to00:54:44
21 days then you will say this to me00:54:47
Ju So this is perfect this is00:54:48
brilliant This is very good in fact right00:54:51
especially for patients who are00:54:53
very stressed so there are dogs that00:54:56
are very aggressive if you are going to do00:54:58
a blood glucose test on this patient in the time to00:54:59
collect blood he wants to eat your head00:55:02
his blood sugar increases cats This is an00:55:04
absolute truth for many of the cats00:55:07
we treat not because of aggression00:55:09
but out of fear because they are scared and00:55:12
this reflects in the increase in blood sugar and00:55:15
this masks our diagnosis so00:55:17
fructosamine is an alternative that00:55:21
we have so we can check the00:55:23
values of the last 14 and 21 days, this00:55:25
dog, this cat, didn't live 14 days00:55:27
at the peak of stress, right?00:55:36
like fructosamine it is an Albumin00:55:38
linked to glucose if I have a disease00:55:41
where Albumin interferes I don't know00:55:44
where I have hypoalbuminemia or00:55:47
for example in hypothyroidism where I00:55:49
have this CL how do they talk about00:55:52
protein cleansing I forgot what The00:55:55
technical term for this is that it has a00:55:57
different time period, fructosamine will give00:55:59
unreliable values, you know, it's00:56:02
not such a wonderful thing, everything00:56:03
will be resolved in fructosamine, no, it00:56:06
will be used in these special conditions00:56:08
in which I'm suspecting diabetes00:56:10
because there are clinical signs. But I'm a00:56:13
little confused with the process,00:56:15
it's great, with the00:56:17
stress process that my patient has in the00:56:19
outpatient clinic, most of our00:56:22
patients won't need00:56:23
fructosamine for diagnosis, okay, I don't00:56:25
know if I did myself, Clara, but that's it. Ok, if00:56:28
I didn't, let me know here, Jessica00:56:30
said to Blood Glucose that you use a00:56:38
glucometer, it gives errors of up to 20% of the00:56:41
real blood glucose value, so the most00:56:45
wonderful thing in the world would be for us to have00:56:47
laboratory values, but I have00:56:49
to collect them and I have what to process because00:56:51
if this sample of mine stays there on the bench for00:56:53
half an hour an hour It takes two hours to be00:56:55
processed, the blood glucose is already consumed and the00:56:58
values are already completely wrong,00:57:00
like me Juliana doesn't have a00:57:03
collection routine, the blood enters the laboratory and00:57:05
immediately processes the blood test00:57:08
I only use the glucometer, Manu,00:57:12
professor, in addition to diabetic cholelithiasis, he00:57:15
may have chronic liver disease due00:57:17
to diabetes, he may have00:57:18
liver disease, he may have pancreas,00:57:22
exocrine pancreatic disease, he may have00:57:25
comorbidities, yes, over time, you know, with00:57:28
chronic disease, but we will be00:57:30
concerned Manu with diseases that00:57:32
are very closely linked to00:57:35
diabetes, such as periodontal disease and00:57:38
urinary tract infection. These are the ones00:57:40
that we monitor in the day to day life of00:57:41
diabetics. At00:57:48
first I don't know if it's Iara or if it's Lara00:57:51
I have a vision problem here But00:57:53
you asked me Iara or Lara00:57:56
glycated hemoglobin has fallen into00:57:58
disuse because it's a human kit00:58:01
So it gives me values that aren't very00:58:03
reliable so Among these choices,00:58:05
fructosamine is the best, it is necessary00:58:08
in the diagnosis, if I have a dog00:58:11
with clinical signs of00:58:13
fasting hyperglycemia and glycosuria, I do not need00:58:15
fructosamine, I have already confirmed the00:58:16
diagnosis, okay, that's it,00:58:20
so let's move on to our second part, which00:58:23
is treating diagnosis, you saw that it00:58:26
is simple, right? We just can't00:58:28
complicate things and don't forget any step00:58:31
clinical signs fasting hyperglycemia00:58:34
with glycosuria, then when we talk about00:58:37
treatment, we see the Clinician getting all00:58:39
confused, right? and what are the main ones?00:58:42
problems that we observe in the00:58:44
clinical routine of this fear of treating a00:58:47
diabetic patient, a lot of people Focus on the00:58:51
veterinarian, really on the lack of00:58:54
knowledge, the fear of having an00:58:56
endocrinopathies on our hands, right Why00:58:59
Because we often, often00:59:01
not in our entire lives the We are00:59:03
super immediate, right, we want to do00:59:05
something, we want it to work, we have to have the00:59:07
result today, it's not like that, and then when00:59:10
we don't, we're still a little afraid of00:59:12
that disease, this anxiety00:59:14
creates even more distress in our00:59:17
heads, so we don't have clarity on what00:59:20
we expect in00:59:22
diabetic therapy, see a diabetic dog can00:59:24
have a normal life, yes, this is something00:59:27
we already talk about De Cara to our00:59:29
client in the consultation, right, because when00:59:31
we say that the patient is diabetic00:59:33
What do we notice in the office00:59:34
some Some clients some Bob00:59:37
clients are fine, right? Some cry, they00:59:39
are sad, they think the dog is going to00:59:41
lose its paw because it will have a wound00:59:43
on the tip because the mother had it00:59:45
because an uncle had it died, he was very00:59:48
ill and not in the veterinary routine,00:59:51
our patients live much less, you know, the00:59:54
survival time, not because he is00:59:56
diabetic, because the dog lives less time,00:59:58
so many things related to01:00:00
complications in human medicine, we do01:00:02
n't even see a diabetic dog in veterinary medicine,01:00:05
he It is possible to have a01:00:07
normal life but he will have some01:00:11
differences because he will receive01:00:13
medication but he will have a quality01:00:15
of life similar to a non-diabetic dog.01:00:18
This is what we look for in therapy but01:00:20
pay attention to this and this will not be01:00:23
achieved. in a week this01:00:25
is often not achieved after a month of01:00:27
starting therapy and we Clinicians have01:00:30
to reduce the level of anxiety and say01:00:33
this at the first consultation So01:00:35
look, we have a disease now with01:00:38
Bob Dog, which is a disease chronic, we01:00:41
have no expectation of curing a01:00:43
diabetic dog, we just want this dog01:00:46
to have a quality of life and01:00:47
disease control, so we will01:00:50
work especially personally on01:00:53
four fronts, one is the use of insulin, the01:00:57
other is practice. of physical exercise the01:01:00
other is a specific diet and the other is01:01:04
clinical monitoring congratulations you01:01:06
now have a patient for the rest of01:01:08
his life every three months our01:01:11
diabetic patient has to visit us because it is01:01:14
a chronic disease so oh Ju so01:01:16
life his is just like another dog, that01:01:18
's not why, right? Because he's going to receive a01:01:20
diet, I'm saying in a perfect therapy,01:01:23
okay, I know it can't be done in01:01:25
everyone, but in a perfect therapy and and01:01:27
When are we going to talk about01:01:29
perfect therapy in all patients when I01:01:32
diagnose and sit down with Bob the client,01:01:34
my explanation of treatment is01:01:37
exactly the same for all Bob01:01:40
clients, we will adapt to01:01:43
that client's Life from that patient01:01:45
to arrive at the best vision for that01:01:47
moment of our Clinical case but at the01:01:50
beginning our conduct will be the same,01:01:52
our conversation will be the same as we just want to01:01:54
do the perfect therapy, right? So01:01:57
what will change in Bob Filho's life?01:02:05
injectable medication and he will come to the vet01:02:08
every three months or if something along the01:02:10
way goes wrong he will come sooner but01:02:13
he will be a dog that will sleep well01:02:15
which will reduce clinical signs and I mean it01:02:18
will even put an end to the01:02:21
clinical signs he It's a dog that will01:02:23
play that will have food that won't01:02:26
get sick to its stomach, it won't have any01:02:27
of that, it will have a normal quality of life,01:02:29
but Bob, client, I need01:02:32
Bob the dog to reach01:02:36
therapeutic stabilization, which I will01:02:38
need. I will need to understand what01:02:41
Bob Dog's body needs, so he will01:02:44
take insulin. I need to know01:02:47
if he will adapt well to this type of01:02:49
insulin. I will apply01:02:51
the dose every 12 hours that I am going to take.01:02:55
I will need to understand if the family01:02:57
will be able to have an01:02:59
exercise routine. I will be able to understand01:03:01
if he will01:03:03
receive it financially. Is it possible to go on01:03:05
a therapeutic commercial diet?01:03:14
It was Fê who commented to me on01:03:16
Monday here, I think it was01:03:18
Fernanda. Sorry if it wasn't her, she said it01:03:20
like this, I think it's really bad to keep01:03:22
putting it up for the client to choose what it will01:03:23
be or not, people understand, this is a01:03:26
chronic disease if I keep putting it in. you have to01:03:29
do this you have to do that oh you did01:03:32
n't do that how come you didn't do that01:03:34
the client doesn't stay with me and I and at the01:03:37
end of the day there are many01:03:39
implications and not having a client as a01:03:41
financial one but at the end of the day01:03:44
one of our main goals01:03:46
when you dreamed there that you were going to be01:03:48
a Clinician, remember months or years back in01:03:51
your life when you thought man, I ca01:03:53
n't believe I passed the entrance exam01:03:55
to become a veterinarian, then in the middle of01:03:57
graduation you thought, man, I'm going to be a01:03:59
Clinician at that moment in your life. life you01:04:01
could even think about money but01:04:03
at that moment in your life what did01:04:04
you think most man I'm going to help01:04:07
dogs and cats that's not what01:04:09
we're for01:04:13
see01:04:16
my dog arrive all finished and whatever01:04:19
Days, weeks, why not months after01:04:22
I'm treating To stop being immediate,01:04:24
it's about that, illnesses are chronic,01:04:28
therapies are chronic, improvements01:04:31
take time to happen, many times you01:04:33
're not bad, it's simply because you're not01:04:35
There is a rule there, do this dose,01:04:38
apply this schedule, there is no such thing,01:04:40
we will have to understand in that01:04:42
family for that patient what01:04:44
the context will be, understand, and then, stop01:04:48
this rigid thing,01:04:51
flex, flex, don't flex with01:04:54
your client. Of course, I'm not telling01:04:56
you to do anything I'm01:04:57
saying within the Clinical context so01:05:00
that in the end that veterinarian that01:05:02
veterinarian that you idealized to help01:05:04
your patients you will succeed01:05:06
man you will01:05:08
achieve it you just have to remove that01:05:11
anxiety and you have to tell Bob the01:05:13
client in the first consultation what do01:05:14
you expect? So what's my01:05:16
conversation, man, we're going to change several01:05:18
things, Bob, the client, my idea here01:05:21
is to change three little things in Bob C's life,01:05:24
diet, exercise and introducing insulin,01:05:27
you understand, it's just not easy for01:05:31
client, this guys, it's not easy for01:05:34
many clients to pick up a syringe, you're a01:05:36
technician, you do a subcutaneous scan, your01:05:39
client doesn't often, so take it01:05:42
easy, let's prioritize what's most01:05:45
important, so in the first consultation01:05:47
with Bob, client, my conversation is01:05:50
standardized like What diabetes is,01:05:53
I show him how we confirmed the01:05:55
diagnosis, right, yesterday I was even seeing it01:05:57
on Instagram, it was just one, it was super01:06:00
funny, a girl, a01:06:02
veterinarian, talking about the types of01:06:03
veterinarians, did you see this? It was the01:06:06
veterinarian, Cat friendly, I really01:06:08
identified with it. right, putting a little sachet,01:06:10
arranging the little table, it's like it's real, that01:06:13
was a veterinarian, I don't01:06:16
remember which one and the second one was a01:06:18
professor veterinarian who takes a piece of paper01:06:20
and goes and I do it Exactly that, so I01:06:22
get the exams, show the exams Oh, you01:06:25
spent with this exam but it's here,01:06:26
we confirmed hyperglycemia, hard glucose01:06:29
with these signs, so my first01:06:31
phase is after confirming the diagnosis,01:06:34
that's fine, we established01:06:36
Bob the dog's diagnosis, he has01:06:38
diabetes, now let's move on to the second side01:06:40
of our conversation here, therapy See the01:06:43
long term Bob client we are going to01:06:46
make Bob eat a01:06:49
special diet this special diet for01:06:52
diabetics which can be homemade or01:06:55
a therapeutic food for diabetics01:06:58
this food Bob client it will help01:07:01
keep his body's glucose level01:07:06
stable Furthermore, Bob the client, we01:07:09
will put him in his life. If that is01:07:12
possible, an exercise routine, there is no01:07:15
point in Bob the dog going for a01:07:17
walk on Saturday, that is terrible,01:07:20
diabetic dogs that suddenly at the01:07:22
weekend the client is in a good place.01:07:24
So he wants to walk with01:07:26
his dog, he's going to pick it up and go to the park for a01:07:28
walk because it's good to exercise01:07:30
for diabetes and it's because when01:07:32
he moves the insulin that comes from the01:07:35
application site is more easily01:07:38
distributed beyond, you know, the process of01:07:41
fact of muscular physiotherapy that01:07:43
exercise promotes so the01:07:46
exercise routine is important but not so the guy01:07:49
who is diabetic who does a01:07:51
totally rough and different routine on one day01:07:54
of the week he has01:07:55
hypoglycemia So he won't go for a01:07:58
walk with Bob the dog, he will being01:08:00
every day at 7 am is a routine01:08:02
of life let's do this let's go This will01:08:05
be the second little ball and another little01:08:06
ball will be the insulin plan all of01:08:09
this takes time folks so this is the01:08:11
first thing you're going to leave here01:08:13
today from my Bob's office, the client,01:08:16
understands how to apply01:08:18
insulin, I'm going out to write 70001:08:21
prescriptions. No, I'm saying, hey, today I01:08:24
'm going to ask you to buy this01:08:25
insulin, we're going to apply this01:08:28
amount, come here with me, let's go to the01:08:30
service table, I'm going to get a01:08:32
syringe with physiological solution I will01:08:35
teach him how to pull the syringe01:08:37
I will teach him how to apply it So01:08:40
you go there especially If it is01:08:42
possible from the rib cage region in the01:08:45
morning on the right side at night on the01:08:48
left side standardize sides so that he01:08:50
does it he has a routine protocols this01:08:53
is easier to place on the01:08:55
client's head you will apply alcohol against01:08:57
the hair you will pull the skin this way01:09:00
you will administer it if the guy has more01:09:02
dexterity you will pull the plunger to01:09:04
see if blood comes like you applying01:09:06
a subcutaneous you you're going to administer01:09:08
that one, you're going to count to 10 And then you're going to take out01:09:12
the syringe and the needle, you won't need to01:09:15
massage any of that, let's go, you01:09:18
understand. Now I take another01:09:21
physiological solution in the syringe and ask him to01:09:23
do it on the other side to see if he's01:09:24
applying it correctly If he's doing it right,01:09:26
man, this is the first01:09:29
consultation, this is super difficult for your01:09:31
client and then when he's leaving01:09:34
I tell him like, buy this01:09:35
food because I like food, right, buy01:09:38
this food, put it in Bob's life,01:09:40
see. If he adapts to this, I don't even want01:09:43
him to eat food from tomorrow,01:09:45
it's not ok, let's start this01:09:49
insulin process, let's see if Bob01:09:51
will accept this brand of food, you know,01:09:54
in the meantime, when he stops01:09:57
losing weight, if This is an01:09:59
important sign from your patient, so now01:10:02
let's make this diet more01:10:04
restricted so that a correct diet01:10:06
can do this, let's introduce an01:10:09
exercise routine into his life, if01:10:12
everything is very good, people, if01:10:14
we get the insulin dose right01:10:16
first time If Bob the dog accepts the01:10:18
food if Bob the client started the01:10:20
journey I'll be here for at least01:10:23
a month a month and a half to talk about beauty01:10:25
this is the life of the moment for Bob the dog and the01:10:28
family Bob Ok So what's the life that follow in01:10:32
three months you will come back and we will01:10:34
do a new follow-up or if any01:10:36
signs appear but there are times when01:10:39
this happens here, I take the01:10:42
insulin dose the clinical signs are the same01:10:44
the dog did not have any01:10:47
clinical improvement so I I have to see if I'm going to01:10:48
readjust the dose and that's normal, it's not01:10:51
because you don't know endocrine. This will01:10:54
happen depending on the patient's type,01:10:56
including your01:10:59
client's ineffectiveness in applying01:11:01
insulin. I was able to understand this, so01:11:03
see that the path of therapy that I01:11:05
What I want to show you here is that01:11:07
you also become aware that this01:11:09
is going to be done01:11:11
slowly, we don't have an01:11:13
emergency situation, this guy is not in01:11:16
diabetic ketoacidosis01:11:19
Diabetic ketoacidosis is an emergency condition, it's01:11:20
not possible to, like, let's see the01:11:22
little stars being born. No,01:11:26
diabetic ketoacidosis will occur in a patient who will01:11:28
have other signs, it is a diabetic person who is01:11:30
known to be diabetic before or who arrives01:11:32
at the ketoacidosis crisis with a hint of01:11:35
hyperglycemia with hard glucose and01:11:37
ketone bodies, it is often possible to01:11:39
measure it on the glucometer itself, right,01:11:42
butyrate. But beyond that, he's a guy who01:11:44
arrives dehydrated with nothing to do01:11:47
with the signs of diabetes, dehydrated with01:11:49
vomiting, anorexia, this guy is an insect,01:11:52
acidosis, no, this guy is an internist,01:11:55
this guy, I'm going to put fluids, this01:11:57
guy, I'm going to control potassium, this one. Dude,01:11:59
I'm going to take regular insulin,01:12:01
which will lower this blood sugar level faster.01:12:04
That's another situation. I'm talking about01:12:06
diabetics who have 300 to 400 blood sugar levels in01:12:09
their office.01:12:14
already diagnosed,01:12:16
now let's step by step institute01:12:19
therapy so that we can reach01:12:21
stabilization and achieve what the client01:12:24
wants, which is a normal life And then look at the01:12:27
first consultation still telling Bob the01:12:29
client pay01:12:31
attention, Bob the client will start to01:12:35
get crazy How to evaluate the improvement of01:12:37
your Bob dog at home for me01:12:40
Clinician, the first thing I need to01:12:42
start observing for improvement is that he01:12:44
stops losing weight, so pay01:12:47
attention once again, not because01:12:49
I said that in the mentoring class01:12:50
It wasn't here, pay attention here to the01:12:52
importance of you having your patient's weight,01:12:56
man, stop using01:12:58
last week's weight, look and talk, hmm,01:13:01
I think it's 14.501:13:03
14650, no scales, scales will weigh the01:13:07
dog every time this diabetic01:13:09
arrives you will weigh because you have01:13:12
this specific disease but this applies01:13:13
to several examples, hey,01:13:16
weight loss, stopping losing weight is the first01:13:19
sign that tells you Oops We are heading in01:13:21
a good direction01:13:23
now, I don't know, I'm treating this01:13:25
dog, it continues to lose weight Oops Do01:13:28
I have it? Is this insulin01:13:29
going well for my dog? Am I01:13:32
on a good dose? These are the doubts that01:13:34
start to arise that we're going to talk about01:13:36
now, okay,01:13:39
okay, and here comes this, which is the hook01:13:42
of what I'm Telling you that it's the01:13:46
glycemic curve, pay attention, have you ever01:13:48
heard of the glycemic curve,01:13:51
hey Ju, when a very01:13:55
common question is I started treating a diabetic,01:13:58
do I do the curve when I do the curve, how do01:14:00
we pay attention to the glycemic curve?01:14:04
came to revolutionize our lives01:14:08
many years ago because when I graduated01:14:11
when I started to provide services, I even did01:14:13
this on my Instagram feed01:14:15
last week, like Clinical, have you ever fallen into01:14:17
that madness of asking your client01:14:20
to buy a glucometer, have you already done this?01:14:22
People, our lives01:14:25
become oh my God because it's like this, if you01:14:28
get one If you get one, let's01:14:30
imagine that you're not diabetic.01:14:38
I'm sick01:14:41
because people's blood sugar fluctuates a lot01:14:43
throughout the day, but it's very low and it's01:14:46
high up there, you say, oh my God, this has01:14:49
something to do with everything, your sleep,01:14:51
what you eat, how you did01:14:54
physical activity, everything fluctuates in01:14:56
blood sugar so take note of this as well, having a01:15:01
low blood glucose value in diabetics doesn't01:15:05
say01:15:06
anything Ju for the love of God I'm here01:15:10
with a diabetic dog Bob fil I01:15:12
diagnosed him and then he's been on insulin for a week and01:15:14
then he came here at 1001:15:16
in the morning I did a blood sugar test, it's 5, it's01:15:18
High, it didn't even show it on the glucometer, it's so01:15:21
high, I'm desperate Don't01:15:24
do that, you know why, you can't even01:15:26
explain this to the client, the client01:15:29
won't understand this litany that01:15:32
blood glucose fluctuates throughout the day because the01:15:34
guy is desperate seeing a high blood sugar01:15:36
and if he's at his house then and01:15:38
you said it's cool the blood sugar is01:15:40
up to 250 go there the dog has 32001:15:44
Doctor today Bob at 8 in the morning was01:15:46
320 Doctor today 1 o'clock man01:15:50
your life is going to become crazy so don't01:15:52
do that Don't do that and don't do that01:15:55
or you in the office because you having01:15:57
a blood glucose value doesn't tell you01:16:00
anything that's why there is the glycemic curve the01:16:03
glycemic curve she will have another idea01:16:06
the glycemic curve I will mimic these01:16:08
fluctuations throughout the day but over a01:16:11
longer period of time the glycemic curve01:16:15
is the one that I, for example, let's01:16:17
imagine that Bob the dog receives insulin at01:16:20
8 am, so the glycemic curve I01:16:23
will monitor this patient for 1201:16:26
hours, so how do you do the glycemic curve01:16:28
for at least 12 hours, right? There are01:16:31
devices that you leave on for01:16:33
days measuring the patient's glycemia, this01:16:36
is an option, right?01:16:44
blood and see the glucose within01:16:48
Bob Dog's normal lifespan, then 8 hours01:16:51
he does the insulin beauty 7 7:30 in the01:16:54
morning you will measure blood glucose, you will01:16:56
offer Bob Dog food, you will apply01:16:59
Bob Dog's insulin and the01:17:01
curve will start then 8 am faith blood glucose 10 am noon01:17:05
2 pm 4 pm 601:17:09
pm 8 pm 12 hours of measurement01:17:12
don't forget to check the value before01:17:14
applying insulin too ok 12 hours of01:17:18
measurement of the glycemic curve And then this01:17:20
will also be one area won't be01:17:23
cute there Here it is Look how cute it's01:17:25
getting bigger it's regressing no because it01:17:26
depends on what happened in Bob the01:17:28
dog's life he ran a lot that day he01:17:31
slept all afternoon he ate like01:17:33
a pig I don't know, everything will fluctuate01:17:36
Glycemic levels are fine, even in a controlled environment,01:17:38
but what is the idea of the01:17:41
glycemic curve? I'm going to do the glycemic curve01:17:44
to find out if my insulin works,01:17:46
if the insulin time is adequate, and if01:17:49
I have to adjust the01:17:51
dose, then go back to what I said.01:17:53
For you, I know it's a lot of01:17:55
topics for us to talk about in one hour, right?01:17:57
I know that and the immersion brings this so01:18:00
that we can make a boom in our heads,01:18:02
but I have to bring these01:18:03
important points so that we can stop making01:18:05
confusion in the office and think that01:18:07
diabetes is a monster No, we just01:18:09
have to have this clarity in the information,01:18:12
so pay attention to what I'm telling01:18:13
you, a guy who is using01:18:16
insulin, how do I change his dose,01:18:19
you're just going to change the dose of this dog01:18:21
after the glycemic curve because what is01:18:24
the function write down what is the function of the01:18:26
glycemic curve know if01:18:28
this dog's insulin is ok if the type of01:18:30
insulin is ok know if the01:18:33
application interval is ok and know if you will01:18:36
readjust the dose, so it only makes sense01:18:39
to do this after the glycemic curve, but01:18:43
I didn't tell you that,01:18:45
diabetic therapy is all about taking it slow, going slowly,01:18:49
right, starting the treatment The result will come01:18:52
with days That means people,01:18:55
when you start therapy or01:18:58
when you changed your insulin dose,01:19:01
anyway, when you are at that moment01:19:04
when you have just readjusted or started01:19:06
insulin, I need at least 7 days01:19:11
for this body to understand this new dose01:19:14
or the start of the medication, so it only makes01:19:17
sense for me to readjust the dose after S days01:19:22
since I started or changed the01:19:25
insulin dose, let's summarize this in a01:19:28
more succinct way for you, glycemic curve01:19:31
So let's go diagnose, I need to01:19:33
do a glycemic curve, no, it has01:19:34
nothing to do with the diagnosis.01:19:36
Diagnosis is a clinical sign of01:19:38
hyperglycemia with fasting and glycosuria01:19:40
that's the good diagnosis I'm going to start01:19:43
treating Bob client These are the three little01:19:46
balls that we're going to work on but01:19:48
today our focus is which one on insulin01:19:50
We're going to teach the guy how to pull it we're going to teach01:19:53
the guy to apply it with serum and he's going to buy01:19:55
insulin and you will start doing it at home01:19:57
Establish schedules What is your life like Bob01:20:00
client Ah I wake up at 6 am and get01:20:02
home from work at 4 so you will01:20:04
apply 6 am and 6 pm take a01:20:07
break every 12 hours which is the dose01:20:09
that I'm going to give you here that is01:20:11
recommended for dogs OK, okay, let's01:20:15
see if he managed to understand the01:20:16
application, I was in doubt as to whether the guy01:20:19
understood, ask him to be there tomorrow morning01:20:21
and apply it in front of you,01:20:23
man, make sure he knows how01:20:25
pull and if a little ball comes into the01:20:27
syringe what is it going to do all01:20:29
this we have to worry about01:20:31
what we see the most you know01:20:34
what it is now I'm going now Some can01:20:36
follow this thought here Some01:20:38
will get it wrong if whoever gets the bug Don't worry,01:20:40
okay, but I want to tell you that01:20:42
the complexity of the problem is there,01:20:45
most clinicians readjust the dose01:20:48
because when they receive the patient they think01:20:50
there is hyperglycemia, but But01:20:52
this is an effect, which is an effect,01:20:55
you started a therapy, blood glucose01:20:58
dropped so much that in the physiological rebound effect01:21:00
there was hyperglycemia01:21:03
And then when you get that01:21:04
isolated event of hyperglycemia you think the01:21:06
insulin dose is low but in01:21:08
fact it is high enough01:21:11
to cause hypoglycemia and the body01:21:13
tries to tell the vet Wake up, my dear,01:21:16
it's going to kill the01:21:18
dog, this suog effect is very serious and01:21:22
we're increasing the dose, but look01:21:24
here, Juliana, I have a patient01:21:25
receiving very high doses and he doesn't01:21:27
respond well, man, there's the technical error,01:21:29
you made a mistake when readjusting the dose,01:21:31
why? There was no glycemic curve01:21:34
because the dose was readjusted with a01:21:36
single high blood glucose level, that's not how you start01:21:39
therapy, calculate correctly and see that until01:21:44
I change the insulin dose, folks, until I01:21:46
Juliana say great, let's use it because01:21:48
you'll see that my01:21:50
insulin doses are very low I'm already super01:21:53
careful not to cause hypoglycemia01:21:55
than a diabetic dies of01:21:57
ketoacidosis which is a complication but01:22:01
most of your dogs don't God01:22:03
save me from yours no but the world where they01:22:06
die from veterinary technical error01:22:08
they die from01:22:09
hypoglycemia hypoglycemia it kills much01:22:12
more in the routine Real clinic why01:22:15
Because of an error in insulin therapy then the01:22:17
Clinician despairs and wants to forward it,01:22:19
it's not simple, start slowly, the ones I01:22:22
'm going to give you are the ones I use01:22:25
very low, maybe you'll have to01:22:27
adjust this dose including, but pay01:22:29
attention so I can get to the point where I'm talking about01:22:31
Bob, client Let's increase the dose, man,01:22:35
a lot of things were discarded, is he01:22:37
homogenizing the insulin correctly, is01:22:40
he mine, is the volume low, is01:22:43
he?01:22:45
Are you seeing what you are01:22:47
applying? Are there air bubbles coming01:22:49
in place of the insulin? Are you01:22:51
counting up to 10 when applying01:22:53
the needle? Are01:22:55
you throwing this insulin01:22:57
into the environment when applying the needle? The volume is small, you01:22:59
can't even see that the dog has wet I01:23:01
wonder if the dog is letting him01:23:03
apply it I wonder if he's remembering to01:23:05
apply it, healthy guy V Is the01:23:07
insulin out of date Look at so many01:23:10
things that we have to think about beforehand01:23:12
to say Okay, I need to increase the01:23:14
dose because increasing the dose,01:23:16
increasing the dose is what will kill the01:23:18
patient Ok So this is a concern01:23:21
that we have to have but we just have to be01:23:23
careful that this will not happen so01:23:25
the glycemic curve So OK,01:23:28
diagnosis, I treated, I gave insulin Ju,01:23:31
I can do a glycemic curve01:23:33
tomorrow, you're scared, do it, but not01:23:37
thinking that the dose will be bad,01:23:40
thinking that, oh, Ju, I'm very scared,01:23:43
pay attention, it's mine, the bad case I01:23:45
brought from the mentor It's exactly this,01:23:47
she started in our community,01:23:50
she diagnosed diabetes, so we01:23:53
talked about the doses, I helped her01:23:55
make the recipe, she said this,01:23:57
beauty teacher, but I'm very scared01:23:59
because it's my first patient that I've01:24:00
treated, I'm with very scared because in01:24:02
class I talk a lot about01:24:03
hypoglycemia, you know, killing hypoglycemia,01:24:06
I'm very scared of that, are you01:24:08
scared, do a glycemic curve on the first01:24:10
day of treatment but for what01:24:13
purpose just to know if there is01:24:15
hypoglycemia Because if there is you will01:24:18
do a smaller dose just for that reason, but01:24:21
then, well, I'll arrive later and01:24:23
tell her about her case better, but I want to01:24:25
draw attention here to the glycemic curve.01:24:27
When are we going to do it? If you've just01:24:30
readjusted the dose, if you've just01:24:33
started to insulin therapy you01:24:35
can create a glycemic curve but it01:24:38
will only have one purpose, which is if01:24:41
your patient has hypoglycemia, that is, if01:24:45
at some point in this curve the blood glucose01:24:47
is below 80, this shows you that the01:24:50
dose is high, okay, there you go01:24:52
reducing the insulin dose is the only thing01:24:55
you need to pay attention to is that01:24:58
the curve on the first01:25:01
day of treatment will be useful now so I can know if it's01:25:04
going well if it's maintaining good blood01:25:06
glucose concentrations, that is, I01:25:09
started treatment on that01:25:11
Bob the client's first day let's imagine that Bob the01:25:13
client understood everything Everything is perfect01:25:15
I'm super sure that this is my01:25:16
conversation with him come back I like to01:25:19
do it in 10 days okay but come back in a01:25:21
week Bob the dog's return will be01:25:24
in a week this week he will do01:25:27
a curve on this return I'm going to do a01:25:29
glycemic curve then it's not too early,01:25:32
there's not a week of treatment I'm going to01:25:34
do the curve and see what the curve is like01:25:36
but I'm not going to go crazy adjusting the01:25:38
dose I'm going to weigh the Bob dog He kept his01:25:42
weight okay, let's keep this dose Let's01:25:44
see him in another 15 days with this calmness,01:25:46
this coldness OK now, no, he01:25:49
decompensated, the signs got worse, he01:25:52
lost a lot of weight, the glycemic curve increases,01:25:55
the blood glucose level is very high on the curve, Let's01:25:58
increase the dose then is the time when I can01:26:00
increase it has been at least a week of01:26:02
treatment the curve is showing me that the01:26:05
Nadir of the curve the blood01:26:07
glucose concentration is high with that dose So01:26:09
let's change this we understand the01:26:12
dose readjustment maneuver So what? we01:26:15
continue when I'm doing very well on the dose01:26:18
Bob Filho has already stopped losing weight Let's01:26:21
focus more on di01:26:23
let's make Bob the client understand the01:26:25
importance of diet let's start01:26:27
exercising if that's how01:26:29
we're going to do it for this patient and01:26:31
then when you least notice your01:26:34
diabetic is round every three months01:26:37
he won't come to you every three01:26:39
months you will do a general assessment01:26:40
of this patient, remembering, right?01:26:47
He's going to do01:26:51
biochemistry, he's going to do urinalysis, he's going to do01:26:53
abdominal ultrasound, everything you can01:26:56
for a general checkup because he has a01:26:57
chronic disease, right? Also, be very01:27:00
careful with urinary tract infections,01:27:02
which are very common asymptomatic in01:27:05
diabetics and I treat them when they have bacteriuria cysts.01:27:08
subclinical and also every three months he will01:27:12
do the glycemic curve and this is01:27:14
Bob the dog's life this is the life of the01:27:16
diabetic But he has a normal normal life01:27:18
but he has this01:27:21
extra care than a dog wouldn't hurt,01:27:23
right? What is the curve to know if you have01:27:26
hypoglycemia?01:27:40
and this is where we will use01:27:44
to change the dose of your therapy at01:27:47
least 7 days after the introduction Ok when are01:27:50
we going to do it then on the day of01:27:52
treatment on the first day if you are01:27:55
afraid you can do it to find out if there is01:27:57
hypoglycemia just to this now for01:28:00
you to do all the analysis of the type of01:28:02
insulin of the dose man P man at least 701:28:05
days of therapy Ok 12 hours every Two01:28:08
hours checking giving food normal life01:28:12
normal routine is the01:28:15
recommended treatment for the diabetic dog people there are01:28:18
three little balls that I I told you,01:28:20
the specific diet, routine exercises01:28:23
and today, you know, in the consensus that01:28:26
we had, I think it was 2021, right,01:28:29
the last diabetes consensus came out, now I don't01:28:30
know if it was 2021 or 22, I don't know the last01:28:33
World consensus that came out. of diabetes01:28:35
brings us once again that the01:28:37
insulin of choice for dogs is cane01:28:40
insulin, right, that's the veterinary one, and then how do01:28:43
I do it? Look, if you look at the01:28:46
literature, you'll see that I'm super01:28:48
super super super01:28:51
Ah,01:28:52
careful when I close the diagnosis01:28:55
of my patient and in the diagnosis01:28:57
his Glycemia is less than 360 I use the01:29:00
dose of 0.25 units kil bid when the01:29:03
Glycemia Sorry guys here Missed a01:29:05
three huh when at 60 God forbid it's01:29:08
hypoglycemia, right when the Blood glucose is01:29:10
greater than01:29:12
360 I start with a dose of half a kilid unit,01:29:16
plan your patient's follow-up01:29:19
This is the success of the therapy and01:29:21
tell your client that everything is slow,01:29:24
we just can't have new signs, right?01:29:26
dog started vomiting dog01:29:28
started If you become apathetic, you have to bring it01:29:31
to me so I can evaluate it Because this can be a01:29:33
complication and look at the01:29:35
complications, guys, have you ever seen signs01:29:37
of hypoglycemia, [ __ ], these are signs that are also01:29:39
super difficult for us to evaluate, right?01:29:46
It's01:29:48
important, so when in doubt, if you01:29:50
work close to where your client lives,01:29:52
bring it to you so you can make sure01:29:54
there's hypoglycemia or01:29:57
ketoacidosis, okay, you can't do that. I01:30:00
always ask you to put that01:30:01
corn syrup on your tongue and come, okay?01:30:05
plan, right? At the beginning you can do the01:30:08
curve that your concern is if01:30:09
hypoglycemia is the only thing the curve is you will01:30:12
evaluate insulin then after seven days and01:30:15
after stabilization every 3S months01:30:18
monitor it has stabilized this is the time you01:30:21
will tell the [ __ ] to be spayed it01:30:23
has stabilized It's time to clean01:30:25
your patient's mouth because01:30:27
periodontal treatment has to be stabilized. It's01:30:30
time to perform a01:30:31
patellar luxation correction, I don't know what you're going to01:30:32
do if this dog needs any01:30:35
other assistance.01:30:37
I want to bring it to you so01:30:39
we can go here for the chat that I've already01:30:42
said too much today, right, sorry about the01:30:45
time, it's a Clinical case And then I already01:30:47
imagined that we were going to talk a lot so01:30:49
I only brought one today, it's01:30:51
a Clinical case of Beautiful, right? It's Bebel,01:30:54
a 7-01:30:58
year-old SRD dog who was very cute,01:31:01
polyuria, polydipsia, polyphagia,01:31:04
weight loss, diagnosis of01:31:07
fasting hyperglycemia of 380 with glycosuria, so the01:31:10
diagnosis was very simple, right, you just01:31:12
needed that support from the teacher01:31:14
to say, okay? you confirm the01:31:17
diagnosis is correct, right now what01:31:19
is the step, let's start treating her, you01:31:22
followed our line of01:31:24
treatment here as her blood sugar level was above01:31:27
360, she started cane insulin, we01:31:29
half-baked the prescription together and01:31:32
Life What follows is that then she confessed01:31:34
to me what the teacher says, I'm very01:31:36
scared, I wrote the prescription but I'm afraid the01:31:39
patient will get sick. How can I01:31:41
follow up, right? So what's the idea here01:31:44
of bringing this up, which is a very01:31:46
common question, right? When we start to treat01:31:49
and we take the case for us, you know, of01:31:51
diabetics who are not suffering from insect acidosis,01:31:53
remember that, right, so what did I01:31:55
tell Bela, let's start, I said,01:31:58
Bela, let's do it like this, Bob, dog, right,01:32:01
we all say everything by Bob the dog01:32:03
brings Bob the dog to your mind How are01:32:05
you going to talk to this client are you01:32:06
going to explain what diabetes is you are going to01:32:08
explain what the therapy is based on the01:32:10
therapy diet exercise and insulin but01:32:13
see Bob the client there are a lot of things let's01:32:15
focus the main thing today is insulin01:32:17
Ok, let's go buy the food, let's see01:32:20
what the food will be like, we01:32:21
chose a brand there, we gave three01:32:24
brand options for Bela's dog's food,01:32:26
right, I'll tell you the ones01:32:27
I always prescribe it's either from RS, right, or from01:32:30
Royal or from Vet Life Ok, we01:32:34
also use Premiere a lot, okay? I'm not01:32:37
saying that the other actions are bad,01:32:38
I'm saying here we use it Well01:32:41
anyway, and then ah b b b I was talking about01:32:44
da poob client then makes the01:32:46
Ration recipe and says let's01:32:48
buy it let's see how it goes p p01:32:49
man but let's focus on the beauty on the insulin01:32:52
so the beauty went there and took01:32:55
physiological solution and gave it to the client to apply it she01:32:57
felt a sense of security in her client but01:32:59
if she didn't If it felt ok,01:33:01
come back tomorrow to do it again, man,01:33:03
make sure you're pulling and applying it01:33:06
correctly, this is the basis for01:33:09
diabetic therapy Ok, great, with this confirmation01:33:12
I said, Bela, then do the following, ask01:33:15
PR tomorrow for her to stay with you for 1201:33:19
hours, she could do it At home, the01:33:22
glycemic curve, [ __ ], it's the perfect scenario, right?01:33:25
If she was available, the beauty would go01:33:27
there every two hours, it would be perfect, right?01:33:30
But she lives in a big city, it was01:33:33
difficult anyway. Ah, so she asked to01:33:35
stay in the kennel of the clinic where she01:33:38
works, right? Then it arrived in the morning,01:33:40
Bela gave her blood glucose, Bela gave her food, and01:33:45
applied insulin and started01:33:48
her chart every two hours to say every two01:33:50
hours, she was so scared that she01:33:52
did it every hour, she didn't even need that, okay,01:33:54
but She01:33:56
checked her blood sugar every hour and she didn't do it for01:33:58
12, she did it for01:34:00
16, but then it's okay, it's the impact of Fear,01:34:04
okay, people, what matters is doing the01:34:06
minimum, right? So she was there for 1601:34:09
hours, she was on duty with the01:34:10
dog monitoring her blood sugar and what01:34:12
is the focus Bela pays attention01:34:15
Ignore this dog's blood sugar values01:34:18
You will only pay attention if01:34:21
any blood sugar there is equal to or less01:34:24
than 80, something was she said but I want to01:34:28
show you the values I don't want01:34:29
I don't even want to see these values, you01:34:31
know why we go crazy, I just01:34:33
want you to tell me some value there is01:34:36
less than or equal to 80 she said no I01:34:39
said Great then go home and in01:34:41
S days you will return and you It's going to create a01:34:43
new glycemic curve, understand? And then01:34:47
lower your client's expectations. The01:34:49
dog is diabetic. We're not01:34:51
worried about wounds. We're not01:34:53
worried about a heart attack.01:34:58
100 to01:35:02
250 It's ok for the curve to stay in this parameter01:35:06
if the Clinical signal is controlled It's01:35:08
great, it's just that this will take some time and the01:35:11
first signal, client Bob, that we01:35:13
will notice is that Bob the dog will01:35:15
stop losing weight, okay, maybe with01:35:18
one week you'll arrive Ah, you'll01:35:20
weigh it, the weight hasn't dropped, okay, let's01:35:24
keep it the same way and then a week01:35:27
after it happened with the beauty, right?01:35:34
same therapy and01:35:37
I said fine, let's start reinforcing01:35:39
the diet with your client Bob, Bob accepted,01:35:44
let's start putting more of the new one than01:35:46
the old one until, I don't know, 10 days from now,01:35:49
Bela, he's only eating the01:35:50
therapist food, maybe, maybe, and So you01:35:54
understand, so people, it's about having clarity in01:35:58
your head so that you don't cover yourself up, do01:36:01
n't get anxious, don't despair, don't01:36:03
waste the night, have you already lost sleep01:36:05
because of a patient, I've lost it, but many01:36:07
times, and look, I'm very good at01:36:10
sleep, talk about bed, I'm very good01:36:12
at sleeping, I can really be like this01:36:14
this week, this week we01:36:17
're here in the immersion, launching the01:36:19
course, the new mentoring class starts, it's01:36:21
live today, I have until Saturday to01:36:23
deliver a chapter of a book, I'm01:36:25
like this, I'm a mother of two, like you,01:36:28
I'm not saying that my life is more01:36:30
difficult, not everyone has their01:36:31
difficulties, but I lie down and01:36:34
sleep, I sleep, I dream about books, but I sleep,01:36:38
but when I see a patient and I'm01:36:41
insecure I start to think, is01:36:43
my recipe right? Did I do it? Can I01:36:46
have lime? Can I?01:36:47
It's not desperate, it's01:36:50
desperate, but today, thank God, I wo01:36:54
n't say that I'll never go through01:36:55
this, not when I answer some01:36:56
diseases that are much more difficult to happen01:36:59
on a routine basis I'm also a camel, people, I01:37:02
study my01:37:03
patients, it seems crazy, but I01:37:05
arrive with my files and01:37:07
I'm going to see if I ate any balls during the01:37:09
exam, I'm very attentive, in fact,01:37:12
so you know, I am. today much more than01:37:14
I used to because I already have fewer patients,01:37:17
I choose the time I see them, right? So01:37:19
I have fewer patients, I can give them01:37:20
but obviously my consultation is more01:37:22
expensive today too, right?01:37:27
today Every now and then I lose sleep01:37:29
when I, um, guy, ate a ball like this one without01:37:32
this one the other day I was talking to01:37:33
João and I said I saw a patient01:37:35
here about 15 days ago01:37:37
when I was seeing him for about 20 days and I didn't01:37:39
I thought about going to Adrena, now I'm going01:37:41
to get him and then I spent that night01:37:43
thinking, man, how come I didn't think about01:37:44
going to Adrena? And then it consumed me, right,01:37:47
everyone goes through this, people, so having01:37:50
clarity makes this happen less,01:37:52
but Once in a while it will01:37:54
happen, anyway, with all that said, let's look at01:37:57
your doubts and invite you once01:38:00
again to help you01:38:03
in this process of faster evolution,01:38:05
because our last meeting here01:38:07
for immersion for you to meet people,01:38:11
meet people, it doesn't cost anything, click On the website,01:38:13
ask us to send you the01:38:16
mentoring link so you can understand what01:38:18
the schedule is there, I'm sure it01:38:20
really will be great if you01:38:23
reach this stage that I described to01:38:25
you, who is it, I'm sure01:38:28
she The mentoring will help you a lot,01:38:30
in addition to bringing technical knowledge,01:38:31
this support is really cool and I01:38:34
really want you to join, right? Why?01:38:36
Because I really like doing this and I01:38:39
really take hours out of my office01:38:41
to dedicate myself to you, see, so I I01:38:43
really want to get to know you and for you01:38:46
to be part of this mentorship from the heart,01:38:48
so we are there with registrations01:38:49
open tonight, tonight is our01:38:51
first live meeting and I01:38:54
really want to I know that many of you are01:38:56
leaving now, right, while we01:38:58
talk but before you leave,01:39:00
I want to sincerely thank you for01:39:03
your company over these three days at01:39:05
lunch, I know it's super busy, anyway,01:39:08
and you took the time here to01:39:10
listen to me, I'm very happy, thank you very much01:39:12
for your company, remember that tomorrow is01:39:15
half -day we're here again, right, but01:39:17
the immersion ends today with the01:39:21
official registration process for mentoring and on01:39:23
Thursday for those who are in the01:39:25
first second third period for01:39:27
those who want to follow up on fine-grained subjects01:39:29
that it's not time for this01:39:30
faster transformation, we have our lives at01:39:33
noon Alright, so now I'm going to come01:39:36
here to chat for whoever stays, right, it's01:39:38
almost 2 o'clock in the afternoon, we talked01:39:40
a lot today, right, I think we stopped01:39:43
here, right, ha, you said01:39:46
no, no It was at Iara or Lara, which01:39:50
I don't know how to read here, you know, about hemoglobin,01:39:51
which we responded to, now Aline01:39:53
said, there are foods that we can01:39:55
give to diabetics, besides01:39:59
Ration, there are actually things that we01:40:01
have to prioritize, the line here is something01:40:03
that we don't like snacks, for example, that01:40:06
don't have a high percentage of01:40:08
fat, right? And that have a high amount of01:40:11
fiber, okay, that's what nutritionists01:40:14
recommend there as snacks and today there are01:40:16
even commercial snacks for01:40:18
diabetics, right? and every time I can, I01:40:21
use this because I No, I haven't already told01:40:24
you, right? I don't like nutrition, it's01:40:25
not something I study. If the guy wants01:40:27
a homemade diabetic diet, I01:40:29
'll send it here, look, the specialist can01:40:31
see, I'll send it to the nutritionist because01:40:33
it's something I don't want. I can't even01:40:35
learn, okay, so I'll pass it on to the01:40:38
professor, I had a question. When should I01:40:40
ask for traditional glycemia or01:40:41
glycated hemoglobin? We're never going to01:40:43
ask again.01:40:51
for cats, but when we have01:40:53
very stressed dogs, the collection, the01:40:57
release of Hip nephrin at the time01:40:59
of collection, causes hyperglycemia and you are01:41:02
a little confused. If that was due to stress01:41:05
or if it is real hyperglycemia, then01:41:08
fructosamine is an option. Manu01:41:11
asked if an ideal follow-up01:41:13
would include a physical examination, urinalysis, glucose levels and01:41:15
Alt fructosamine, and every three months,01:41:17
would there be another test that would be01:41:19
necessary? Manu, when I see a01:41:21
diabetic patient for 3 months, he01:41:23
has returned the glycemic curve. Is it a follow-up01:41:26
for me to evaluate this insulin therapy?01:41:28
glycemic curve I don't even do01:41:30
fructosamine, okay, if it's not possible to do a01:41:33
glycemic curve, fructosamine is a01:41:35
monitoring option also with the01:41:37
limitations that we mentioned.01:41:40
Furthermore, I have to remember that this is01:41:42
a systemic and silent disease in01:41:44
some aspects, so general physical examination It01:41:48
should always be done in any01:41:50
re-evaluation of any disease,01:41:52
including even the vaccine, right, and with01:41:55
emphasis on the evaluation of the oral cavity,01:41:58
listening to this patient,01:42:00
abdominal palpation, let's go for01:42:02
complementary exams, blood count, basic screening,01:42:05
right, I'm not going to do blood glucose because I'm going to01:42:07
do a blood glucose curve, Ok. so blood count01:42:10
urinalysis01:42:11
ultrasound If possible, if not at01:42:14
least every month, I do01:42:17
ultrasound and then biochemically I do01:42:20
LT, phosphatase, urea, creatinine,01:42:26
albumin This is my protocol,01:42:31
depending on changes, we01:42:33
associate other things Ju there is a01:42:36
screwed up financial restriction01:42:39
glycemic curve is the least we have to01:42:40
do every 3S months ok And then this whole01:42:43
parameter every six months01:42:46
ok Paula Ju How long after it is01:42:49
rehabilitated to adjust the01:42:51
insulin dose at the beginning it started Paulinha 7 to01:42:54
10 days the glycemic curve is OK Ana I'm01:42:58
at the end of my01:43:00
degree I'm at the end of my degree01:43:04
Hey Ana you know that the other day this is01:43:07
very funny The other day I was01:43:09
saying this to João I said this man we01:43:10
keep talking about diabetes01:43:11
diabetes diabetes but we only realize01:43:15
the difficulty now in mentoring when the01:43:17
student goes to prescribe and we say, what01:43:20
is this, right? How can I not even01:43:22
calculate it, see Ana, because calculating01:43:25
insulin is very easy, you will do01:43:26
the dose times the weight you will get a01:43:28
concentration of 40 units01:43:32
exactly I'm saying this because I01:43:34
said this on Monday in the first01:43:36
mentoring class, it's an01:43:38
injectable medication calculation class And there I explain01:43:40
exactly the Paranauê of the unit that01:43:42
we have, this one looks like when it came out of01:43:44
the milligram per kg our head went wrong It doesn't01:43:46
seem like it but it's exactly the same the01:43:49
units say Ana if the dose of the01:43:52
product, for example insulin, the dose01:43:54
works in units per kilo the01:43:57
concentration of the product will be units01:43:59
per ml Can you fix this if01:44:01
someone isn't talking You're saying the01:44:03
wrong thing, when we have a dose in01:44:05
milligrams per kg, the presentation of the01:44:08
injectable will be in milligrams per ml01:44:10
because this will be cut off in the equation,01:44:13
so if you have a unit per kilogram01:44:16
of insulin, the presentation of insulin01:44:18
is a unit per ml in the end to calculate01:44:21
which is your question there is no01:44:24
difference in weight times dose divided by01:44:26
concentration for example in the case of01:44:29
Bela let's imagine that he weighed 8 kg01:44:32
you would do 8 which is the weight times half which01:44:34
is the dose divided by 40 which It's the01:44:36
concentration of the insulin cane, that's not01:44:39
the problem, you know what the problem is, it's01:44:42
converting this into a syringe for the01:44:45
client, that's the problem, right? And then01:44:47
we have a class in mentoring just about01:44:49
that because we put it in01:44:51
after the We realized the01:44:52
difficulty because man you have a syringe01:44:54
that is 100 units per ml you have a01:44:57
syringe that is 30 you have 20 you have the01:44:59
insulin cane syringe but when01:45:01
you Ana pay attention I prescribe an01:45:03
insulin cane that uses her syringe01:45:05
your problem is over, you go and pull it,01:45:07
it's all very easy but each syringe01:45:10
costs R$ 5 and theoretically you have to01:45:11
change them, two per day, 10 R 300 per01:45:14
syringe, there are customers who don't pay01:45:16
that, mine at01:45:18
least So we have that readapt01:45:21
a human syringe that costs 2001:45:23
cents into an insulin that is crazy that is01:45:26
veterinary So I would01:45:29
gladly explain this conversion to you here but it's01:45:30
too long the explanation we01:45:32
wouldn't be left with it would just be you and me here but01:45:34
we have a class about this and if I01:45:37
recommend you what you are at the end of your01:45:38
degree, you can also talk to01:45:40
your professor, right? So that you can put this01:45:42
into practice because it is very important and01:45:44
we only realize it in the office when01:45:46
we are with the client Oh great, you're01:45:49
going to give two ages of cane insulin,01:45:51
how can I pull this into the syringe that I01:45:53
can afford? It's not easy, right Ju, you01:45:58
could do a live on ketoacidosis01:46:01
Good tip Jessica, we also have a01:46:03
mentoring class just about ketoacidosis01:46:05
See, to care for and care for a patient01:46:07
like this at home Hey, let me01:46:10
tell you something. Theoretically, the best ones are01:46:13
stable, right? I'm not saying acidosis,01:46:16
but the best diabetes treatments01:46:18
are in home care because then01:46:20
you take the context of the01:46:23
patient's life to do the curve, the01:46:25
results are much better for us01:46:27
to interpret, so you can do it at01:46:30
home, the Malu effect is the01:46:33
sound effect, it is01:46:38
rebound hyperglycemia, it is possible that a diabetic dog01:46:41
needs a dose lower than 0.25 Manu,01:46:44
I've never used a dose lower than01:46:47
0.25, I think I might even have to01:46:49
re-evaluate the diagnosis, the01:46:53
glycemic curve, to make the animal need01:46:56
to be hospitalized, well, if so,01:46:59
let's go, in short, I think the last one01:47:01
Oh, no, it's not the one. glycemic curve M it01:47:04
can be done with the hospitalized patient01:47:05
as long as you have a good hospitalization, right, other01:47:08
than that hospitalization where01:47:10
the dog is there undergoing01:47:12
absurd stress, it won't be cool if your01:47:13
hospitalization has good01:47:15
management conditions It's an option one Another option is for the01:47:18
curve to be done at home, the01:47:20
veterinarian goes there every 2 hours or01:47:23
you ask your client every 201:47:25
hours to collect the blood is also an01:47:27
option, right because you can collect it from the tip01:47:29
of the cushion's ear and write it down on a piece of01:47:31
paper there If the client is not01:47:33
careful with this, then the guy01:47:36
has learned to do my good, he will work from 301:47:38
in the morning to 2 in the morning. So if the person01:47:39
is a more normal person, not01:47:42
those crazy clients, you can ask01:47:44
him to check every 2 hours and then01:47:46
give you the report or you can01:47:49
use that continuous monitoring which01:47:51
is a little device that you place on the01:47:53
patient that can stay there 24 hours,01:47:56
you leave it there and then every time it is01:47:59
programmed every hour it measures the01:48:01
blood glucose level there. of the interstice and gives you01:48:04
a Value there, with the dog in01:48:07
normal life, right, no one needs to manipulate01:48:10
it, Janderson, the glycemic curve needs to01:48:13
be done in the first seven days,01:48:15
the therapy started after the seven days, you are01:48:19
afraid of hypoglycemia, you can do it01:48:21
before, but only it will help you to tell whether01:48:24
or not there is hypoglycemia so you can evaluate01:48:27
the curve. After 7 days that you started, I'll01:48:31
do it with 10. Live will be recorded,01:48:35
Live Theoretically, Live is our01:48:37
immersion, what are you talking about, or01:48:39
YouTube Live, our immersion? it's01:48:42
available Theoretically it was 24 hours, right,01:48:44
but you're all watching it at01:48:47
night and so on, we're extending it a01:48:49
little bit, I don't know how long João01:48:51
will leave it, but in principle it's 24 hours,01:48:53
now YouTube Live happens01:48:56
live and it stays the link is available for01:48:58
those who are in the YouTube group that01:49:01
we also think we have01:49:11
Live messages today Live is about that the link01:49:13
to access later is this if anyone01:49:16
wants the link to the YouTube lives if01:49:18
you are not there send it to João or01:49:20
me and we will forward you to the01:49:22
group01:49:24
if Bebel presented at the first01:49:27
curve If the result is less than 80, what is the01:49:29
good procedure, Eli, if she had01:49:31
hypoglycemia, we would reduce01:49:36
the dose of insulin we01:49:38
started by 10 to 25% and then tomorrow, for example, she will01:49:42
do a dose 10 to 25% lower, she will create01:49:45
a new curve to see if01:49:47
hypoglycemia happens, that's perfect, ok,01:49:50
every patient with diabetes will01:49:52
experience weight loss as part of the01:49:56
diabetes process, for sure, but01:49:58
you may have a very attentive client01:50:00
who still doesn't see weight loss as01:50:02
an important sign, right, but that's it. he has already01:50:07
brought you because other signs have started01:50:09
so diabetes will progress with01:50:11
weight loss But depending on the phase you01:50:13
reach it may not be Ju and then how am I going to01:50:16
follow the signs of weight loss01:50:19
he is the first one that stops happening01:50:22
but the signs will regress So let's01:50:25
imagine that you, Nadia, have a01:50:29
patient that you diagnosed, he doesn't even01:50:31
lose weight, he still does, he's obese,01:50:33
even if he's obese, this can happen, right01:50:35
? You'll realize when01:50:37
you start therapy, he'll be less01:50:40
hungry. he will be one we will evaluate01:50:43
four important parameters he will01:50:45
start drinking less water he will be01:50:48
less hungry he will not lose weight in this01:50:51
case and he will increase his activity oh01:50:53
he is more active at home he is01:50:55
happier he is interacting better then01:50:58
these monitoring signs if he01:51:00
loses weight the first thing01:51:02
we observe is to stop losing weight but01:51:04
the other signs in the monitoring will01:51:06
happen he will drink less water he will eat01:51:08
less he will be more active ok that's the01:51:11
clinical monitoring that's it what01:51:13
we expect is what we tell the01:51:15
client Thank you for asking because I01:51:17
hadn't said that, right? Cludia liked it01:51:20
That's good, I said a lot, right, we said a lot,01:51:23
but it's the last day, we're also01:51:24
immersed, we could spend the afternoon01:51:26
immersion, right, and not do anything else with your01:51:29
life Manu, the curve in this case where the01:51:32
patient was not eating only01:51:35
therapeutic food at the time the curve was made, the01:51:37
curve would have to be01:51:40
redone Ah, I understand what you said01:51:43
in the idea that I talk about the concept,01:51:46
right? treatment started A few days later01:51:49
we started the curve And then the diet will change, it would01:51:52
n't necessarily be necessary but01:51:55
I'm scared, do it oh, from01:51:59
that day onwards he's eating and01:52:00
he's eating how he says he's eating01:52:03
strictly strictly I don't know, okay?01:52:05
eating only the therapeutic food01:52:07
counts for seven days and makes a new curve, there's no01:52:11
problem but we don't do it but we're01:52:13
scared, do it in fear, do it, give you01:52:16
security so you can put your head on the01:52:17
pillow and sleep well, this is01:52:19
important, human insulin is also01:52:21
effective in the long term, can insulin is01:52:23
better Aline, human insulin is the01:52:25
second option, so when it is not01:52:27
possible to make cane insulin,01:52:30
human insulin nph is the option Thank you Ju,01:52:33
incredible Thank you Abdala again here01:52:36
with us, I love saying that name01:52:37
Can you explain step by step the day of the01:52:40
curve feeding measurement Aninha01:52:42
normal life dog let's suppose he is at01:52:44
your clinic to do the curve and he takes01:52:47
insulin at 7 in the morning you will ask01:52:50
him to arrive at your Clinic 6 so he can01:52:51
adapt to the environment 6:30 you will01:52:54
offer the food, you will offer it, it will01:52:56
arrive at 6 o'clock in the cold, the blood glucose level01:52:59
will adapt to the dog 6:30, you will give the food 701:53:02
hours, you will apply the insulin And then the blood glucose level every01:53:04
two hours 7 9 11 13 1501:53:09
17 19 that's it It's 12 hours after01:53:14
application, apply new insulin, go01:53:16
home, analyze the curve, ok Manu, these01:53:20
snacks you have to ask a nutritionist01:53:24
to calculate, if you're going to add several01:53:26
snacks, we ask a nutritionist, then you want to01:53:29
add snacks and I've seen a01:53:32
nutritionist come by like this, just ask. For there are01:53:35
clients who like01:53:37
working on these snacks so much that they blend the01:53:39
food in the blender and put it in the01:53:43
oven to turn into food biscuits or they01:53:46
often add it. I see them01:53:48
add chayote, zucchini and carrots, that's01:53:52
what I see them put in, Manu and01:53:55
I. I'm going01:53:57
to this Live on diabetes in cats, that's another01:54:00
subject, right? We also have it there in the01:54:02
mentoring only for cats. I saw a vet using01:54:05
metformin meforma in diabetic dogs,01:54:08
what would be the indications?01:54:13
to01:54:15
make glipizide the same as making ascar bos01:54:19
and they will bring the intention of continuing to01:54:22
reduce blood glucose a little to be an01:54:25
adjunct to insulin,01:54:27
particularly I don't use it01:54:29
in my routine, okay, I think they are more01:54:31
complicated, I still see it that way for my01:54:34
client owners Bobs Profe, it's not01:54:37
dangerous to do the curve at home01:54:38
due to clinical monitoring01:54:41
with Vete, it's not dangerous to do the01:54:46
glycemic curve I don't understand, it's dangerous Why do01:54:49
you think the patient might01:54:51
decompensate?01:54:56
It's ok if he's01:54:58
decompensated he doesn't have to be at01:55:00
home he's emetic acidosis in01:55:02
hypoglycemia it's not there01:55:04
diabetic patient it's the dog you're01:55:05
walking on the street and seeing at the gate, you know, I've01:55:08
heard in my internship that insulin should01:55:11
always be administered in the same place01:55:13
precedes Nádia, insulin therapy is01:55:16
subcutaneous and must be done where the01:55:18
client can, right? Now, if we are going to01:55:21
standardize, if the dog allows it, if the01:55:23
client has dexterity, I always ask to01:55:25
do it on the rib cage, right side in the01:55:28
morning, left side in the afternoon What do01:55:31
you think about the freestyle? Can we01:55:33
trust the result? I've heard some vegos01:55:35
say a producer buy yes. This is one01:55:37
of the glucometers we use.01:55:40
We can01:55:41
trust it. It varies with the01:55:44
biochemical, right?01:55:48
blood that you send to the01:55:50
laboratory, which is instantly01:55:52
processed by the glucometer, it tends to01:55:54
be lower than the01:55:58
laboratory value, but it's our resource, right?01:56:08
he always stays at01:56:10
this dose At some point it decreases like01:56:12
us, it's not difficult to say that huh01:56:16
Nice [ __ ] that are intact after01:56:20
you Castrate You may have to01:56:22
reduce the dose because we have a01:56:23
hormonal factor that influences PR [ __ ]01:56:26
dog or [ __ ] already01:56:29
spayed I think it's very difficult for you to reduce the01:56:32
dose unless you do it started with01:56:35
high doses the doses I use for01:56:37
example always stay with the same dose see01:56:40
m thanked Malu thanked Noel01:56:44
thanked people 60 people are you still01:56:48
warriors or are you doing it01:56:49
another thing, right, listen to me for two01:56:52
hours, congratulations, huh, you really are01:56:54
warriors, even I can't stand it, that's it,01:56:57
guys, let's end01:56:59
our immersion here by really thanking you from the bottom of my01:57:02
heart, I really wanted to give01:57:04
each one of you a kiss, thank you01:57:07
for your company We'll see you01:57:09
at the next event soon, which01:57:11
we're going to launch for you, we're going to think01:57:12
carefully about the themes and those who are going to be01:57:15
mentored are very welcome,01:57:18
don't forget that today we start01:57:20
our live class at 19 hours Ok kisses01:57:24
guys, stay with God Thank you very much,01:57:26
thank you Kelly Kelly, we'll see you01:57:30
tomorrow for sure, right Kisses guys, stay01:57:33
with God01:57:34
Sandrinha wonderful dish in01:57:37
front Ah, I'm going to eat too, I have a01:57:41
dip next time, I'm going to have lunch01:57:43
with you here You know, having lunch or an01:57:46
afternoon snack, I don't know, kiss everyone01:57:49
Kisses, Mi, stay with God, bye guysDescription:
Vet, temos um problema por aqui! Você que é clínico geral pode não gostar de endocrinologia e está tudo bem! Mas eu sei que muitos colegas gostam, entretanto, na hora de atender um cão com diabetes ficam com inúmeros receios. A insegurança para estabelecer o diagnóstico de uma doença crônica e, especialmente, manejar a insulinoterapia do paciente podem ser desafiadores. Assista nosso 3 dia da Imersão em Clínica Médica de Cães e Gatos. Hoje irei te mostrar o caminho com mais clareza. Começamos abordando o diagnóstico e irei te mostrar como conduzir o tratamento desse paciente. Depois que assistir comente se essa conversa te ajudou, combinado? Nossa primeira Imersão online está chegando ao fim! Quanto assunto abordamos em 3 dias, não foi? Para você que se dedicou e reservou tempo para estudos, ficou a certeza de como o conteúdo teórico é fundamental nesses caminhos? E de como ter clareza fará você desenvolver as trilhas em sua mente e certamente sua conduta e conversa com o cliente serão mais satisfatórias? Enfim, você consegue enxergar como esse percurso pode te levar até a (o) veterinária (o) que já idealizou um dia?? Se você sente esse momento dentro de você, eu te convido a conhecer meu Programa de Mentoria. Com aulas EXCLUSIVAS, abordando diagnóstico e tratamento das doenças de rotina, esse programa de duração de 12 meses irá te proporcionar conhecimento e clareza técnica. E você será acompanhado por mim e pelo Dr João por 12 meses. Isso mesmo!! Acompanhamento diário para dúvidas, casos clínicos.. O programa está com as inscrições abertas e no link abaixo você pode conhecer tudo que ele te oferece!! E tb pode se matricular. Vamos juntas (os)?? https://julianapeloi.com/mentoria24 Um grande beijo
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