DIP Episode 462 - USMLE Step 2/3 Rapid Review Series 96

All right, welcome. My name is divine. This is episode 462 of the Divine Intervention Podcasts. Today's podcast will be continuing the Rapid Review series for the USMEL East Step 2 CK Step 3 exams. This is going to be series 96. Now what if they give you a question about a 45 year old man and they tell you that for the last two weeks or you know three weeks, basically sometime more than two weeks, he's been sleeping more often. He has been feeling down on himself, he has had to take time off of work, doesn't feel like he has any energy to keep going on and he says that his managers, if we offer him the ability to work from home, but he finds it difficult to concentrate on tasks at home. And he just feels like there's, you know, again, there's no reason to keep going on. What should you be thinking about here? Well, I really hope you're thinking about depression, thinking about measure depressive disorder. The thing is, make sure to perceive the disorder, honestly, is a very good backdrop on the USMEL exams for many different concepts. It's a very good backdrop for many, many different concepts. So I would try to in this podcast make a lot of integrations. See, I'm calling a rapid review series, but I'm going to make, try to make a lot of integrations with many different things. It'd be so price that the many questions that can be generated just from measure depressive disorders or concept, but let's start with depression.

First things first, we know that depression is something that we diagnose when, when you've had 5 or more other 9 of these Ciggy Caps symptoms for more than 2 weeks, right? So remember the Ciggy Caps, if you look at the name Ciggy Caps, it's 8 words. So one of one extra thing is low mood or an hedonia. So the essence for sleep disturbance, the eye, most of interest, the G for guilt or worthlessness, the E for energy. So they have low energy. The C is for concentration, people that are depressed tend to have impaired concentration. And then the A stands for appetite. Their appetite is altered. So they have too much appetite or too little appetite. The P stands for psychomotoric tradition or agitation. Then the S stands for suicidal thoughts. So those are ethans, but remember low mood or an hedonia is one of those. It is an extra one to make up the 9. So basically you need 5 or more other 9 of the Ciggy Caps symptoms. And then the pressing can be diagnosed with depression. And remember depression is not just also adjusting that classic limelight. There's also going to be people, especially women that are postpartum. Remember postpartum blues versus postpartum depression is one of those things you want to be able to differentiate on the exams. Postpartum blues is going to be people that have had. Basically they don't need the diagnostic criteria for depression. It's been like less than two weeks or they don't have like 5 or more or 9 of the Ciggy Caps symptoms.

But once you go for more than two weeks, you mean 5 or more or 9 of those symptoms, you have just bona fide postpartum depression. So how do we manage depression? Well, depression is often managed with SSR Is, SNR Is. They're pretty good drugs for depression. We generally love those drugs. Although as we know, sexual dysfunction is a big problem with many of those drugs. So we then try other things. They are certain anti-depressants that are not associated with sexual dysfunction. So things like bupropium, things like mertaza, peanut remember bupropium is an NGRI. It's an European infraned dopamine reopticking inhibitor. It's not associated with sexual dysfunction. Same thing with mertaza, peanut. Mertaza, peanut is an alpha-2 antagonist that can be used for depression. Well, think about why does that make sense? Well, if you block alpha-2 receptors, normally the alpha-2 receptor prevents neuropinephrine release. So if you block a preventer of neuropinephrine release, you release more neuropinephrine and the person is going to feel better. Okay? You know, mertaza, peanut also causes food to gain weight. It kind of improves people's appetite. Let's think of it more accurately or something that improves your appetite and it can also help with sleep. So again, just in general, although when the person is depressed, usually when I go ahead and reach out for an SSR, I want to go ahead and reach out for an SSR. And remember again, people that are depressed, right?

They are certain findings you'll find certain things you'd see, right? In fact, the very similar findings to people that have an arcolepsy, people that have depression, they tend to have like a decreased REM-Litancy. So that means they get to REM sleep very quickly. And when they get to REM sleep, they actually stay there. So they literally have increased REM sleep. So they have decreased latency, but they have increased REM sleep. It doesn't take them long to get to REM sleep, but once they get there, they stay there pretty, pretty good. So that's something that's pretty high to know. And we know that people that are depressed, right? I mean, they're stressed. The single also probably applies to, it's not probably, it also applies to people that are anxious, what have generalized anxiety disorder. These people, they're stressed. So it would make sense that their cortisol should be elevated. Their cortisol should be elevated. So don't be surprised. You see a USML question where a person is depressed and they have like elevations in their cortisol. They have elevations in their cortisol. It's pretty high to know for exams. And then sometimes, the USML is they'll actually give you questions where a person is depressed because of something else. So many times, they love to kind of throw in drugs or organic diseases. So if you think of drugs like data blockers or you think of an interferon alpha, we use that to treat hep C sometimes. It's as good as depression.

Don't forget respiratory donor and your anti-psychotics because those things raise your prolactin levels. Sometimes they can cause erectile dysfunction. Anti-psychotics, they definitely can cause, they can definitely cause a depression. So there's something I want to keep in mind, right? Well, beta blockers are a nice one. And also, people that have heart strokes don't ignore that. People that have heart strokes or people that have recently received like a nasty cancer diagnosis, those things can cause them to be depressed. People that have thyroid abnormalities like hypothyroidism that can cause them to be depressed. You can even see a depression presentation in a person that has like colored urine and abdominal pain. That's going to be a cute intermediate infusion, that can certainly cause depression. So just be kind of mindful of that on exams, right? People that have strokes, especially like left MC strokes, have a pretty solid association with depression, have a pretty solid association with depression. And again, remember, these anti-the drugs used to treat depression, right? There are many different ways they can go with these drugs. Like for example, we know that the anti-depressants, especially the SSR Is. Again, they can cause sexual dysfunction. We can actually use that drug side effect to a benefit by giving them for premature ejaculation. So you see a person, the ejaculate too quickly, you can slow them down sexually in a sense by giving them SSR Is.

They remember SSR Is, they also use for many other things, right? You can use them for OCD, you can use them for bulimia, you can use them, you know, first line from alcohol therapy, white's for PTSD, you can use them for generalizing anxiety disorder, right? And remember, some of these anti-depressants have some key, kind of cool key things to know about them. Like for example, peroxetine, you don't give it to pregnant women, it can cause pulmonary hypertension in the in the fetus. It's kind of a not a good SSRI to use in pregnancy. And then remember SSR Is, you can withdraw from them. So, fluoroxetine doesn't have that problem though. Of all the SSR Is, fluoroxetine has a pretty, pretty strong half life. So it's, you can stop it abruptly and the person is not going to go into SSRI we draw. And sexually of all the anti-depressants is probably like one of the biggest ones that can throw you into a discontinuation syndrome. Although remember, we really, really love sexually in the setting of pregnancy. It's a pretty good anti-depressant in pregnancy. Although of all the anti-depressants of all the SSRI, CTALO-PRAM is a very, very good one. It's a very, very good one. Very, very safe. Although remember, it can actually prolong the QT interval. So see, for example, you've had a RSA Myocardial Infraction. Getting CTALO-PRAM may not always be the smartest idea. It'll always be the smartest idea, right?

So they give you a question again about a person that is depressed, static, and this is RRI. This is not having sexual dysfunction. Honestly, just go ahead and either switch or add on, will prop you. Again, remember, prop is a very, very good drug. It's an NDRI. It's an urban efframe dopamine reopticking inhibitor. But remember, it can also help with smoking cessation so that's good. It can help with weight loss. That's pretty good as well. And again, it has no sexual dysfunction. But let's not discredit the fact that it can lower your seizure threshold. So if, for example, you have a history of a seizure disorder. Let's say, for example, you're an alcoholic. Remember, alcoholics can have seizures. Just remember, if you're drunk from alcohol, remember one of the big, big things you know, alcohol withdrawal is seizures, like delirium tremens, for example. Or let's say you have an eating disorder, like an erectio bulimia that can create electrolyte abnormalities that can cause you to have seizures. I'd be careful about giving a person an NDRI. Be very careful about giving a person an NDRI. If not, you can get seizures that way. And then don't forget your SNR Is. It can raise blood pressure. So if a person has a history of severe hypertension or a history of a fiochromositoma, it's maybe not the best idea in the world to put them on a drug like vanilla vaccine. It's maybe not a great idea. It's not a great idea. And again, remember, these serotonergic agents, right?

If you combine them together, you can certainly get serotonin syndrome. Even this herbal supplement, St. John's work. Many people use it for depression. But St. John's work, remember, it's an inducer, of cytochromp 450. That's one good thing to know. But in addition to being an inducer of CP450, it could simply be used for depressive symptoms. It's also a serotonergic agent. So St. John's work can certainly trigger serotonin syndrome. And again, being an inducer of CP450, it can certainly make a person metabolize drugs really quickly. So just imagine they can give you a question about a person on OCP's that gets pregnant and they're taking some kind of herbal supplement for their depression. That's going to be St. John's work. It's going to be causing, it's going to induce cytochromp 450 to get metabolize away there. OCP is very quickly and they're going to get pregnancy of the half sex. So just something you want to keep at the back of your mind. And then don't forget your MEO Is. The big big one thing with these things is again, obviously they can trigger serotonin syndrome. But again, don't forget that they can also trigger a hypertensive crisis. Because monomyneoxidides helps those breakdown tiring, tiring, it's a sympatomyetic agent. But if you're taking an MEOI and you take a tiring rich food, then you've inhibited MEO so it's no longer able to breakdown tiring. That tiring is a sympatomyetic.

It's going to cause you to have absolutely just crazy crazy crazy crazy crazy crazy hypertensive crisis. And many times when people have that hypertensive crisis, consider giving them something like phentoolamine. That's like a very good alpha blocker where you can give something like like dropper side. You can also bring down the blood pressures very, very quickly. Okay, so just be careful, careful about about that. And then under group group of anti-depressants, right, the tricyclic anti-depressants that CC As. Remember the big big thing with CC As is they can cause anti-colonergic symptoms. So they can cause like urinary tension, delirium in the elderly, they can cause an anti-colonergic toxic syndrome. But don't forget they can also cause also study type of tension because they block out for one receptors. But don't also forget that they are cardio toxic. It's actually pretty high yield to know that these drugs are sodium channel blockers. So they can cause cardio toxicity, they can widen the QRS. That's like the big big thing you're going to see on an EKG with CC As. And we're going to trade that with sodium bicarb. So then by carb, literally you're giving sodium, you're going to reverse that blockade that you get with with a tricyclic anti-depressant. And you know, they are certain cases of delirium of of depression that are, you know, they're kind of called like atypical depression where you see a person, they feel like they're heavy.

There's this whole concept of lidden paralysis. They have like hypersomnia, they sleep a ton or they eat a ton. Because many times like many classic cases of depression, those who are having trouble sleeping, they don't eat, they just feel completely tired. But would I have like atypical depression, they tend to have hypersomnia, so they sleep a ton, they tend to have hyperfigia, they eat a ton. And again, they can have this concept of lidden paralysis. They just feel like the weight of the world is on their shoulders. And these people, if you, let's say, break up with them or say, oh, I'm no longer your friend, they take it very harsh. It really crushes them. They have this hypersensitivity to rejection. Whenever you see these atypical depression, really consider an MEOI as an answer in these people. Think of that as an answer in these people. And again, please don't screw up adjustment disorder. I just mean the disorder. Many people tend to mess it up with depression. It's not the same at all. Basically, when you see an adjustment disorder question, it's going to be a person that either has anxiety symptoms or depression symptoms, but you don't need the full criteria for those problems. And then you're going to notice that you have a recent stressor, like a death in the family, recent diagnosis of an illness, blah, blah, blah, blah. When you see something like that, think of adjustment disorder. Think of adjustment disorder.

Usually, the recent stressor is going to be like pretty recently, usually like a few days ago or a few weeks ago, usually on exams. And again, remember, when a person has depression, you know, just low level depression, chronic you for a long time, sometimes we call that persistent, depressive disorder. I think back in the day, we used to call that this time. But I think these days, it's called persistent, depressive disorder. Again, just something we want to keep at the back of your mind, for exams. And again, we're still going to treat those people with SSR Is. Now, one thing I want to see, again, don't confuse, confuse depression with bipolar disorder. If you were to have bipolar, you're going to see some element of menia in the question. You're going to see some element literally of menia in the question. So just FYI, just be careful about that. Just be careful about that. Because sometimes if a person has bipolar disorder, you catch them in the depressive state, and you're like, oh, yeah, this person has depression. And then you slap them with an SSRI, that can actually trigger manic symptoms in those people. So it's just very important to make sure you can differentiate, make sure to perceive the disorder from bipolar disorder. Bipolar disorder, again, you're going to see some symptoms of menia. Obviously, if a person has bipolar disorder, then we're going to use more for mood stabilizer.

So something like lithium, remember, lithium can cause me for gene diabetes and syphilis. So you can use something like lithium, you can use something like for peric acid, lamotrygene. Sometimes you can even use antichycotics, believe it or not for people to have a bipolar disorder. Okay, so I think these are the things that I kind of want to mention with regards to depression. But please, just make sure you know about depression, right? Make sure you know about depression. It's just one of these things that you know, you can see a lot on exams. Even though, forget ECT, Electroconvulsive Therapy. It's one of these very good abortive therapies for depression. So it's going to be a person who has depression and they're like actively suicidal. You try many things. They're not getting better. Go ahead and try ECT. An ECT by the way is pretty safe in pregnancy. Remember, you know, there's this amnesia side effect that we're about. But many times people are going to recover their memories back. And the amnesia can be both retrograde and an antigrade. So I think I'm going to go ahead and stop here. For those that are taking step one to step three anytime soon, I'd go for courses for that. I actually have a bunch of classes coming up within the next few days. Next tomorrow, which is Thursday, I have an NBM test taking strategies class. It's two and a half hours long. It's for step one all the way to step three.

If you want to get good at taking tests, it's not a content review course. It's a test taking course. You're going to get very, very good at taking USMLE based tests. And then for step one to step three, I have a bio stats class on Friday. It's going to be from four to eight PM, but it's a bit slender time. Again, bio stats these days. Many of the questions are not plugged and chugged. They're more reasoning based questions. So if you want to be good at reasoning through bio stats, taking step one to three, you probably want to sign off of the class. And then I have a social sciences ethics, quality improvement, communications, health care systems, reviews, a five hour class. Also for step one to step three, it's going to be taking place on Saturday from three to eight PM, specific standard time. Again, these classes, many people have taken them and it's caused dramatic score improvements for people. Many people have taken these classes and found them to be extremely helpful. And then I also have a 20 hour review that's going to be taking place next week from one. It's going to be on Monday, Tuesday, basically Monday to Friday, except Wednesday. And that's for step two, step three. And also if you're maybe taking shelf exams, I want a good solid review for most of your shelf exams. It's a perfect course for you. Again, I've had people get very high scores from this, from these courses. So if you're interested in any of them, just shoot me an email.

I'll give some information. I'll give some more information. If you just shoot me an email, they're all over Zoom. These are primarily not lecture based courses. They are almost exclusively practice questions. Because the thing is at the end of the day, just giving you lectures is not going to be helpful. Right? So it's going to be a lot more helpful if you see how those things are more likely to present on exams. So if you're interested in any of these things, just shoot me an email through the website. I'll give you some more information. I also offer one on one to run for step one to step three, pre-clean comments, call exams, study, show off exams. And then I have these podcasts on the major apps, Apple podcasts, Google podcasts, Spotify. I actually also have another website called Divine Interventional Life Lessons.com. Many of you know I'm a Christian. So from a biblical perspective, I upload two podcasts every week that I'm doing a life lesson podcast. From biblical perspective, we talk about common problems that are faced by humanity. So if that's something you're interested in, just check that out. There's actually an Apple podcast associated with it called the Divine Interventional Life Lessons Podcast. And then finally, have a You Tube channel called Divine Interventional US Emily Podcasts and Videos. That's where I post the videos that I make. So just check those out. I think you're going to find those to be helpful.

So until episode 463 of a wonderful day, God bless you. Bye for now. Thank you.

Ciggy Caps (or 9 symptoms): Low mood/anhedonia, Sleep disturbance, Interest loss, Guilt/worthlessness, Energy changes, Concentration impairment, Appetite alteration, Psychomotor agitation, Suicidal thoughts.

Blues is mild and lasts less than two weeks; PPD requires meeting the full diagnostic criteria for MDD and lasting more than two weeks.

Hypersomnia, hyperphagia (increased appetite), leaden paralysis ("weight of the world"), and hypersensitivity to rejection.

SNR Is (Serotonin-Norepinephrine Reuptake Inhibitors).

Cardiotoxicity (sodium channel blockers, widening the QRS on EKG) and Anticholinergic symptoms.

St. John's Wort.

Mood stabilizers (e.g., Lithium, Valproic acid).

Paroxetine.

Decreased REM latency and increased total REM sleep time.

Adjustment Disorder.

MAO Is (Monoamine Oxidase Inhibitors).

Bupropion (NDRI).

Mood stabilizers (e.g., Lithium, Valproic acid).

Paroxetine.

Decreased REM latency and increased total REM sleep time.

Adjustment Disorder.

MAO Is (Monoamine Oxidase Inhibitors).

Bupropion (NDRI).