DIP Episode 229 - USMLE Step 1 Psychiatry Review Series 1

Okay, welcome. My name is Divine, I'm a resident. This is episode 229 of the Divine Intervention Podcast. And in this podcast I'll be going through a comprehensive review series for the USML's phone exam with respect to psychiatry. I know that I'm also working on this clean SP curriculum. Again, those podcasts will kind of filter in as time goes over, goes on over the course of this month. But psychiatry is something that you know, it's something that's like you know, pretty high yield for the exam and it's not something that people necessarily know super well, right? So it's one of those things that our cover in a comprehensive series. I mean, ultimately the goal is to cover the vast majority of what's in the first day for the USML's phone book. I mean, for the most part I've probably covered like 40% of the material in that book across my different podcasts, like all the pharmacology in first date, including psych form. I do actually have pretty good podcasts, pretty good, pretty comprehensive podcast for those. So again, if you want to know what podcast use for a certain subject, go to the exam topics list portion of the website and you'll see a Google sheets link. If you click on that, you'll see different tabs like step one. And then each of the first dates subjects like psych, you see what I already have and stuff like that. So let's jump right into it. So and many of these things I'll review them with clinical vignette.

So you can see how they will present on a test and then I'll discuss the concept after after I'm done, right? So what if they give you a question about like like a 10 year old girl, right? And they tell you that this girl, she has been completely of like like lower like she's been completely of like pain around her genitals. And then let's say they tell you that own physical exam, she, she has like a fresh laceration in her vagina, right? What's your next step or what's your diagnosis on the test? I would really hope on that those circumstances that you're thinking about child abuse, right? That child has been sexually abused, right? So the classic presentation on NBM Es, almost always going to be, it's almost always going to be, you know, like you can be like a boy or it can be a girl, right? But usually it's, I'll say for the most part, it's girls on tests. And typically, so typically it's girls on exams, right? And the thing is those girls, they'll present with like weird things. You'll be like, man, this girl is like nine years old. Like how is she, how do she have like a fresh laceration on her vagina, right? Or you may be like, man, this girl has like a purulent vaginal discharge. You test it, you test it, it comes back as positive for like, like, chlamydia or like, nice, you're going to really like, hmm, that's really weird or like, tricklemonous, right? Like whenever you see an STD in a kid, that's like nine years old, 10 years old, that's super, super odd.

Or let's see this patient like in the doctor's office or in the presence of other people is demonstrating like advanced sexual behavior, right? So let's see, this person is like doing things that look like for play or like, like, you know, like simulating like, you know, like touching breasts and genitals and just things where you're like, you're a kid, you should not really know how to do this. Although we know the world we live in today is kind of like a odd place, but you know, besides that on MBM is right? The MBM is not, is like an ideal world if you may, right? So whenever you see things like that, or you should begin to worry that, there is some sexual abuse that's likely going on here, right? I remember the sexual abuse usually, the abuser is usually like a guy, right? But again, think about sexual abuse under those circumstances. And again, whenever you see sexual abuse in a child, right? You want to do a complete physical exam, you want to swap everything, check for HIV, check for hep C, check for hep B, check for all those things, right? But you also need to admit that child to the hospital, right? And you need to call child protective services, right? That's what you do on a test. And I guess the close causing of this is like a child that has been physically abused, right? So whenever you see like again, the classic thing like, you know, bruises in many stages of healing or fractures in many stages of healing, or you see like a spiral fracture, right?

Or you see a child with a sub-draw hematoma, right? That's kind of weird, right? You see a child with a sub-draw hematoma, or they tell you that, oh, you see like circular burn marks on the child's skin from like cigarettes, right? Or you see a child with like retinohamorrhage, like bilateral. That's very high you to know bilateral retinohamorrhage on a test. Again, that's child abuse, right? Once you have an exospecies of child abuse, you need to contact child protective services on your test, right? And a closely related thing here, I want to kind of talk about this in a cluster. A closely related thing here is if for example, right, they give you a question about a child and they tell you that you know, this child is like we've drawn from the environment. This child does not seem to be as moderate as it comes to the physician's office. Doesn't respond to anything the physician is saying, right? And this child has very low weight, like is at that second percentile for a weight or whatever. You want to think about neglect, right? So basically, like if a mom, you know, parents in general, you know, they don't show their kids any affection, they don't give them food, they don't like, that skin to skin contact really does a lot for babies, right? So that thing can actually cause like infantile death. Again, whenever you see stuff like that, again, you want to go ahead and alert child protective services for neglect, okay? Child protective services for neglect.

And the thing is in general, if you do this for a long enough period of time, right, the baby can actually die. The baby can actually die, right? So this is one of those things you want to kind of like watch out for on an MBME exam, right? So again, if you see any of these things, this things are pretty easy. These are things you should try to not get wrong on a test. Now, what if they give you a question about like a 21 year old college student and this college student for the past six months, he has been, you know, performing pretty poorly in school, right? And they tell you that he's always in his dorm room. He doesn't want to come out and he always holds a radio to his head because he's hearing some space forces that are communicating with him or you know, like just weird stuff. Whenever you see that and let's say they tell you that, oh, on physical exam, this, this guy looks on chemt. So on chemt is UNKEM PT, right? I know it's a word that many people don't use often. And they tell you that on physical exam, you know, they try to ask this person questions. He's not responsive. He's very like almost like an allergic, that's an, I know it's an immunology term. But this person is like an allergic human being. If you see that, what are you thinking about? I would really, really hope you're thinking about a schizofrenia, right? Schizofrenia, remember in psychiatry, your timelines are the name of the game. Timelines are the name of the game in psychiatry, right?

So remember, if you, if a person has like schizophrenia styles symptoms for more than six months, right? That'll be schizofrenia, right? But if they have symptoms between a month and six months, that's a schizofrenia form, the solder. And if they have symptoms for less than a month, that is brief psychotic disorder. You do need to know those timelines for purposes of the USMLE exams, right? Now, so obviously I'm talking about schizofrenia. And the key classic thing here is the presence of auditory hallucinations, right? This person is hearing a lot of voices, right? This person is hearing a lot of voices. The other kind of hallucination, I guess you may see on your test, is like a visual hallucination. People with schizofrenia can have visual hallucinations, but that's not a classic mbim exam presentation. Whenever you see visual hallucinations on an mbim exam, the things you want to think about, you want to think about things along the lines of like a delirium, the lyrium is a classic cause. I should probably drink water at some point. So the lyrium is a classic cause of visual hallucinations. I'm under thing that can cause visual hallucinations is when a person has like alcohol withdrawal, there is a stage of alcohol withdrawal that is known as alcoholic hallucinosis that typically presents as visual hallucinations.

And then another thing that can cause visual hallucinations on mbim is, is if a person has low body dimension, classically, we'll be a person that keeps having all these syncopal episodes. They have all these episodes where they keep falling over, falling over, falling over, falling over. And then they tell you that this person has visual hallucinations like these sea monsters in the room or whatever. If you see that, you want to think about low body dimension. Remember that has an association with alpha-synuclein, collecting in those low bodies in the brain. Although remember that alpha-synuclein is also what you find in people that have a Parkinson's disease. So schizophrenia, what are the things you want to look for in schizophrenia? You want to look at a combination of positive or negative symptoms. And the thing is, many people tend to ignore these positive and negative symptoms. But I promise you, I promise you, ignoring these positive and negative symptoms is not a great idea. The thing is, your friends at the MBME, they've been known to write questions where they list a bunch of symptoms as answer choices. And then you have to pick out a symptom that is a positive symptom or a symptom that is a negative symptom. So the positive symptoms, the things like, if a person has delusions, again, a delusion is like a fixed false belief, despite evidence to the contrary. So if you believe that you're like President Obama, for example, that's a delusion.

You're obviously not President Obama, but there's all this evidence to the contrary, and you still believe it. That's a delusion. A delusion is a positive symptom. The hallucination, the auditory hallucinations where they are here in voices, that's another positive symptom. Or if, for example, the person, in their speech or conversation, keeps jumping from topic to topic. Let's see, they're talking about monsters. And then they start talking about the coronavirus. And then they start talking about New York. They're jumping from place to place with their conversation. They have essentially loose associations, disorganized speech. That's another positive symptom as well. Or if you have disorganized behavior, let's say they look on chemt. Looking on chemt is MBME code word for disorganized behavior. Or the person is catatonic. Let's say the person stays in one fixed position. Does he move their hair? Does he move their arms? They're stiff. If you see that, that's a that's a caratonia. Those are all examples of positive symptoms. And remember that those positive symptoms are controlled by having high levels of dopamine in the misolimbic pathway. Those positive symptoms are controlled by having high levels of dopamine in the misolimbic pathway. The negative symptoms are things like, you know, you cannot get anything from the patient. So like a flat effect. Or they are stuck in their dorm room all the time. They don't want to come out. So like social withdrawal.

Or you tell them to complete a motor task or participate in a physical exam. They don't want to do it. So like, I think that term in psych, I think it's called like, illusion or something like that. Where they don't just want to participate in life. Or you know, they're quiet. They have a positive of speech. So like, they have poor speech, poor thoughts. They don't want to think or they don't want to speak. Those are all examples of negative symptoms. I mean, generally, if you have two of these positive plus negative symptoms that I've mentioned, you can confidently see that the person likely has that the person likely has a schizophrenia. And against schizophrenia, there are some very high old things you want to keep at the back of your mind. It's very common in men. And it tends to shop much earlier in life in men on NBM exams. It tends to shop much earlier in men on NBM exams. And remember that if a person is a teenager, there is an association. There's a very well-established association between using marijuana and having an increased risk of schizophrenia. And the thing is unfortunately, schizophrenia is one of those disorders that has a very strong association with committing suicide. Almost half of the people that have schizophrenia at some point in their disease course actually end up committing suicide.

And again, like I said, remember the misolimbic pathway, having high levels of dopamine in the misolimbic pathway, is what controls the positive symptoms of schizophrenia. But having high levels of dopamine in the misoccurricle pathway, actually, I take that back, having low levels, very high to know this, having low levels of dopamine in the misoccurricle pathway is what controls negative symptoms. We'll have to correct my brain there for a second, right? So again, please don't mix this up. I promise you, you may say, divide why you're making a big fuss about this. I promise your mom making a big fuss about this because I like to hear myself speak. No, that is very far from the truth. You're absolutely need to understand this, especially if you want to understand pharmacology. And the thing is in these podcasts for psych, even if again, I know I already have like psych pharmacology podcasts that you should listen to that going to the stuff in detail. I will try to sprinkle psych farm as I go through these podcasts. So essentially, again, I'll say this again, the positive symptoms are from having high levels of dopamine in the misolimbic pathway. Okay, the negative symptoms arise from having low levels of dopamine in the misoccurricle pathway, right?

And remember that when people have schizophrenia, right, when people have schizophrenia, if you do bring imaging, I mean, I'm not saying every person has schizophrenia will have this, but this is something they will have on an MBM exam. They will have diluted lateral ventricles. They'll have an increased size of the lateral ventricles on imaging. That's a very high yield thing to know for purposes of MBM exams, right? And then what are some other pathways that, you know, kind of relate to dopamine, right? Because again, they're kind of high yield to know. Some other pathways that you want to keep in mind, you want to keep the migrostradal pathway in mind, right? Whenever you have low levels of dopamine in the migrostradal pathway, right? That tends to be associated with having extra pyramidal symptoms of the anti-psychotics, right? So like having things like acute dystonia or acathesia or Parkinsonism or tiny dyskinesia, those extra pyramidal symptoms, they all arise from having low levels of dopamine in the migrostradal pathway, right? Or if they give you a question about a patient that's being treated with an anti-psychotic, and let's say it's a guy and he's studying having like enlarging breasts, right? So like gynecomastia or a woman, and let's say, you know, she's like in her 50s, and she's like licking breast milk from her breasts, right? Like, you know, just signs of hyper-prolatinemia or like low libido and stuff like that.

You want to think about the the tubero-informed Ebola pathway, right? Remember, when you have low levels of dopamine in the tubero-informed Ebola pathway, right? That will cause a hyper-prolatinemia, okay? That will cause a hyper-prolatinemia, right? So do not forget that factor, right? That's why again, anti-psychotics can really kill a person's sexual function because they cause hyper-prolatinemia. I remember that prolatin is a potent inhibitor of GNRH, right? So when a person has hyper-prolatinemia, I mean, that's why women that are breastfeeding, right? Essentially, again, I'm not seeing this, you didn't hear this from me, right? Again, remember, these podcasts are not for clinical decision-making, right? They are more for test-taking purposes. I feel like I have to, you know, kind of say that, you know, just to protect protect myself. But basically, when a person has high levels of prolatin, if you're breastfeeding, for example, that's why women essentially don't have men'sses for the first six months or they're about after they deliver a baby and really for pregnant woman, if a woman for the first six months after she delivers a baby has sex, she'll probably not get pregnant, although the exceptions to that rule, right? So that's why you should never trust in that again. Don't say, oh, divine said on this podcast that after I deliver a baby, I can have sex for six months and no worry about having a kid. No, I'm just explaining pathophysiology here.

Again, I'm not giving you any marital or sexual advice or anything of that sort. So let's kind of leave it at that. Okay, so because again, remember, another name for dopamine is prolatin inhibiting factor, right? So if a person has low levels of dopamine because you've blocked dopamine receptors, through that tubular and fundabular pathway, the person will have a hyper-prolatin. Okay, good. Now, so schizophrenia, right? So, you know, after you've obviously met the diagnosis of schizophrenia, what, how do you treat schizophrenia? I feel like the way to talk about this, let me kind of, again, go into some detour on pathophysiology, right? So the thing is we've said that the pop because schizophrenia, the two things you want to try to control are the negative symptoms and the positive symptoms, right? You want to control the negative symptoms and the positive symptoms. You want to control the negative symptoms and the positive symptoms, right? But notice what I said earlier about that isolimbic pathway and the misoccurricle pathway. When you have high levels of dopamine in the misolimbic pathway, right? That will make the person's positive symptoms worse. But when you have low levels of dopamine in the miso, so let me try to speak. So high levels of dopamine, misolimbic pathway, positive symptoms worse, low levels of dopamine, misoccurricle pathway, negative symptoms worse, right?

So if you wanted to treat positive symptoms of schizophrenia, it would make sense that you want to give something that is pretty awesome at blocking dopamine receptors, right? You want to give something that is phenomenal at blocking dopamine receptors. That's one goal you want to try to accomplish. But if you want to treat negative symptoms, you actually want to try your very best, right? You actually want to try your very best, to increase levels of dopamine in that misoccurricle pathway, right? That will help you treat negative symptoms. That's one factor. I want to go over a series of related facts and then I will kind of talk through like the high yield from ecology you want to know with regards to the anti-psychotics for purposes of the USMLA exams, right? That's one thing. The second factor I want to talk about is in the misolimbic pathway, you tend to have more dopamine receptors than serotonin receptors. I'll say that again. In the misolimbic pathway, you tend to have more dopamine receptors than serotonin receptors. That is not the case in the misoccurricle pathway. In the misoccurricle pathway of dopamine, you tend to have more serotonin receptors that you have dopamine receptors. I'll say that in the misoccurricle pathway, you tend to have more serotonin receptors than dopamine receptors. Again, I know some of you may be seeing divine who cares about this.

I promise you, if you understand these facts, then anti-psychotic pharmacology will be like a joke to you literally. And I know that that's a sore spot for many met students. That's what I'm trying to spend time breaking it down here. Although again, I also talk about these things in the site from a ecology podcast. Now, the third fact is there is an inverse relationship between dopamine and serotonin. Whenever you have high levels of dopamine, you have low levels of serotonin. Whenever you have high levels of serotonin, you have low levels of dopamine. And the reverse is the case. Let's say you have low serotonin, you have high dopamine, whatever. Just basically remember that there is an inverse relationship between those things. The thing is, if you look at the classic drugs that I used to treat schizophrenia, the anti-psychotics, like the first generation anti-psychotics. So, you know, things like haloparidol or flufenazine or tri-floperazine. I think tri-floperazine is spelled as TRI, FLU, OP, ERA, VIN, I think that's the way it's spelled. So tri-floperazine, right? Those typical anti-psychotics, those drugs are phenomenal. They are remarkable at blocking dopamine receptors. If you block those dopamine receptors really well, you can already begin to see why these drugs would be great for positive symptoms, right? They are great for treating positive symptoms. The first generation, typical anti-psychotics, they are amazing for treating positive symptoms.

But they actually worsen negative symptoms of schizophrenia, okay? They actually worsen negative symptoms of schizophrenia because think about it. If you block those dopamine receptors, even if they are few and the mesocharical pathway, you are almost like pharmacologically lowering the dopamine even more, right? You're lowering the dopamine even more. And that would increase the person's risk of having negative symptoms. That's why if you notice, when a person gets like haloparidol, if you don't like a psychrotation or anything like that, you notice that those people tend to be docile, they tend to be quiet, they tend to be like super calm, like they don't really interact with life much because you've worsened their negative symptoms from getting those anti-psychotics. And again, that's why if a person is acutely agitated, right? They tend to, or if a person is acutely manic, you can actually give them an IV anti-psychotic, that will calm them down very quickly because it's almost like you are inducing negative symptoms in those people pharmacologically, right? So those typical anti-psychotics, right? You know, they are good for positive symptoms, but they are not great for negative symptoms. That's where the second generation of the atypical anti-psychotics coming to play. Those atypical anti-psychotics, they are, those atypical anti-psychotics, they are very good at treating both positive symptoms and negative symptoms.

Now, you may wonder, okay, define, how do those atypical anti-psychotics work? The truth is, those atypical anti-psychotics, their primary mechanism of action is that they have the ability to block serotonin receptors. I'll say that again, the atypical anti-psychotics, their primary mechanism of action is that they have the ability to block serotonin receptors. The thing is, they also have a minor ability to block dopamine receptors, right? So don't say, or, define say that they cannot block dopamine receptors because that would not be true with it, right? So that would not be true, right? They do actually, in fact, have the ability to block serotonin, so they block serotonin receptors for the most part, but they also have the ability to block dopamine receptors, right? So think about this for a second. If we're dealing with the mesochotical pathway, where I said in rule number two, there is a very large number of serotonin receptors in the mesochotical pathway and a much smaller number of dopamine receptors, if you block those serotonin receptors, remember, rule number three, where I say that there is an inverse relationship between serotonin and dopamine. If you pharmacologically blocked those serotonin receptors in the mesochotical pathway, that will raise the levels of dopamine, in the mesochotical pathway. So that will actually help with treating the negative symptoms of schizophrenia, right?

And then because these drugs have some mild ability to block dopamine receptors, and I said that they are high levels of dopamine receptors in the mesolumbic pathway, it would make sense that those drugs can also somewhat help with the positive symptoms. But the thing is, because these drugs have like multiple mechanisms of action, right? You know, in addition to block inserotonin, they also blocked dopamine, right? They are not super, super great at one thing. Versus the first generation like Hallopere dole, fluffenas, intriphloperes, where the entire job in life is to block dopamine receptors. If you only do one thing, let's say like you only do root canal as a dentist, you don't see any other kind of patient, you'll be awesome at that one job you do, right? So that's the exact same thing that happens here. If you're a drug that blocks dopamine receptors as your primary means of like your primary like a job in life, that's like your job description, you'll be great at positive symptoms, right? So the first generation, the typical anti-psychotics, they are the best for treating positive symptoms, but the second generation anti-psychotics, they're actually the best for treating negative symptoms. They are not as good as the typical anti-psychotics at treating positive symptoms, right?

But the thing is, in general, in clinical practice, if a person is being studied on a medication for schizophrenia, usually at least in my experience, and this is actually something you want to take with you to step 2ck. In addition to step 1, which I know is the primary thing you're worried about here, in general, in general, in general, you can, people tend to start with the typical ones because as you learn very soon, they have the lowest side-effect profile of the anti-psychotics, right? They have the lowest side-effect profile. So that's a very high-yield thing you want to know for the purposes of exams, right? And again, if you're blocking these dopamine receptors, right? You already know what's going to happen, we've talked about the tuberculosis pathway, you already know the mechanism behind the hyper-productive emia, and we've talked about the mechanism behind many of the extra-parameteral symptoms. So although those extra-parameteral symptoms are kind of high-yields to know in terms of how they present and how they treat it, right? So the first one is like, I mean, there's this numonic that most people remember, like, adapt, right? So, ALDA-PT, adapt, adapt, right? So that's like a numonic to remember the order of symptoms in a person that has the extra-parameteral, like, whatever, right? So the AD, right? Doesn't stand for Anthony Davis, I mean, you guys know my Likers fan, I think Likers are the best thing in the world, but that's a different conversation.

But AD stands for acute dystonia, right? Acute dystonia, right? So the classic presentation of acute dystonia is usually will be a person's face or upper extremity that is held in one position. Or they have like weird, like, oh, they may say like, oh, they hyper-extend their neck or they repeatedly hyper-extend their upper extremity. If you see that and they'll usually tell you that, oh, they were studied on a drug for schizophrenia, like a few days ago, if you see that, think about acute dystonia, that's why it's called acute dystonia. It's a dystonic reaction that happens acutely, right? Whenever you see that on an NBME, the drug you typically want to give is Diphon hydramine, right? You want to give Diphon hydramine. Diphon hydramine is a H1 blocker, but it also has very powerful anti-colonelgic activity. So in general, I'll say like 95% of the NBME questions that I have seen where a patient had acute dystonia, the correct answer to that question was the use of Diphon hydramine. You can also use a Ben-stropine, right? Well, Ben-stropine, think of it as a second line on an NBME example, right? So Diphon hydramine is the big bad boy you want to use on an NBME exam, right?

And I mean, you can already imagine if Diphon hydramine has an anti-colonelgic properties, that's why, you know, they could write a question where a patient like, you know, has been having like a cold and the patient has been taking like over the counter-code medicine and then the person starts seeing monsters in the room. That's the Lyria, right? Because if you're taking over the counter-code medication like Diphon hydramine, you get the anti-colonelgic effect and the person can have the Lyria. That's why again, over the counter-code preps are not very great for elderly people, right? Or you can even give you an anti-colonelgic toxic, toxic, drum question from a person that has been taking over the counter-code medication, right? So like, again, the patient has like urinary attention, so they may have like superpublic fullness, right? Telling you that their bladder is distended, what do you mean? Have like DMEB hyperthermic, DMEB tachycardic, DMEB constipation and all that stuff, right? They may have like bilateral and my dry asses, right? Those are all things that tell you that, oh, this person is going through an anti-colonelgic toxic, right? So those are the, so that's acute dystonia, right? And then the next one is acathesia, that's the A, right? Acathesia, basically those people cannot sit still. They feel like their bodies are about to jump out of their skin, they are basing about on the test. If you see that, your first line medication will be prepranolone.

You use a non-selective beta blocker like prepranolone as first line. If prepranolone is not an answer choice, then go with a benzodiazepine. Benzodiazepines are very good for the treatment of acathesia, right? Although sometimes your friends at the MBME, they may really try to, you know, like, royally mess with your head by giving your prepranolose as an answer and giving your benzodiazepine as an answer. And then let's say somewhere in the question, they may give you something that is a contraindication to those people getting prepranolone. For example, right? If a person has like reactive airway disease like asthma, right? It's probably not a great idea to give those people a beta blocker because I mean, I mean, it's only if you want to, you know, maybe close up their airways for a change. If you do that, I mean, you know, obviously patient will die if you do that. So, you know, you don't want to do that, right? So, if a person, if they give you a contraindication, in fact, I tell people this, this is actually a test taking strategy right here. If you see two drugs that can treat the same disease on an exam, go back to the question and look for contraindication to one, okay? That's a very high-yield test taking strategy to know for the purposes of the USMLE exam. So, although they tend to play that trick more on people on step two CK, but they also do that quite a bit on step one. You know, so there's something to watch out for, right? So, acathesia, right?

So, first line is a non-selective bit of blocking, like, per per normal. Second line is a benzodiazepine. And then the Parkinsonism, right? Parkinsonism, like, it will be a person that will study an anti-psychotic, and the person will have, like, co-guarigidity. They won't be moving much, right? So, they'll have, so they'll have co-guarigidity. They'll have, like, poor movement, right? They'll have, like, the resting tremors. If you see that, right, you absolutely want to think about Parkinsonism. And the drug you want to use as first line on your test is Benstropin. Benstropin is a most chronic receptor antagonist that can be used to treat the Parkinsonian things that people get with those anti-psychotics. And the thing is Parkinsonism. Parkinsonism, one thing you're, okay, let me talk about two things here. First thing I want to say is, just like I said, there's an inverse relationship between serotonin and dopamine. There is an inverse relationship as well between acetylcholine and dopamine. So, if you give something that blocks acetylcholine receptors, that will raise the presence dopamine levels, and that will help with treating those extra pyramidal symptoms, especially the one with Parkinsonism, right? Because it arises from having, like, low dopamine in the migrostradal pathway, right? That's one thing to know. Second thing you want to keep at the back of your mind.

The thing is, your friends at the NBM already know that most people think about Parkinsonism as a side effect just with these anti-psychotics. So, the thing is the occasionally, it's not even occasionally, they vary frequently, right? Questions about a person that has Parkinsonism, but they are not taking an anti-psychotic, right? They typically go after this with like the drug for diabetic gastroprysis, like metoclopromide. Remember, metoclopromide is a dopamine receptor antagonist. It can cause any of these extra pyramidal symptoms, right? Another classic one is like these drugs that are useful like nausea, like intemotherapy, right? So, they can write questions relating to this. So, things like clopromazine, right? Or fiery dazine, right? Those drugs are used for nausea. They don't use them as anti-psychotics in general. They either use to help people sleep or to help people like MSS or like nausea. They get those drugs. Those drugs have the ability to block dopamine receptors. So, you're absolutely for the purposes of NBM exams. Want to know that those drugs can also cause extra pyramidal symptoms on a test, right? So, they can give you like a non-skits of freinia-based question where a person is having extra pyramidal symptoms. You want to watch out for that on a test, right? And then, don't forget, so I guess that's what I'll say about Parkinsonism, right? So, first line for Parkinsonism is bench-stroping.

But second line on a test, you can use a dopamine agonist like bromo-cryptin or carburegulin, right? And then the final one is started with this kind of gerat. So, usually this involves the tongue on an NBM exam, right? So, the person will be having like these web movements of the tongue and all that stuff. If you see that, like repetitive movements of the tongue or their face, or something, think about hardy dyskinesia. It tends to shop like months or years after the person is getting started on the anti-psychotic. And your first step in management is to go ahead and stop the anti-psychotic. And then, you can actually switch them to an e-tipico. Usually, those people would have been on a typical anti-psychotic for a prolonged period of time on NB Ms. So, your first step on the exam is to stop the drug. Whenever you're having toxicily from a drug, you need to go ahead and stop that drug. It's kind of obvious, right? Stop the drug. And then after you stop the drug, the next thing you do on an NBM is to switch them to an e-tipico anti-psychotic. Okay, you switch them to an e-tipico anti-psychotic. And then, don't forget, right? If you give your question about a person that, again, has taken any of these anti-psychotic drugs or metoclopromide or fireydezino clopromazine, and then they tell you that, oh, this person has this person, you know, has like a very powerful luchocytosis with a preponderance of neutrophils.

And the person's creating kinase is elevated, and the temperature is 103, and they have muscle rigidity. What are you thinking about on an NBM exam? Well, I would really hope you're thinking about your elliptic malignant syndrome. Okay, your elliptic malignant syndrome, right? And the way you treat that is, you know, you go ahead and stop the offending agent, obviously, right? And then you want to give those people dantrulling. Remember dantrulling is a calcium channel blocker. It's a ryanodine receptor and antagonist that can be used to treat tally this, sorry, that can be used to treat NMS, right? Although you can also give a dopamine agonist, but if you saw dantrulling, pick dantrulling first over that. Remember, NMS presents very identically to malignant hypothermia on an NBM exam. It's just malignant hypothermia, who have a different kind of exposure as the inciting agent, right? So for example, the person would have been exposed to like, soxinocoline. So maybe it's a person that has this presentation after they were in to be dead, right? And got like a muscle relax and whatever. So like, soxinocoline or like being held on aesthetics like, Hallothane, for example, right? Those things can cause malignant hypothermia, right? And again, the treatment is the same. Although for that, again, you for sure want to go with dantrulling on an NBM exam. And remember malignant hypothermia is a genetic disease, right?

Remember, it has like autosomodominant inheritance and it tends to arise from like mutations in the ryanodine receptor or the dihydroperidine receptor, right? And I know some of you may be seeing the vine. How does that make sense? Well, think about it. The ryanodine receptor is a receptor that physically is theatered to the dihydroperidine receptor that we find on T tubules, right? So think about it. Whenever you, if you think about normal muscle contraction, you know, the action potential wave is traveling down the T tubule. When the T tubule, you know, starts jerking, the dihydroperidine receptor will open. When the dihydroperidine receptor opens, it is physically coupled to the ryanodine receptor, right? So when the dihydroperidine receptor opens, the ryanodine receptor will open and then calcium will be released from the sacroplasmic reticulum. And that will promote like aberrant muscle contraction, right? And then that will cause the muscle rigidity and all that, all that stuff, right? So if you wanted to treat the problem, right? It will make sense that you block those ryanodine receptors with a ryanodine receptor antagonist like denturally. In fact, sometimes on the NBM, I can imagine them writing a question where instead of saying, Oh, this person has malignant hypothermia, what's the pathophysiology? Instead of writing like mutations in ryanodine receptor, it may write an answer that says mutations in a calcium channel, right?

That's a way they can present that on a test and again, pretty much everyone will get it wrong, but hopefully you won't get it wrong because I mentioned it in this podcast, right? And then just to, I guess as I begin to think about ryanodine appear because I have something I got around for pretty quickly, one thing you want to think about, right? So let me just do like a quick run through of the high yields with the anti-psychotic medications, right? So if for example, they give you a question about a patient that is on an anti-psychotic and the patient has like a like a neutropinic fever or has a granulocyteosis, I hope you're thinking about clasping on the those circumstances, right? Remember clasping can cause a granulocyte osis, obviously, you want to stop the drug if the person starts having those problems, right? If you see a person that is on clasping and the person develops a fever, stop the drug, stop the drug, okay? Stop the drug. Remember clasping can also cause like hypersalivation, there's this thing that's called like wettelocene drug and it can also cause myocarditis, right? So you can present as a diliphic cardiomyopathy on an NBM exam and then please don't forget that clasping is one of the two drugs in all of psychiatry that has been shown to decrease the risk of suicide, right? The other drug is lithium, that's a high yield, floridly high yield factor to know for purposes of the USMLA exams, right?

And then if they give you a question about a patient that's taking an anti-psychotic and they have like signs and symptoms of hyper-prolactinemia, what's the drug you want to think about? I hope you're seeing a respiratory, right? Respirato, or if they give you a question about a patient taking an anti-psychotic and they have like torsad the plant or they have like a prolonged cutie interval, what do you want to think about? I hope you're thinking about the prassy don't, the thing is all the anti-psychotics have all these side effects, but if you're asking about these, there's one drug typically, the NBM wants you to worry about and that's what I'm essentially really not to you here. What if they give you a question about a patient that's taking an anti-psychotic and this patient then develops cataracts, what are you thinking about? I hope you're thinking about with thia peen, right? I hope you're thinking about with thia peen, that's the drug that's I think commonly known as seroqua in the hospital, right? And then if they give you a question about a patient that's taking an anti-psychotic and the patient, you know, develops diabetes or develops hyper-prolactinemia, where you want to think about oolanzapine, right? When you think about oolanzapine, I remember oolanzapine has that strong association with like weight gain, metabolic syndrome, but remember oolanzapine is also third line for the treatment of OCD, okay?

It's third line for the treatment of OCD on NBM and then if they give you a question about a patient that has like an anti-colonetic toxic syndrome, after taking an anti-psychotic, you want to think about the low potency, so I didn't necessarily talk about this, but the first generation anti-psychotics gain two groups, right? There's the low potency ones and the high potency ones. The high potency ones are the drugs like aloe peridol, flofenazine and tri-floperaazine that I talked about earlier. The low potency ones are drugs like clopromazine or thiofixine, right? Those drugs are associated with the presence of anti-hamm side effects. What does the ham stand for? The heach stands for heach one, the heast stands for alpha one and the M stands for M one, right? So if you block the most chronic receptors, you can get an anti-colonetic toxic syndrome. If you block the alpha one receptors, you can get orthostatic hypotension, right? So they can easily make up a question about a person that's taking one of these anti-psychotics and then he's started on a drug for angina like a nitrate and then the presence that's having syncopal episodes, think about orthostatic hypotension that has been exacerbated, right? And then the anti-heach one, right? Those drugs can cause sedition for sure, right? So again, you know, there's something you want to keep in mind. The other drug class in general is psychiatry that has those anti-hamm side effects, like your tricyclic anti-depressants.

I'll talk about those in a future podcast. So do remember already talked about these things in the psych-pharmacology podcast. Okay. And then I think I apologize again, I promise I'll answer. But there are some other things that have skits in the name that people tend to screw up that I've not talked about, right? So I'll just mention them here. I've talked about skits of friendly form, right? That's skits of freinia. The symptoms for like one to six months. I've talked about skits of freinia, obviously. And you want to know skits, soy personality disorder, right? So skits of personality disorder, I remember skits of personality disorder in general, right? These are people that are loners and they actually don't want to hang out with people, right? It's a skits of, it's called a skits of personality disorder, right? And then there's and that one a skits of typo, right? So skits of typo. So skits of typo people are people that are loners, but they are loners because they're weird, right? So no one wants to hang out with them, right? So you know, a person has like, we're thoughts on things or they're weird like all these like things that you may see in people that are in the occult, right? So like all these like amulets and chains and stuff or you know, they're kind of like dressed weird whenever you see things like that, think about skits of typo personality disorder, right? So essentially it's like a person that has like symptoms of skits of personality disorder.

So they are loners, but you have like all thoughts on things like all thoughts if you see that. Think about skits of typo personality disorder. And then another one that is, people usually get this wrong on test for some reason, it's a skits of affective disorder, skits of affective the way I think about it is I think of it as an equation of two things. One, the person will have a recent stressor and then two, the person will have MDD-like or generalize anxiety disorder like or a mania-like symptoms, right? But if you actually go through the question and you physically count out that criteria for those disorders, they don't meet the full criteria for any of those things, right? So say for example, you calculate only like three out of nine of the C-CAP symptoms. So they have five out of nine of those C-CAP symptoms only for like three days, right? If you see that, think about that like that I'm talking about, MDD-like, GAD-like or mania-like, if you see that in combination with a recent stressor, oh wait, sorry, in combination with psychosis, whoops, you know what, actually, I just made a mistake. So this thing I just talked about this equation because I whenever I treat other people, I talk in terms of equation sometimes to simplify things. This thing I just talked about is adjustment disorder. So I guess think of that as a bonus, my apologies, skits of affective disorder is the person will have like psychosis as the first symptom that shows up in their life.

So let's say they've had like, they've been here in voices for five years. But then two years ago, they started having like depression, style symptoms or mania-like symptoms or anxiety-like symptoms. If you see that, that skits so affective disorder. And in general, the timeline does not matter on MDM's. I mean, two weeks is something you can, I guess, stick to the bank, but in general, the timeline doesn't matter. So if you see a person that has psychosis first in their lives, like that's the first thing that showed up in their lives. And then they started having like an affective disorder like depression or anxiety or mania, so like bipolar-ish symptoms. Think about skits of affective disorder under those circumstances. And then I guess with the anticycotics one drug, one drug I'd mention was a RIP Brazil. It's a passion agonist at dopamine receptors. So remember, whenever you have full dopamine around, if you have a passion agonist around, it's essentially acting as an antagonist. So I think I'm going to go ahead and stop here. As I do at the end of every podcast, I do offer one on one theory for many exams, right? So like step one, two CK, two CES, step three, preclinical medical exams, 30-ish-off exams. I've talked about my longitudinal tutoring that I do in many podcasts where I tell you for all your block exams or all your shelf exams. And at the same time, I'm also building up a solid knowledge base for your USML exams.

Again, I've done that with people, they've done really well with that. And then I offer booster courses, right? It's 20 hours for either step one or step two CK or step three. Basically, we meet in 21 hour sessions or 10 to hour sessions, where we review the most notes, the most notes, right? So the highest of the high yields for those exams. I review those high yield things with you in a Q&A, like integrated format, very rapid fire. And again, many people have seen like very big scoy increases, they found it to be super helpful for their exams. So if that's something you're interested in, I feel free to reach out to me. And then if you're a medicine or a plant to residence here, so like an ERAS application, or a college student applying to med school, so like an Amcass application, I go offer like one on one like Advising, or you can call it coaching for these exams, right? So like like rec letters, editing and writing, personal statements, editing and applications, mocking reviews for different specialties. I go offer those things again. The vast majority of people I work with, imagine their first choices in very competitive as specialties and in very competitive locations. So if you have a tricky application like low scores or no research or no aware rotations or post-shelf grades and stuff, reach out to me. Again, I've been an admissions committee member, right?

So there are ways you can overcome these tricky situations by constructing a well put together application, right? So if you're interested in any of those things, I feel free to reach out to me and I'll be happy to point you out in the right direction. And again, if you have anybody that needs tutoring for the MCAT or any of the pre-med subjects, I tutor for those of you have bodies that are residents, like I am resident, so peace resident, I tutor for the in-training exam specialties and the board exams. So thank you for listening. I want to go over my life lesson. My life lesson is the value of what is a life lesson I wanted to talk about. The value of doing an excellent job, right? So the thing is, unfortunately, medicine is one thing that almost like predisposes people to having this bad habit, right? And that's doing a half-ass job, right? I mean, like the thing is, if you're doing is better to not do something at all than to do a half-ass job, right? If you're studying well first, if you're studying for a step, you might as well do a good job, right? So if you're doing something, just do it with all your heart, right? You know, like, like, do something to wear like, if you look at you, be like, man, like, you have like this internally economy that you've done the right thing that, man, I've done a really good job here. I feel like I didn't screw over this thing. I feel like I put in my heart and soul into this thing I did, right?

So anything you do, just do it with all your heart. I mean, there's a part of the Bible that says, if your hand finds anything to do, you know, do it with all your heart as on to God, right? So, you know, whenever you do something, just do an excellent job. The thing is people that do excellent jobs are the people that tend to be rewarded, right? And the thing is when when there's like a bad circumstance, right? So let's say like in a particular field, let's see everyone is losing their job in that field. The person that is the best, the person that does an excellent job will still have job security, even in the time of crisis, right? So again, it's just one of those things, one of those attitudes that is one of those things where if you're excellent in one part of your life, you're usually excellent in other parts of your life. So thank you for listening. Sorry, this kind of went long, but thank you for listening. Please subscribe to the website. It's a Word Press website, divine intervention podcast.com. Subscribe to the podcast. It's on you. This podcast on Apple podcasts, beyond Spotify, they're on Google Play. I know like the first like 70-ish episodes and not on those websites on those apps. I don't know for whatever reason, I've tried those things many times and for whatever reason, those early episodes do not pour over. So if you want those episodes, just go to the website and download them.

Again, the website is divineinterventionpodcasts.com okay, with an S at the end. And if you want to reach out to me, you can either reach out to me via email, divineintervention.com again, podcast with an S at the end. Gmail.com. Or you can reach out to me through the website and also please subscribe to the You Tube channel. It's called a divine intervention USML podcast and videos. So thank you for listening. I will see you in the next podcast. God bless you and have a wonderful day. Thank you.

Bruises in multiple stages of healing, spiral fractures, sub-dural hematoma, bilateral retinohemorrhage, or fresh genital lacerations/ST Is in a young girl.

Schizophreniform disorder (Symptoms lasting between one and six months).

Lithium and Clozapine.

Typical (first-generation) antipsychotics, which block D2 receptors.

Diphenhydramine (an H1 blocker with powerful anti-cholinergic activity).

Benztropine (a muscarinic receptor antagonist).

Delusions (fixed false beliefs), hallucinations (e.g., auditory voices), disorganized speech/behavior, and catatonia.

The mesolimbic pathway (high levels of dopamine).

Low weight/second percentile, lack of affection, poor hygiene, and multiple bruises/fractures.

Schizotypal Personality Disorder.

ADAP Ts (Acute Dystonia, Akathisia, Parkinsonism, Tardive Dyskinesia).

Anticholinergic toxic syndrome (due to blocking muscarinic receptors).

Delusions (fixed false beliefs), hallucinations (e.g., auditory voices), disorganized speech/behavior, and catatonia.

The mesolimbic pathway (high levels of dopamine).

Low weight/second percentile, lack of affection, poor hygiene, and multiple bruises/fractures.

Schizotypal Personality Disorder.

ADAP Ts (Acute Dystonia, Akathisia, Parkinsonism, Tardive Dyskinesia).

Anticholinergic toxic syndrome (due to blocking muscarinic receptors).