DIP Episode 442 - USMLE Step 2/3 Rapid Review Series 92

Okay, welcome. My name is Divine. This is episode 442 of the Divine Intervention Podcasts. It's a podcast. I'm going to be continuing the rapid review series for the USM list step two and step three exams. This is going to be series 92. Let's get right to it. What if they give you a question about 22-year-old female? They tell you that in the question that she is afraid to go and see her friends because she is afraid of their dogs. And they tell you during the therapeutic encounter with the physician. She says that dogs really freak her out, dogs really scare her and that she hasn't gone to see any of her friends over the last two years because many of her friends have pets. And then in the question they tell you that all the division asks her that doesn't she have any friends that have no animals. But she says that she can't take those chances. She can't take those risks. And then they tell you in the question that when the physician talks about dogs that the person has facial power, the person seems tense on physical exam. If you see something like this, what should you be thinking about? First things first, I'll tell you this. The Mbim is the old, and you know, they can say this has been going on for months or whatever. The Mbim is answer choices. They'll put like a panic attack as an answer. You can put like panic disorder as an answer. They can put PTSD, they can push in our license side of the disorder. Or be there at all the right answer being the circumstance.

I'll really hope you're saying divine. This sounds an awful lot like a specific phobia. This sounds an awful lot like a specific phobia. The thing is the Mbim is these days they're just very good at writing questions closely enough to wear. Sometimes it may be hard to distinguish one from the from the other. But again, if you know certain salient factors, then you should be in good shape with sorting these questions out. So if you notice in this question, there are a few critical things. One, this person, all the worries, all the fears, everything centers around dogs, dogs, dogs, dogs, dogs, is centers around only one thing. Doesn't center around multiple things. That's one. Two, so the fact that he centers around one thing and not multiple life domains tells you that it's more likely to be a specific phobia and not generalizing anxiety disorder. Because people that have generalizing anxiety disorder, it's multiple things that cause them to have their same like have their symptoms. They don't just worry about one domain of life. They worry about literally multiple domains of life. So that's something you want to keep in mind. Now, if you also notice, this person has not suffered any specific trauma from a dog. It's not like they had a traumatic experience in the past where the dog ripped them apart or some family member of theirs was ripped apart by dogs or they got very ill from a dog or anything like that. They've literally not had any trauma from that dog experience.

Like the dog has not like, they've not had like a real trauma from a dog. At least it's not mentioned in the veneer that I gave you. So that should hopefully draw you away from thinking about things like PTSD in this question. That'll be a very good distractor. But remember, people that have PTSD, they typically will have like some history of like defined trauma in the past. And maybe as we continue this, when I discuss why this is specific phobia, I'll then talk about some of these other distractors as well. But again, this person has not specifically been exposed to trauma from a dog in the past. So it's very, very unlikely to be PTSD. And then, you know, this is not a panic attack or panic disorder because typically in a question that talks about a panic attack or a question that talks about a panic disorder, there will not be any identifiable trigger for their symptoms. If you see like a trigger, you're like, wow, you can give a reason why your person is freaking out about something, sweating, heart rate going up hyperventilating. If you can find a reason, then by definition, they don't have a panic by definition, they don't have a panic attack. They don't panic the disorder. If you notice, this person's symptoms can be traced to either the thought of going to see dogs or seen dogs. So because there is an identifiable trigger for this person's symptoms, this cannot be a panic attack. This cannot be panic disorder.

So hopefully with these key critical things I've said, you can differentiate between a specific phobia and, you know, generalizing anxiety disorder or PTSD or panic attack or panic disorder. Right. So members of the phobia is basically just going to notice a person's going to be like super, super anxious about either like a kind of situation or something. And many of those times these people just make every effort to avoid those things. Or when you bring, oh, let's see, you bring up those things in conversation. They start freaking out, they start flipping out. So people have like fear of animals, some people, you know, they have a agoraphobia, you know, they're just afraid of many different, like, you know, there are many different things that can be the trigger. Blood can be one. That's a pretty common one on exams. They love to put those ones in healthcare students on the USM at least because obviously who are the people that don't make consistently exposed to blood. It'll be a healthcare person or a person that's probably involved in like law enforcement. So it's something you just kind of want to keep in mind. Right. So the thing is what are some other things to know about specific phobia? The critical things I'll say is these people almost have symptoms for more than six months. Remember in psychiatry, time frame matters for so many things. So they must have symptoms for more than like six months. And again, they must be like very distressed by these symptoms.

They must have some kind of dysfunction. Like this person should you to see their friends, not going to see your friends for two years is a little bizarre. So this person just being very freaked out about one thing again, about one thing for more than six months, you know, think about a person having specific phobia. Think about a person having specific phobia. Again, it will center around one thing. Right. Either when you see the thing, they freak out. Even when they imagine or they are talks about that thing, they freak out that specific phobia. And remember, in general, the best treatment for a specific phobia is to just give the person CBT because sometimes on the USM is they're very good at asking, what is the most effective treatment for the patient's presentation for specific phobia. The best treatment is CBT. Right. You can do like exposure therapy. You can do systematic desensitization. You can do things like that. But there is one caveat I will, I guess, throw in here. If you get a question or a situation where the exposure, the thing that causes the person to freak out is so infrequent, then you can give this person a benzodiazepine like a small amount for a short period of time. They can be an abenzo. So let's say for example, a person has like this crazy fear of flying and the flying maybe like once a year, you probably don't need to put them in long-term CBT for something that is so infrequent. Or a person has a fear of MRI scanners.

Again, it doesn't make any sense to put those people in CBT for a long period of time for something like that. Right. It's something, how many, I mean, it's only for patients like malignancy that spread and they need to be checking, checking, checking them so frequently to see progression or response to chemotherapy. But most people don't fall in that category. So if people have a fear of something that is very infrequent, a short act 10 benzodiazepine for a very small amount of time is probably the right move on an exam. And again, remember PTSD basically, for a person that has these intrusive thoughts, you'll have these intense experiences, you know, they'll be like very aroused, very active when you think of certain like traumas of their past. Right. And you see them, they try to avoid any kind of reminder. They don't want to, they don't want to talk about it. I don't want to talk about it. Right. When they're like, okay, can we talk about this bath in the middle of our body or your life? And usually they're going to have had this for more than a month. Remember if it's less than a month, we call it acute stress disorder, but for more than a month, we call it PTSD. And usually, these people would have had some kind of identifiable trauma in the past, right. Either they've been a victim of violence, they're like a first responder, they've been in the military, they've seen many people die, they've been sexually abused, they've been raped, stuff like this.

These are the things that go with acute stress disorder. Again, if it's less than a month, it's more than a month, PTSD. And then remember these PTSD, right. These people are going to need CBT of some sort. They're going to need an SSRI. It's really going to help them. And you know, for the nightmares, Prasovsign is pretty good. And then again, for this GAD, something that you're going to have more than six months, but again, like I said, the person's going to be worried about multiple domains, not just one thing. The question I gave focused on one thing, dogs, not on multiple domains of life. So since this person, they have initials of multiple domains of like is no GAD, GA Ds, multiple domains of life, worry, worry, worry, intense for more than six months. And we treat GAD with SSR Is and SNR Is. And then, I guess panic disorder again, like I said, or panic attack, this person will not have any identifiable trigger in the question. So if you notice that there's an identifiable trigger, then it cannot be a panic attack. But if there's a reason that is given in the question for Prasovsign flipping out, then think, think more of something else. If there's no reason, you're like, man, this person just starts sweating, hyperventilating for like no good reason at all. There's no like, nothing you can be pointing the question that's kind of making them freak out. Then honestly, you probably shouldn't be thinking about any other thing about a panic attack.

And obviously, if you keep having a recurring panic attacks, recurring panic attacks, then that's panic disorder. That's panic disorder. That's panic disorder. Okay, so let's go ahead and move on to conversation. And again, I just want to throw a chip in. If you're taking a USML exams, I have a test-dicking strategy score sticking place today. It's something you'd find to be profoundly helpful. If you're taking step one, step two, step three, if you want to know how to take tests, we're going to be addressing this evening from five to seven, 30 p.m. mountain time. Again, tons of people have taken the course, they found it to be supremely helpful. I've had many people have very strong square improvements from taking the test-dicking strategy scores. And then, if you're taking step two or three, I have a review course that starts on Monday. It's five hours, four days, so that's 20 hours total. Again, we'll go over a lot of IMP, psych, surgery, neuro, OB-guine, multi-systems, processes, and disorders. And again, it's not going to be a series of lectures. It's going to be like a series of scenarios. And we go over like tons and tons and tons of scenarios that will really teach you a little very high-yield content. Again, many people have taken the course, and it's provided that really solid push for them to really well on the exams.

And then, also have a biostatistics class that's coming up later this month, and the social sciences and ethics class that's also coming up later this month. All these classes, except the step two, step three class are very appropriate for step one or the way to step three or complex one to three. So, if you don't show, we'll biostatistics, or you'll show, we'll be like these healthcare systems questions, professionalism, quality improvement, ethics, social sciences, and things like that, communication, professionalism. You should consider those two classes, and they also have a step one class coming up in the month of March, God willing. So, what if they give you a question about a patient? And they tell you that this is a 17-year-old child or a teenager, comes to the, you know, his birth of the emergency room, his friends. They say that he's very sweet talking with physician, that he's a toxic, his speech is not fully discernible, person's speech is very smurred, and you know, they tell you that the person's publicary exam is unremarkable, and that the person vomits once in the emergency room, and you know, this person just doesn't seem to be too worried, they say the person is like, oh, I'm feigning the ER, what should you be thinking about? Well, again, what can the in-beam is do? Obviously, this is probably a drug-obvious kind of situation.

They'll put many different answers, put many different things, they can put like, you know, methamphetamine, they can put marijuana, can put cocaine, put a bunch of stuff, but what's going on here? Well, this person very likely has some kind of intoxication, probably with alcohol. You see a person, they have like disinhibited behavior, slurred speech, etaxia, and all these things, you want to think about alcohol intoxication. So I know some of you may be like, well, divine, couldn't this be marijuana? But again, I didn't say anything about the person having like conjunctiva or edness, I didn't say anything about the person being very hungry. I didn't say anything about the person being toxic. I mean, sorry, I didn't say anything about the person being hungry. I didn't say any of those things. You didn't see conjunctiva issues, hunger, or the person being in an accident or having like a slow reaction time. I didn't say anything about any of that. So this is probably not marijuana. All right, so this is alcohol intoxication. So how those alcohol intoxication typically present on the exam? So typically, there will be a person, you know, there are many different ways. The person will be very disinhibited. You know, they'll have like almost like a lococious personality. They're not afraid of anything. They may be walking within traffic. Many times they tend to have etaxia. They have like slurred speech. But typically people don't have alcohol intoxication.

They don't typically have respiratory depression. Usually don't have respiratory depression. And you know, people that alcoholics, you know, they can have an elevated GGT, the ASTLT ratio can be to the one or more, although that's not a hard and fast role. Basically, the AST will just be higher than the ALT. I wouldn't be so fixated on that to the one ratio that is, you know, thought in many resources. You know, they can be hypoglycemic because remember, when you're taking so much alcohol, you consume so much alcohol, you're what he tries to metabolize it with alcohol dehydrogenase and acetaldehyde dehydrogenase. These dehydrogenases literally produce any DH. So your body's going to have more NEDH than NED+. If you have way more NEDH than NED+. It's going to be really hard for glycolysis to run. Glycolysis runs partly because of NED+. But if you have so much NEDH and you have so little NED+. You're going to have a lot of trouble running glycolysis. If you're kind of wrong glycolysis, you're going to have decreased energy production. Even gluconeogenesis is not going to work well. So you're going to be hypoglycemic. You're going to be hypoglycemic. hypoglycemic is pretty classy in alcoholics. And remember, alcoholics, they can also present with signs and symptoms of renegies. They can be confused. They can have a formal pleaser. They can have it taxia. They can come up with signs and symptoms of renegies.

That's why many times, when alcoholics come to the hospitals on the USML Es, you want to give them farming, whether they have renegies or not. Because you're just trying to kind of Steve that off. And you know, alcoholics, again, because they have like, they can have like a ketoacidosis. They can have a high in iron, gap metabolic acid doses as a result of that. So just something you want to keep in mind with with alcohol. Alcohol has some very classic symptoms. Many times they will know how publicary issues. So that's something you want to keep out the back of your mind. Is rare in MBM Es for an alcoholic to offer a spirituality depression. So it pretty has alcohol intoxication. I mean, really, you just have to kind of bring them into the ED, supportive care fluids, give them, you know, farming, check their glucose, give them glucose if they're hypoglycemic. Although remember, give the farming before glucose, that's very important. And then, you know, you can also put them on a, especially if they have been admitted to the hospital, you can put them on a benzodiazepine as alcohol withdrawal preferlaxis, like a long active benzodiazepine, like chlorodazzy boxide. Because again, don't want those people kind of getting in trouble and getting into like their delirium tremits. And then you know, when they leave, try to get them to alcoholics and animals. And then you can use drugs like no tricks, so you can proceed to kind of help them with the alcohol use disorder.

And then just again, like I did for the first vignette we talked about, you know, some other things, right, like this cannot be, this was just not going to be marijuana because again, people that are zonk from marijuana, you know, they want to eat, they're like super, super one, needy of food. They also tend to have like congenital issues, you have like a very slow reaction time. Everything just kind of seems to slow down around them, right? You would have marijuana intoxication, they very likely would have a slow speech, very likely would have a taxi on the USMELIS. This is certainly not opioid intoxication because it's not opioid intoxication, those people have like respiratory depression. They'll have bilateral popular illnesses because of the decrease in the ripenafrin that's released when you take a lot of opioids. So they'll have like pinpoint opioids on both sides. So that pretty much rolls out opioids. I remember opioid intoxication, I'm going to trigger my locks, so not not now, Trexon, we certainly should should be using the locks and for opioid intoxication. Well, you know, they can even put a benzo because a benzo is kind of similar to alcohol in a sense. But again, benzoes, they can have respiratory depression, but they'll have like normal, popularly finedents. They'll have normal, popularly finedents. Again, this inhibited behavior slurred speech attacks here.

Honestly, those are not, even these like electrolyte problems like glucose issues, high-end, metabolic acidosis, we don't really find those with benzoes. Although, again, if a person has benzo intoxication, remember you can trigger a flow mass in it, flow mass in it. It's a GABA antagonist that you can use to rapidly reverse the effects of benzos. And you know, benzo with role is fetal, right? And benzo with role is actually fetal with benzos. So there are two withdraws that are typically fetal in exams that you cannot just say, oh, just deal with it. No, it's going to be alcohol on benzos. Those you got to treat you, you got to treat those things. There's others, but those are the classic ones they love to test on exams. And again, this cannot be meth of cocaine because this person's, I didn't say anything about like high blood pressure. People that have like cocaine intoxication, for example, the blood pressure is like super, super high. They'll have popularly dry asses because of the adrenergic stimulation, right? Alpha one receptor is going to cause you to have my drastic opales. So these people don't have my dresses. They don't have any of those things. So just something to kind of keep in mind there. Something to keep in mind there. So, and again, remember, cocaine intoxication are treated with a benzo that is a pain.

Usually people that have meth intoxication because sometimes you'll struggle to differentiate meth from cocaine intoxication, but typically people that have meth intoxication, in addition to all these high-pride-generic symptoms like high blood pressure, popularly dry asses, in terms of you tend to have very prominent hallucinations. That's like a very classic feature on the USML Es. Prominent hallucinations tells you a deal more with meth than cocaine. People that have cocaine, you know, they tend to have like more like chest pain, signs and symptoms of like an MI. They'll have like pressure at speech, super-tacky cardiac, crazy high blood pressures. By a lot of popularly dry asses, it's kind of a deal. So I think I'm going to go ahead and stop here. Again, I really hope you found this podcast to be helpful. Again, I do offer one or one tutoring for all the USMLE exams, all the complex exams, step one to three, complex one to three. I also have review courses for step one. That's a 25-hour class, first step two and step three. That's a 20-hour class. A biostatistics class that's four hours long, very, very helpful because again, biostat, they could just memorize formulas, but as you see on the USML Es, these these most biostat questions are not formula based where you plug and chalk. Most of them are reasoning questions. So that four-hour biostat review is more of a reasoning review with scenarios.

And then I also have a five-hour class that focuses on social sciences and ethics and professionalism, communication, healthcare systems, quality and permanent things like that. Again, also for step one to three, just like the biostat class. And then I have a test against strategies class, also for step one to step three. And then I have these podcasts on the major apps, Apple Podcasts, Google Podcasts, Spotify. So just please check those out and subscribe and eat a little bit of support, certainly helps. And then I have a You Tube channel, the Vine Intervention USMLE podcast and videos. That's where I post the videos that I make and also post some podcasts on there as well. And then finally, I have a new website called Dividing Innovation Lifelesses.com. It's a website that many people say, oh, divine, I love your life lessons that you put at the end of your podcasts, at least of some of your podcasts. So I say to make a separate website, Dividing Innovation Lifelesses.com. There is actually an Apple Podcast associated with it called the Dividing Intervention Life Lessons Podcast. And I post two podcasts a week about 10 to 20 minutes long each and using the Bible like the Scossa Life Lesson. Again, many people have also found that to be pretty, pretty helpful. So thank you for listening to me today. I hope to see you in the next podcast. Have a wonderful weekend and God bless you. Bye for now.

Specific phobias center around a single, specific object or situation (e.g., dogs), whereas GAD involves worry across multiple life domains.

Panic Disorder/Panic Attack (These require the absence of an identifiable trigger).

Ataxia and hypoglycemia.

Pinpoint pupils bilaterally.

Acute Stress Disorder (ASD). (If > 1 month, it's PTSD).

Benzodiazepines.

Symptoms must persist for more than six months.

Cognitive Behavioral Therapy (CBT), including exposure therapy or systematic desensitization.

Excessive metabolism of alcohol depletes NAD+, which impairs glycolysis and gluconeogenesis, leading to low blood sugar.

Prominent hallucinations (Meth often causes more prominent psychosis/hallucinations).

Pinpoint pupils bilaterally.

Long-acting benzodiazepines (e.g., lorazepam).

Symptoms must persist for more than six months.

Cognitive Behavioral Therapy (CBT), including exposure therapy or systematic desensitization.

Excessive metabolism of alcohol depletes NAD+, which impairs glycolysis and gluconeogenesis, leading to low blood sugar.

Prominent hallucinations (Meth often causes more prominent psychosis/hallucinations).

Pinpoint pupils bilaterally.

Long-acting benzodiazepines (e.g., lorazepam).