DIP Episode 426 - USMLE Step 2/3 Rapid Review Series 87

Okay, welcome. My name is Divine. Welcome to episode 426 of the Divine Intervention Podcast. Into this podcast we're going to be continuing the Rapid Review series for the USMELIS step-2 CKN step-3 exams. And I believe this is going to be series 87. I believe this is going to be series 87. So, what if they give you a question about a patient and they tell you that this patient was recently started on an anti-depressant and the patient is brought to the emergency room because they've been having seizures, the fact too generalized tonic lonic seizures. And they tell you that this person has also been in the past, on the past being tried with an SSRI. In fact, they are still on an SSRI, but another anti-depressant was added and they now they have seizures. And then you notice that while this person, they give you some labs, you notice that the person's sodium is like 123. And you know, the person's potassium is roughly normal. And then you notice that the aeronols molality is like 900, some really high number. When you see something like this, what should you be thinking about? Well, I really hope you think about SI in each and the combination of both propion as the cause of the person's seizures. So, maybe like, divine, what's the deal with that? Well, let me explain. The thing is many times when people are placed on SSR Is, if SSR Is are not adequately controlling your symptoms or you're taking an SSRI and you notice that you're having some of the sexual side effects.

One acceptable treatment typically on in-beaming exams is to add bupropium. Bupropium is actually very helpful. You can be on an SSRI and be on bupropium. And bupropium can essentially cover over the sexual side effects associated with taking an SSRI. Believe it or not, that's something that's pretty high to know for purposes of the USME Ls. But why is this person then having seizures? And why does this person have hyponytry? Well, here's the thing. When people have a taking SSR Is, they can develop SIDH. SR Is are the most common drug cause. This is very high yield. SR Is, they are the most common drug cause of SIDH. So because they cause SIDH, SIDH obviously, you're going to be sucking up a lot of free water from your urine. So your urine is going to be very concentrated, but the serum is going to be very dilute. So the person can have hyponytrymia as a result of that. When you have that hyponytry Mia, the thing that's going to happen is that if you then throw in bupropium, remember bupropium is one of the drugs that has the ability to lower your seizure threshold. So if you throw in bupropium there, then you lower that person's seizure threshold. And even at sodium values that are not too terrible, the person can have seizures. So remember bupropium lower seizure threshold. So on endemic exams is not a good idea to give bupropium to a person that has a history of a seizure disorder or a person that has problems or challenges that can predispose them to having seizures.

Especially people that have eating disorders, for example, like people that are anorexic or people that are bulimic or a person that has just had like a really bad illness where they are vomiting a lot. It's probably not a good idea to give those people bupropium because again, bupropium will lower the seizure threshold. All these people that have eating disorders and whatnot, they can absolutely positively have an electrolyte and nominees that can predispose them to seizures. And then when you throw in bupropium, it's like a double one and you're going to really put those people in a lot of trouble. So that's something you want to keep at the back of your mind on exams. So again, most people have learned that eating the disorder angle, that if you have eating the disorders, don't take bupropium. What are friends at the end being is they're very smart. Again, that's one of the things that you see on the exams these days. The stuff you know, they just bring some weird scenarios, but it's still the same concept, just a somewhat different application. So they can give you literally a question about a person that has SIDH for some reason, and then you give them bupropium and then they have problems. And you can see that angle between SSR Is. Again, I just said that literally many people take SSR Is and bupropium at the same time. So you can see the link that you can give you a question as almost like a drug interaction style question, right?

Because again, if you give that person bupropium, you give a SSRI, SSR Is can cause SIDH and cause hyponitremia. And if you slap in bupropium there, the person can have hyponitremic seizures as a result of that. And just real quick, with bupropium, don't forget that bupropium works as an NDRI. It's an Norepinephrine dopamine reoptic inhibitor, right? It's an NDR, it's a Norepinephrine dopamine reoptic inhibitor. It's very good in many contexts because number one, it helps you stop smoking. It's actually very helpful for smoking cessation. Number two, it helps you lose weight. In fact, people lose, I think up to like 15 pounds of their about. Obviously, there are many factors that interact with that when they are studied on bupropium. And then a third thing that bupropium can also do for you is that it does not have sexual side effects. It is one of those anti-depressants that has the claim to think of not having sexual side effects. But bupropium unfortunately also has the problem of lowering your seizure threshold. So again, if you have a history of a seizure disorder or you have a, you're taking a drug or you have a condition that can predispose you to electrolyte anomalies, you want to think twice about giving a present bupropium because again, it lowers the seizure threshold. And again, the thing is, again, you can already see the NBM Es. There are just so many angles they can take with these, right?

So they can give you a question about a person that for example, maybe taking one of these diuretics and then it's taking bupropium and then develop seizures. Again, you can begin to make those links because if you notice certain diuretics have the ability to cause high-poony trimia. Diuretics can generally cause electrolyte abnormalities. So that's just something you want to make sure that you can kind of, you know, way through on, on exams. Now, what if they give you a question about a patient, they tell you that this patient is started, you know, was recently studied on an anti-hypertensive. And that for the last three weeks, this patient has been having significant headaches and he just feels like has this bulging feeling in his eye every morning. And then they tell you that, you know, they give you a bunch of blood pressures and it's going to be like for example, the, or let's let's say female, let's say female and then they give you a bunch of blood pressures and you notice that the person's blood pressure is very high, right? And then you also notice in the question that they say, oh, this person has arteriovenosneken on fondoscopic exam and then they tell you that, oh, right, they in the office, the patient is having a headache and then they will say, what is the most likely diagnosis? Now, our friends at the NBM is being smart. One of the things they will do is they will put pseudo tumor cerebride as an answer, you know, the new one in for pseudo tumor cerebrires.

I imagine many of you know, is idiopathic intra-creatal hypertension and that will be wrong. If you notice, this question I literally just constructed is eerily similar to pseudo tumor cerebride but is not pseudo tumor cerebride. So how did I set up this question? I set it up in a woman. I set it up that she has constant headaches in the morning and then I set it up that, ooh, her blood pressure is really high. So some people may be like, oh, wow, divine. And then you know, I described that I in the question. So some people that will read a question carefully, they will be like, oh, yeah, divine, totally pseudo tumor cerebride. But let me tell you this, pseudo tumor cerebride in general does not cause hypertension. Don't get me wrong. Put a pseudo tumor cerebride. You can have hypertension because many times people that have pseudo tumor cerebride are people that are obese but it does not necessarily mean that, oh, wow, this person has pseudo tumor cerebride. And also when a person has pseudo tumor cerebride, when you look at their eyes, they have like bulging of the optic discs and things like that. That's not what we find in this question. This question showed at Tyrvino Sneakend. That's something that we find in people that have really bad severe hypertension. Okay? So this person does not have pseudo tumor cerebride. I also see that right before this problem started, I tell you that the patient was started on some kind of anti-depressant. Right?

So again, just that extra context gives you something that is completely different. This is something I love to go over with people in my, that I tutor or people in my test taking course. That whenever you're taking an Mbim exams, you cannot just depend on a factoid and say, oh, because I see this factoid, it must be this answer. That is not a smart way to take exams at all. In fact, if you take exams in that fashion, you're going to be getting so many questions wrong on exams. You always need to ask yourself, what is the context that you're slapping behind a question before you pick an answer? So I just explained why pseudo tumor cerebride would not make sense for this situation. Now, what will the right answer be? The right answer here is they're going to call it drug-induced hypertension or they can call it hypertension secondary to a pharmacologic agent. That's where they can place this. So what kind of anti-depressant is causing this person to have high blood pressure? Well, the anti-depressant that's causing this at the SNR Is, the SNR Is. Remember, the SNR Is, they are the serotonin, noripinephrine, reoptic inhibitors. The SNR Is are the serotonin, noripinephrine, reoptic inhibitors. So these drugs are class-side effect in general associated with these drugs is hypertension, especially with venlafoxin. venlafoxin is a very, very big one that loves, loves loves loves to cause hypertension. So again, what are the other drugs that are in this drug category?

Well, you know, you see things like, you know, do-lock-setine, you see things like melmacipram? These are all members of that SNRI class. venlafoxin, do-lock-setine, melmacipram, and things of that, things of that nature. Right? So again, just remember the class-side effect of causing hypertension, but also remember what these drugs are used for. These drugs are used for many useful things, right? Like for example, you can use do-lock-setine to treat the peripheral neuropathy associated with diabetes, especially when you have painful neuropathy. Do-lock-setine is very good for that purpose. You can also use melmacipram for fibromyalgia. Fibromyalgia is, you can treat it with many different things, but do-lock-setine is one of the things that you can use, I mean melmacipram is one of the things you can absolutely use to treat fibromyalgia, right? And again, don't forget that these SNR Is, you can use them for major depressive disorder, you can use them for generalizing anxiety disorder. They actually very helpful for those purposes. One other thing you may also see them used for is when a woman has really bad postmenoposal symptoms, really bad hot flashes, you can absolutely use melmacipram for hot flashes. But think of it more as a second-line agent on MBME exams. The first-line agent on MBME exams will obviously be a hormonal replacement therapy when you're having significant postmenoposal symptoms.

But I encourage you to also consider that you can use melmacipram, melmacipram is actually pretty effective for treating postmenoposal symptoms. But again, if a person has some kind of contraindication to a hormonal replacement therapy, let's say they have a history of a breast cancer that grows when you're exposed to estrogen or they have a history of endometrial cancer or they have a history of like DVT or they have a history of PE. Remember estrogen increases your risk of venous thrombone and volic disease. In those circumstances, giving those people a hormonal replacement therapy is maybe not the wisest idea in the world, maybe not the wisest idea in the world. And then what if they give you a question about a patient, they tell you that this patient passes out at a party and they tell you that when he's found, he has his respiratory rate, he's like three and then they tell you that his blood pressure is like 95 over 60 and then they tell you that you know a quick eye exam shows three millimeter perpills and then they tell you that this person is belly arousal bowl and things like that and then they ask what is your next best step in management. And then you see you read the answer choices and you notice that meloxone is one of the answers. I mean it's not sorry. Meloxone is not one of the answers. So what would you do in those circumstances? I would really hope that you're saying, oh divine, I'm going to go ahead and give this person flumasenial.

I'm going to go ahead and give this person flumasenial. Remember flumasenial is a gabar receptor antagonist that can be used to treat benzoye overdose. So some of you may be like divine. How do you know that this question you just threw before us is dealing with a benzoye overdose? Well, let me explain. In a benzoye overdose, you're going to have respiratory depression. But most times these people are not going to have popular refinance. That's a very nice solid way to differentiate benzoye overdose from opioid overdose. Although I was nice and decided to not put an aloxone as an answer. When our friends at the NBA means they can absolutely put an aloxone as an answer. But when a person has been opioid overdose, they'll have respiratory depression. When you have benzoye overdose, you're also going to have respiratory depression. But usually people that have opioid overdose, they'll have popularly male cess. They'll have popularly constriction. Why is that? Because if you really think about it, opioids by binding to the new receptor, the new receptor is an inhibitory G-pertin-copyld receptor that's going to decrease the release of neuro-pinephrin at adrenergic synapses. I'll say that again. When opioids bind to the new opioid receptor, when they bind to it, it's an inhibitory G-pertin-copyld receptor. It causes you to release less neuro-pinephrin at adrenergic synapses.

When you release less neuro-pinephrin at adrenergic synapses, the things that happen because you have neuro-pinephrin around will not happen anymore. Nourypinephrin is part of your sympathetic system. It causes a population. But if you have less of it being released, you're going to have a population constriction. That's very high order now. That's why you have pinpoint-popyls. That's literally the mechanism behind the pinpoint-popyls associated with opioid overdose. When you see this pressing, they have respiratory depression, and they have no population findings. They have no population findings. It just makes more sense that benzoy overdose is likely what's going to be happening there. In those circumstances, what you do when a person has benzoy overdose? Remember, benzoy's are agonists at GABA receptors. The thing they actually do is they increase the frequency of opening of GABA receptors. Remember, those GABA receptors are chloride channels. They cause hyperpolarization of the neuron, they shut it down. They cause it to have respiratory depression. Although usually the respiratory depression is not typically as profound as a person that has opioid overdose. Although it depends on what you take with the benzodiazepine. But they have respiratory depression, they usually will not have publicary findings. They're going to treat it with flumazineol. Flumazineol will very rapidly antagonize the effects of the benzodiazepines and they'll get the person out of trouble.

Now, what are some other useful things that you can use flumazineol for? Remember, you can use flumazineol to reverse Z-drug overdose. Those drugs that we use for insomnia, they are drugs that are known as the Z-drug. So, drugs like Zopidem, Zaleplon, and Zopiclon. These drugs are GABA-air receptor agonists. They use for the management of insomnia. These drugs, if a person has respiratory depression from them, won't absolutely or something you can do is you can also give flumazineol. Flumazineol will basically reverse the effects of those Z-drugs and that can be used to help these patients. Now, I want to say a few more things about benzodiazepines. So, if for example, a person has benzodiazepines overdose, as I've said already, you're going to give flumazineol. What if a person is withdrawn from a benzodiazepine? For a person who has benzodiazepinesol withdrawn, what are you going to do? For a person who has benzodiazepinesol withdrawn, you're absolutely going to give those people. Benzos, as treatment. Benzos are literally the treatment for benzodiazepine withdrawn. Remember, benzodiazepine withdrawn is actually fatal. If you don't treat it, the person is probably going to die. So, the way you treat it is by giving them benzos, is by giving them benzos. And here's the thing our friends at the Indian is they are very smart people. They can give some very bizarre questions relating to benzos. So, let's say for example, a person overdoses on a benzo.

Well, what are you supposed to do? Again, I've already said you're going to give them flumazineol. But the thing is, sometimes you can give so much flumazineol that you can flick the person from benzo overdose to benzo withdrawn. So, what are you going to do in that next step? When you notice that, wow, let's say for example, they tell you that, oh, wow, a person was overdosed on a benzo, you give flumazineol, and then the person started having seizures. What is going to be your next best step in management? Your next best step in management is going to be to give that person a benzo, that is a p. Watch it. They'll literally tell you in the question to sway you that, oh, gee, this person just got flumazineol. All this person just got a reversal agent for benzo overdose. So, the stem of the question we're talking about benzo overdose, and then they'll give you this story about getting a reversal agent, and then the person starts having seizures. Your next best step will be to give a benzo. So, if you give a person flumazineol, you reverse the abenzo overdose, and you notice that, wow, these people are just all over the place. They begin to withdraw from the benzo because you give too much flumazineol. Those people absolutely positively require more benzo. That's how you're going to treat their benzo that is a pin overd- their benzo that is a pin we draw. So, again, just be mindful of a question like that. That's something that you can definitely- I'm going to say that again.

That is something you can definitely see on an MBME exam. Now, remember benzos, we use them for many things as well, right? We can use them for akathisia, right? If a person is- if a person is having one of those extra pyramidal side effects from antipsychotics, akathisia, where you're just piecing all over the place, you can use benzo that is a pin as a second line agent. The thing is, we try to know use benzos if we're going to avoid it because again, it can just cause problems, right? So, we use benzos as a second line agent as a second line agent. The first line treatment for akathisia is beta blocker, but if that doesn't work, you can use a benzo that is a pin. And that thing you can also use benzos for an MBME exam is if, for example, a person has some kind of phobia that is infrequently encountered. It is very high, you'll to know. A person has a phobia that is infrequently, not frequently, because you don't want people being on long-term benzos. That's not a smart pharmacologic therapy play. But if a person has a phobia that is very infrequently encountered, let's say for example, they have a fear of flying. The thing is, I mean, well, if you're working consulting, that's maybe a different story. But most people that have a fear of flying, they just go about flying every single day. So, the thing is, in those circumstances, you can give them like a few pills, a few benzo pills, you know, you can even like two or three or something.

That can help them for those flights. And that's it. Because it's not like it's something that they encounter every single time, right? Or let's say, for example, a person has this fear of public speaking, you can give them a benzo that is a pin, especially in a situation on an MBME exam, where you cannot give a bit of blocker. In those circumstances, it is absolutely fine to give those people benzo that is a pin. And then don't forget that you can also use benzo that is a pin when a person is panicking, when a person is having a panic attack. If they are asking you for pharmacotherapy, many times on MBME's giving those people a benzo is not necessarily the worst idea in the world. Obviously, we can also use benzo that is a pin when a person has a seizure. When a person has a seizure, and you want to control the seizures very rapidly, you can give a benzo that is a pin. You can give a benzo that is a pin. And then also, do not forget that you can use benzos to treat alcohol withdrawal. When a person is withdraw from alcohol, you can give those people a benzo that is a pin. Remember, benzo that is a pin, many of them end in pan, right? So like clonazapam, flurazapam, quazapam, diazapam. Although there is one benzo that's kind of special. So it's something that you can absolutely see on exams because it doesn't sound like the other regular benzos. It's known as clonazapoxid. Clor, CHLOR, diazapoxid, clonazapoxid, clonazapoxid, clonazapoxid. It's claimed to be an MBME exam.

It is a long-acting benzo-daisy pin. It is a long acting benzo-daisy pin. It is a long-acting benzo-daisy pin. So if, for example, you're trying to do alcohol withdrawal prophylaxis. So let's say for example, a person comes into the hospital and you know that they are chronic alcoholic and they are going to be in the hospital for a few days. And you don't want them to start withdraw from the alcohol. You can actually load them up with a clonazapoxid to stave off the person having alcohol withdrawal. You can give that clonazapoxid almost like prophylaxically. But in general, when a person is acutely seasoned, clonazapoxid may not be the smartest idea on an MBME exam. On an MBME exam, you want to use something that's a little, you know, short or intermediate-acted. Something that is short-acting or intermediate-acted. So something like lorazapam or temazapam or oxazapam. You want to give something that acts very quickly, very, very quickly. So in general, on MBME exams, thou shalt not use clonazapoxid for the management of an acute seizure from alcohol withdrawal. Clonazapoxid is something you put people on so that they don't start seasoning the first place. But if a person is acutely seasoned, you need to control their symptoms very rapidly. So because you want to control their symptoms very rapidly, that's why you put them on something like lorazapam or oxazapam or temazapam or some like triazolam. So lam is another name you may see that some benzo de esapinsa ending.

Just something you kind of want to keep at the back of your mind as you as you study. So many of them don't want to keep at the back of your mind as you study. Now what if they give you a question about a patient and the patient has a history of marfans for example and those people have hypertension. What kind of drug will be indicated for the management of hypertension in a person that has a history of marfans? What kind of drug? Because they know some of you may be like divine, that is a weird question. But the thing is sometimes our friends at the MBM is they love to, in fact let me not say sometimes, our friends at the MBM is many times they love love love good old integration because they want to do they want to see if you can decipher concepts across multiple disciplines right that's literally part of what constitutes multi-systems processes and disorders on MBM exams. So just think about it. If a person has a history of marfans and they have high blood pressure, what kind of anti-hypertensive will be good for these people? Well let me tell you this. The anti-hypertensive that will be good for these people is a beta blocker. It's a beta blocker. It may be like divine. Come on seriously man. Come on divine beta blockers. Marfans? Why? Okay let me explain. What is one thing that people that have marfans? What is one thing that they can have? One thing that they can have is aortic dissection. They can have aortic dissection.

When you have aortic dissection beta blockers are how you literally treat that acute aortic dissection. And also if you think about it from this context when you take a beta blocker a beta blocker is a cardio depressive drop. So it lowers your cardiac output. It lowers the force with which your heart contracts. If your heart is contracting with little force then the blood that is going to be coming out of it is not going to come out with too much force. So as that blood slap because remember every blood that is proceeding out of your left ventricle is going to slap the wall of the other. That's literally what it does. The other is a tube that transmits blood from the left ventricle to the rest of the body. So the thing is if a person can have cystic medial necrosis I'll say it again for pressing to have cystic medial necrosis. So necrosis of the media remember blood vessel has the intima the media and the adventition. The thing is the media continues a lot of fibrillin. So if you have like bad fibrillin then the network that you have in your media will not be good. So you're especially pretty supposed to aortic dissection.

So the thing is since that aortic wall is kind of hanging on a thread you want blood that is coming out of the person's heart to come out with less force so that when it's slapping the walls of the yoder it doesn't give the wall of the yoder like a really hard horrible slap because if it gives the wall of the yoder a hard horrible slap then that blood is going to dissect through the intima and into the media and cause an acute aortic dissection. So that's why in general people that have a history of morphins if they have high blood pressure beta blockers are not a bad idea for those people or them being exempts. Well what are the drugs that will absolutely be bad ideas for these people on exempts? The drugs that will be absolutely bad I guess for these people on exempts and drugs that have visual dilators. Visual dilators are a horrible idea in people that have morphins like for example post-recharge out hydrolyze. What do you think is the problem with hydrolyze? Well the problem with hydrolyze is that hydrolyze is a very powerful arterial visual dilator. So it may be like to find I mean it's an arterial dilator of course is going to lower these people's blood pressure they're going to feel awesome. No they're not going to feel awesome they're going to dissect that's what's going to happen right because we think about it if you give hydrolyze in it will dilate your arteries.

So if you dilate your arteries well think about it how does your heart respond if you dilate your blood vessels as your dilating your blood vessels the preload going back to your heart is decreased. So your heart is going to be like man where's my preload down? Well your preload is down because you are dilated. So your heart will be like man my preload is down and your borrower receptors they'll also sense gee my blood pressure is down in my vessels I mean I'm sensing low blood pressure in my vessels. So what will your borrower receptors do? Well they'll talk to your brain through your crinion nerves especially like you know the like crinion nerve 10 right and some other different mechanisms I'm not going to talk about that in this podcast but there are multiple mechanisms that are going to play with this you know like inhibiting crinion nerve 10 that that a bunch of other things but you're going to have a sympathetic discharge. When you have that sympathetic discharge well what do you think is going to happen? You're going to increase your heart rate right and you're going to increase the force of contraction of your heart because you're doing that in response to the low blood pressure because you've taken a visual dilator. So you're going to have a reflex stachic cardio you're just going to contract with more force.

Well if your heart is contracting with more force then that blood that's going to be coming out of the left ventricle it's going to come out with more force and because that blood that's coming out of the left ventricle is coming out with more force then the thing that's going to happen is that it's going to be slapping the walls of the other and when that blood that is coming out with more force slaps the walls of the other that's going to cause you to dissect. In fact in general when a presence having an acute aortic dissection hydrolyzing is not a good idea many met students I've seen this from my personal tutoring I've seen this from questions people have asked me what hydrolyzing is not a good idea at all when you have an acute aortic dissection. So obviously if you have a disorder that predisposes you to aortic dissection like morphins like earlys danlos then it's not a smart idea in general to give those people visual die-laders like hydrolyzing. Again you can see all the integration that our friends at the MVM is can tie into this kind of thing. Now if you're looking for a way if you're looking for a review course that integrates things like this I'll strongly encourage you to consider the 20 hour course that I teach.

In fact I'm having a one in this month in the month of November it's going to be taking place on the 21st on the 22nd on the 25th and on the 26th it's going to be for five hours each day it's going to be from like noon to 5pm mountain standard time each of those days. And then I also have an MVM testing and strategy course where I teach you how to break down MVM questions how to pick out the right answer to questions how to if you answer questions where you don't have complete knowledge of what is being tested. Even like you're down to like a 50-50 situation on wow how do I pick one versus the other those are all things that are addressing these courses and people find it to be extremely helpful. The testing in strategies classes actually going to be taking place next week Friday I believe that's the 18th I believe that's the 18th of November it's going to be from 5 to 7 30 pm mountain standard time and then if you struggle bio statistics if bio statistics is abuggable for you and you are not like oh I just want to memorize the formulas because the thing is again on MVM exams these days what they love to do is the ask questions where it's not the formulas that will help you is more the reasoning. So if you want to get your reasoning with bio statistics right I'll encourage you to attend my four hour bio statistics bootcamp that's going to be taking place on the 20th of this month I believe it's going to be from noon to 4 pm mountain standard time.

So to wrap up today let me just say a few more things about beta blockers so beta blockers remember they do many different things right you can use them for a unique dissection that's like the pharmacotherapy you use if a person has hypertension and you have like heart failure beta blockers are not necessarily the worst idea in the world for this people if a person has hypertension and they have angina beta blockers are not a bad idea because beta blockers are one of the things we literally use to treat angina and the thing is honestly you can use beta blockers for so many things that you see on MVM exams right so like for example if a person has like B9 essential tremors you know beta blockers like propranolol are absolutely awesome in these people right in fact if a person has had like an MI right you and you know you want to put them on chronic therapy remember beta blockers especially like metoprolol carvedolol or be so prolonged they have absolutely been shown to improve survival in people that have CHF they've been shown to improve survival in people that have CHF and but forget you can also use beta blockers for things like academia if a person has teach right to can also use beta blockers for those right so there are so many things you can use beta blockers for and I don't want to forget this it was something that was like I'm sure I feel like I'm forgetting something but we bend those remember you can also use benzodiazepines to treat cocaine intoxication when a person has profoundly elevated blood pressures from cocaine intoxication you can absolutely use beta blockers in those circumstances so I think I'm going to go ahead and pause here again I do offer one or one tutoring for all the USML exams step one two three complex one two three preclinical medical exams third year clerkship shelf exams I have these also help with ERAS applications and mock intervie

ws is something that I've done with a lot of people for the cycle already I've been on an initials committee I'm very good at prepping people for interviews and I will not just coach you on responses but I'll coach you on principles because the thing is you're going to see questions that you've never heard anywhere but you can be prepared to answer those questions if you understand principles behind interviewing so I do mock interviews usually an hour and a half long but if something are going to be found to find to be profoundly helpful I give very detailed feedback and then by the way these review courses I offer like the 20 hour review course I talked about is for step two and step three and complex two and three it's also for people that need a very good solid review of most of what you'll be seeing on the as shelf exams all throughout third year and then my MBA me testing and strategy courses for step two and step three and then my biostatistics bootcamp is for step one to step three and complex level one two three and by the way I've also released this for my desk school next year it's going to be taking place over a three week period next year in May so if you want to sign up there's actually limited attendance available for that shoot me an email through the website and then I have these podcasts on the major podcast apps Apple Podcasts Google Podcasts Spotify and then I also have a You Tube channel called Divine Intervention, USMD Podcasts and videos that's where I post the videos that I make and then finally I have another website called Divine Intervention Lifelesses.com Divine Intervention Lifelesses.com many people said wow Divine the life lessons you put at the end of your regular podcasts I really love them many of you know I'm a Christian so what did I do I said I started a new website and every week I post two podcasts most of those podcasts are like 10 mi

nutes long and I use a Bible verse or something to explain a classic problem that's faced by many people so if you want to check that I'll just go to Divine Intervention Lifelesses.com and finally I even have the podcast the podcast associated with that on Apple Podcasts it's called the Divine Intervention Life Lessons Podcasts so thank you for listening to me today I will see you in the next episode have a wonderful first of a day God bless you and bye for now thank you

SSR Is (Selective Serotonin Reuptake Inhibitors).

Bupropion lowers the seizure threshold, and combining it with electrolyte abnormalities increases seizure risk.

SNR Is (Serotonin-Norepinephrine Reuptake Inhibitors), such as venlafaxine or duloxetine.

Opioid overdose typically causes pinpoint pupils due to $\mu$-receptor binding reducing norepinephrine release.

It is a GABA receptor antagonist, used to reverse benzodiazepine and Z-drug overdoses.

Beta-blockers, as they reduce cardiac output force, minimizing aortic wall stress.

SSR Is $\rightarrow$ SIADH (Syndrome of Inappropriate Antidiuretic Hormone) $\rightarrow$ Hyponatremia.

Eating disorders (anorexia/bulimia) or electrolyte anomalies.

Hypertension.

Flumazenil; GABA receptors.

To reduce cardiac output force, thereby decreasing the sheer stress on the weakened aortic wall and preventing dissection.

First line: Beta-blockers; Second line: Benzodiazepines (e.g., lorazepam).

SSR Is $\rightarrow$ SIADH (Syndrome of Inappropriate Antidiuretic Hormone) $\rightarrow$ Hyponatremia.

Eating disorders (anorexia/bulimia) or electrolyte anomalies.

Hypertension.

Flumazenil; GABA receptors.

To reduce cardiac output force, thereby decreasing the sheer stress on the weakened aortic wall and preventing dissection.

First line: Beta-blockers; Second line: Benzodiazepines (e.g., lorazepam).