DIP Episode 132 - The Floridly High Yield USMLE Social Sciences Review (For Step 2CK, Step 3, and maybe Step 1)

Okay, welcome. My name is Divine, I am a resident. This is the 130 second episode of the Divine Intervention Podcast. And to these podcasts, I will be talking about something that is really high-yield for the US ML Es. This is something that will be very helpful on step 2, see can step 3. And really I am going to be focusing today, it's almost like a grab bag. In fact, I am kind of struggling with a name for this podcast. But the focus is just going to be on weird topics. So weird topics that people usually see on the US ML Es. And they are like, this is not in mainstream resource that I may have studied. I have sort of decided to mentally collect many of these things and sort of talk you through them. And the thing is most of these weird topics are focused on the social sciences. So things like patient safety, social sciences, population health, end of life care, power of attorney, just those little things here and there. There are no things that you can again, necessarily find covered like in a comprehensive text. But they are just little things here and there that you know, like kind of like my risk factor spot cast where again try to cut a lot of risk factors, put everything in one spot. That's what I'm going to try to attempt to do here. I'm going to try to put all these high-yield things in one spot. And we're not possible to present them as like case scenarios. But I will just sort of like it's almost going to be like freestyle.

It's going to kind of seem all over the place. But again, I promise you this stuff is super, super, super high-yield for exams. And I will try to be as quick as possible. But this will be a, again, I promise you if this podcast will be well worth your while. If you sort of take notes and sort of keep things at the back of your mind. Okay, so what if you get a question about a patient that you know they have like lung cancer, it's terminal, the in hospice, and they are not really eaten. What kinds of medications can you prescribe for those people? Well, the thing is you can give them a majestral acetate. It's one of those are projecting analogs. You can also give like some derivatives, like some cannabinoid or derivatives like dronabinoid. You can even give steroids. These things can also spurs up that patient's appetite. So if a patient has like really bad cacacia from cancer, you can spurs up the appetite by giving these drugs. Although the thing is these drugs do not like make them leave longer or reduce morbidity or anything like that. But they spurs up those people's are appetites. And then what if you get a question about a patient again, this is like a terminal patient lung cancer, they are not doing well, they are in hospice, they are about to die sort of deal. And the person is like super depressed, right? Like they are like becoming like hopeless, they feel guilty, you know, like the classic Ciggy cap signs of depression.

What kind of pharmacologic therapy would you want to explore in those people? The thing is you should actually consider because the classic thing you may be thinking is, oh, let me use an SSRI. No, a SSRI is not what you would want to consider for depression in the hospice setting. You want to think more about like stuff that's used to treat ADHD like methylphenidate, for example. I mean, if the person is like super anxious, you can consider like a benzo, okay? But methylphenidate in general is what you want to consider choosing for people that are depressed and are like in hospice, like people that have like weeks to leave sort of deal. And then what if they describe a person that has some kind of malignancy, lung cancer, brain cancer, whatever, and they have like really bad like shortness of breath, so like dyspnea? How do you want to treat those people? Right, you actually want to go ahead and give those people opioids like morphine, okay? Like morphine opioids actually like standard of care for that patient population. And then what if they give and real quick, you want to keep in mind that these people that are placed on opioids, right? You need to place them on a bowel regimen, right? Because remember opioids can cause constipation. Now, what if they give you a question about a patient that you know, he's on chemotherapy or like radio therapy and or they have like really bad cancer and they have like a ton of margin, vomited? How do you want to treat those people?

You don't want to give them a serotonin receptor antagonist or like condensitron, right? Basically the drugs that end in cetro, remember this is just like a different factor, but remember that those drugs have the ability to prolong the acute interval. Okay, now what if they give you a question about a patient, you know, they have like terminal like glioblastoma for example, they have like these or like few weeks to live, and they've been feeling super nauseous and they have like increased ICP. How may you pharmacologically help that nausea in that setting of increased ICP? I hope you're thinking about steroids, right? Like you can give like like a prednisone, dexamethasone, basically glucocorticoids can help under those circumstances. Now, what if you get a question about, let's see, how do I put this? What if you get a question about a patient that has neuropathic pain or UMB in me? So you've got a question about a patient, you know, they have like you know like burning, tingling in the extremities. What kind of pain regimen would you want to consider for those people? Well, I hope you're seeing things like, like you're essentially there like psych style medications, right? So you'd want to use stuff like your like your TCA's, right? Remember your TCA is all-end in triptoline, right? Like TCA's, you can also try some SNRI's like deloxetine for example, as a popular one on the exams, or you can use things like gabapentin, pregabaline, stuff like that.

So those are things you want to keep at the back of your mind. And then, what if they give you a question about a patient that has like cancer pain, and they have a history of depression that has been treated for a long time, and then they tell you that this person was pleased on a pain medication, and then this person, all of a sudden, studied like days later, studied having like myoclonus, and they had like fevers and stuff like that. What are you thinking about? I really hope you're thinking about serotonin syndrome and tromadol. Remember, tromadol can trigger serotonin syndrome, right? It's a serotonin agent. So in general, tromadol is usually the wrong answer on endgymies for like cancer pain, because it's not very strong for pain, and it also has like a ton of interactions. And then, what if you get a question about a patient that has like cancer that is like widely bit aesthetic to like the kidneys, to the liver, and all that stuff, and then this person is having like severe pain? What kind of opioid would you want to consider on that those circumstances? I would hope you're thinking about like fentanyl, right? Fentanyl. It's pretty safe, especially in people that have like kidney disease or liver disease kind of deal. The other opioid is for the most part you want to be careful if a person has like liver failure or kidney failure, right? So say for example morphine, morphine is something you should not use in like liver injury or like kidney failure.

Really, most of the, I mean, there are like super specific requirements here, but most of the other opioids like hydrocodone, oxycodone and all that stuff. If a person has liver failure, you want to be like super, super careful when starting those drugs. So at the very least like lower the dose that you're going along with. And then one common scenario that the endgymies love to throw an example is they can give you a question about a person that has like a person that has like really bad like cancer pain, and they tell you that all that like at the last visit, they are morphine dose or whatever was increased. And then they tell you that they come in, you know, they come in tears, they're still completing off pain and all that stuff. And they ask for the next step in management. For those people, go ahead and give them more opioids, okay? They will try to trick you by telling you that, oh, maybe screen the person for drug abuse or whatever. If a person is terminal end of life, you give them as much pain control as they need, okay? Again, within reason, right? But in general, the right answer on endgymies will be to increase the dose, right? To increase the frequency of the opioid regimen. And again, very high yield to remember, for persons on an opioid regimen, give you a next best step in management, question whether or not to believe it or not, is to actually go ahead and give them a bowel prep, okay?

So things like docucytes, you can give things like these cosmetic agents like like a lactol, sorbitol, peg, all that stuff, right? Those can help on those circumstances. And then, what if you get a question about a patient, you know, end of life care, they have like cancer pain, is there a particular drug you want to avoid? The occasionally throw this on endgymies to master people's heads. I would encourage you to never pick me, basically never pick me, period in ever as an answer choice on an endgymie because my period can cause seizures. So it's usually not the right thing to do. They have very few situations where my period in is ever correct. And I don't see that within the realm of the USM Ls. So that's something you want to keep at the back of your mind. And then one classic scenario mission, an endgymie exam, right? If a person lets assume you get a question about like a physician, you know, that comes in, you have the smell of alcohol on that his breath, and all that stuff. And then they ask for your next step in management, right? Your next step will be you want to go ahead and, you know, mention it to, to like people in charge, right? Either like a chief of staff or like the medical board or like a like an ethics committee at like the hospital or something, right? But you want to report it to some kind of a higher authority. And what is the difference? So let me guess I'll frame this as a scenario.

So if a person is still being treated with like, oh, you know what, we have this intent to cure the scancer. Can that person still going to palliative, can that person still be placed on the palliative care? I will hope you're saying yes to that. The thing is, palliative care actually does not preclude you from getting like therapy that make you're like a certain malignant, like a certain disease or me prolong the person's life. Okay, palliative care believe it or not has actually been shown to improve outcomes in patients, right? So you don't need to be like, oh, this person is about to die to get palliative care. No, if a person is severely ill, you can actually go ahead and even if it's not severe illness. In general, it's severe illness patients that go on the palliative care. You go in on the palliative care. There's no mean that, oh, we're sending you off to die or anything like that. No, you want to try to make sure you exempt to be able to differentiate that from like hospice care where, um, you essentially caring for a patient in the last six months of life. So those are things that are high yield to know for exams. And then, um, I know the question you're missing your test made relates to like a medical error, right? So let's assume they give you a question about like an error that was made, patient was harmed, and then they asked for the next step in management.

Some of these things are kind of obvious, but again, they are not things that people think about all the time as they, as they prepare for exams, right? So, if you have an error, we meet the first thing you want to do is to go ahead and admit it to the patient, right? The thing is the MBM even give you like an ethics style question where they say which of the following is the most likely outcome of admitting this error to a patient, right? The original thinking is when you admit errors to a patient, right? You know, the original thinking maybe, oh, I mean, get sued. The thing is a lot of did like the data in general shows that when you admit an error to a patient, the likely outcome doesn't, the likely outcome is you're not getting sued for disclosing that error. So that can be like a very weird MBM question where they say, oh, which of the most likely outcome of so and so, right? So that's something you want to keep at the back of your mind. You're actually likely to not get sued when you disclose, when you disclose an error. And then this is probably kind of like a touchy topic for me, but I will just sort of make I guess like some general statements that are on MBM that you should keep in mind for MB Ms. But essentially like a physician assisted as suicide is not is not legal. It's illegal in essentially every state in this country.

I mean, there are some like gray areas about like where like a person gets a lethal prescription from the physician, but I'm not really going to say I talk about that. And just in general physician assistant assisted like deaths and suicides, they're not they're not legally in this country again. It's not black or white like that, but it's not legal in this country in every state on MB Ms. So just sort of keep that at the back of your mind. And then what if you get a question about a patient where they tell you that, okay, this patient has like terminal cancer. In fact, we don't necessarily have terminal cancer, but let's assume this patient is like super sick. This patient is the 60s 70s. And you know, there's still some medical therapies that can be considered for them, but a patient says, okay, you know what? That said, I think I want to sort of hang my shingles here. I'm no longer interested in therapy and all that stuff. And then the ask for the next step in management. You want to go ahead and respect those patient that patient wishes, right? You don't want to like impose your will as a physician until then. Oh, no, we can save your life by doing this. No, if the patient demonstrates understanding of the situation, the communicator decision effectively, they understand the risk and benefits of whatever decisions they've made, and you cannot impose or force your will on patients as a physician. Now, the reverse is also the case, right?

So if for example, there's like a therapy that's like futile, like has like, like essentially the like the outcomes are not good with that therapy, like, you're just like, yeah, trying this therapy is just like a whistle. No, let me not put it this way. Let me not see the whistle medical resources, but like it's not standard of care. Like it's therapy where you know that there's not going to be any effect on this patient's outcome. Then all that those circumstances, you do not need to, you're not obligated as a physician to participate in those interventions. Right? So the classic case may be a person that has like a severe illness and they're likely going to die. And then like a relative rushes in and says, do this, do that, do this, do that. Even if those things are not, they'll tell you something that they read on Google or in the newspaper or something. If it's not medically indicated, you are not obligated as a physician to do any of those things. And then another touching issue that pops up occasionally on MBM is especially like with OB-GYN questions, they may tell you about like a physician that, you know, has like certain beliefs on things and says, you know what this intervention is not something I'm comfortable, administer. Even if it's something that the patient requests or the patient needs or something that is medically appropriate for the patient, but the physician like says that, you know what my ethical principles disagree with this.

You actually allow out as a physician to disagree with if something violates your ethical principles on MBM is actually allowed as a physician to, you cannot be forced as a physician essentially to administer that kind of care. But the thing you generally have to do is to transfer care of that patient to another physician. Okay, they'll be able to administer those services to the patients. Okay, again, you may see divine you're kind of all over the place. This seems kind of sound weird, but again, I promise you, these are all things that are very high you to know for step two, CK and for step three, especially. And also step one to a limited extent. Now, what if you get a question about, you know, like an old person that, like very old, they're kind of senile, they're not taking their medications as they showed, they keep getting admitted for things that they should not be admitted for if they were like under the care of someone. What would your next step in management before those patients? I would hope you're seeing to go ahead and like, you know, like a point, like some kind of like legal like guardian or something, because those people, they just need people to like make good decisions for them and take good care of them. Okay, because they'll usually make it like a pretty obvious like scenario where this person, if they were under the care of a responsible party, they would not be admitted this often for these problems. That's like the classic way that presents.

So keep that in mind for for your exams. And then I've sort of talked about this in my first ethics podcast where I said that, you know, if you're less than 18 years old and just like still living with your parents or you're not married or you're not like in the like in the army, the Navy or the Air Force or whatever, then your parents decisions are the things that essentially stand right is not like if you're under the age of 18 and basically most of your decisions do not count right there are certain exceptions though, right like for like substance abuse, mental health, reproductive health, kind of deal. And then another thing that classically confuses people on exams is this whole difference between like capacity and competence, right. So capacity and competence. So remember that capacity, right, is something that you can actually determine as a physician. If you're a physician, you can determine if a patient has decision making capacity. And this is something that is especially important on step three, when a patient communicates a decision to you, if the patient does not have capacity, then that decision to communicate to you does not stand, you should not act on that decision in one of the answer choices, right.

So the classic scenarios may be a person that is like under the influence of a substance or a person that is delirious or a person that is altered when those people communicate a decision, you do not respect those decisions, because those people do not have decision making capacity. And I mean there are certain key things right that tell you that okay, this person has a decision making capacity, right. So first thing is to do understand what's going on, right. And make sure they understand what's going on. You want to make sure that they can sort of look at things from like a risk benefit, sort of a sort of standpoint, right. Like, oh, they know the risks of like refusing so so so and so therapy, they know the benefits of accepting so so and so therapy, right. And then like being able like in clear terms, not like in weight terms, like clear terms, communicate the decision to the provider. Those are all things that tell you okay, this person has good decision making capacity, you can go along with whatever decision, the make but competence is not something that you can decipher as a physician. This is something that's best less best left for the legal system, right. And then the thing is occasionally you may see me questions where they talk about how do I put it. The me give you a scenario. And then like how do I put it's almost like a person that.

So let's say like a person's power of attorney or like a surrogate decision maker, the me give you a scenario of a decision that was made by that surrogate and then ask you that like what's the principle that that person followed in coming to that decision, right. So let's say for example, they give you a question and they say that oh, you have like a 23 year old person, you know, they're like the had like an opioid overdose. And the accomortals in the hospital, they're not responsive. And then they call like their next of kin or whatever. And that next of kin says, you know what, let's go ahead and we draw life support. Let's say the person that is comatos, let's say his name is, I don't know, person a, right person a if he was alive right now would say that he would want to be like on life support and this and that and this and that. If the surrogate decision maker is making decisions based on what he thinks the person that is like comatos would agree with, if he were, if we're like with them. Then that would be an example of something called a substituted judgment standard. Okay. Again, these little terms you may say define this looks loyal. I promise you, if you have experience with the MB Ns and the USM, you know that these things I'm talking about are certainly not loyal. So that's substituted judgment standard. It's is basically what like the principle that's very reflected in this person's decision making process.

But if for example, the give your situation where you know the surrogate decision maker and let's say you're trying to decide for a person that's comatos like, okay, let's go with let's say there are two different like treatment options available and the physician has come spoken to the surrogate decision maker and said, you know what? The data shows that this therapy, you know, improves survival compared to this other therapy and things like that. Then if the person, if the surrogate decision maker says, okay, let me go ahead and now. Go with this option that is better medically. Then the principle that's been reflected here is actually not the substituted judgment standard. The thing that's actually been reflected here is the best interest standard, right? So it's just something where like the easy way I try to explain this to people is if for example, if for example, a hundred medical professionals were standing behind you and saying, oh, this is what I will go with, right? And you are making that decision as the surrogate decision maker for like again, like a comatos patient or whatever. And that is the best interest standard like the thing that you feel like is best for the patient. And the thing is this principle is also used by physicians, right? So trauma patient comes in the patient has no family around. It's an emergent situation. The patient is about to die. The patient cannot communicate in decisions.

If the physician does what like is medically indicated on that those circumstances, that is an example of a best interests standard on that those circumstances, the physician is acting as the surrogate decision maker. Very, very high you to know this. And then if a person has an advanced directive, right? And he designated someone as their health care power attorney, then regardless of what happens down the line, that person that was designated as the health care power of attorney is the person that makes decisions for that patient, right? And again, you want to be able to understand like certain like higher terms, right? Like, like what a living will is right? Basically, a living will is like some document where patient has, you know, kind of giving like advanced has kind of given instructions like, okay, is there a specific kind of treatment I want to don't want if I'm if I'm like a terminal illness at this certain things I would want for pin control. Those are all things that going to a living will right the health care power of attorney is like the person that in that living will say, okay, you know what, this is who I want to make decisions on my behalf, if I'm altered and have no decision making a capacity. And then basically the advanced, in fact, let me maybe make this be a little more clear here so that those I don't sound so weak here.

The living will is where you make like specific instructions on this is the kind of therapy I want this is the kind of treatment I'm refusing all that stuff. The health care power of attorney is the person you designates that, okay, this person is the one that's going to be making decisions for me if I'm if I have like a terminal illness or if I'm altered and I kind of make decisions for myself. And then if you essentially take that living will and combine that with the health care power of attorney like designation that is something known as an advanced directive, okay, that's something known as an advanced directive. But now let's assume a person doesn't have advanced directives on who should make a decision for them, right, and then as a physician you have to like choose, okay, who makes decisions for this patient, right, you definitely want to know like the order, like, oh, this is the person I should go with first. If that person is not available, this is who I should go with next, right, so the thing is the person's spouse is the first person you always go with. If a spouse is not available, you go with like one of the adult children, so children over the age of 18 that's very high or two now, right, if those if a, if an adult child is not available, the next thing is the person's parent if they're still alive, if a parent is not available, then you want to go with like an adult sibling. So again, a sibling that is more than 18 years of age.

So again, those are all high ill things you want to keep in mind for exams. I'm certain if you've taken any endgame exams, you've probably encountered these like bizarre questions where you're like, this is not something I read in any book or something, okay, these are just things that people like often intuit on exams, or they actually things that follow a very logical set of principles. So that logical set of principles is what I'm trying to convey as I go through these case scenarios. Okay, and then I mean, obviously you know this, this is not something that we, I need to talk much about, right, but you need to follow hippo laws basically, right, you cannot like disclose a patient's medical information if like a family members requesting it without the patient's or without the patient's directive that, oh yeah, you know what you can go ahead and share this piece of information, but there is exceptions to that, right. And again, there are multiple exceptions, but the one rule I try to remember like one thing that can help me control a ton of things, right. So the thing I tell people that I tutor is essentially the key exceptions to violating hippo is where you want to try to protect the patient or the general public from harm or you have to be the law, right. If you can keep those three things at the back of your mind and your violating hippo, then that's not a problem on NVME exams.

So key things again, are you trying to keep the patient from harm like killing themselves or are you trying to protect the public? So I'm like a homicide kind of deal or are you trying to obey the law, right. Those three things in general, as long as those three things essentially usually for the most part again, it goes on a key is by keys, but for the most part, those three things to proceed having to obey hippo regulations on NVME exams. Now, what if they give you a question about a resident that's just finishing up its shift and then he's about to hand off to another hand off to the next person that is coming on to take over like a team list or whatever, right. This is essentially like it's like a patient hand off a style of question. What are some key things you want to keep in mind when selecting answers. The thing is, you would want to pick an answer that relates to, you know, a hand off happening like in person, right. You want to try to avoid like phone hand off swear possible, right. Again, the thing is there are many different kinds of questions you can ask on these things. So I'm just trying to give you like the key, high old things you want to keep in mind in selecting answers, right. You want to make sure that handoffs are done like face to face where possible, right. You want to provide like key pieces of information, right. In a standardized fashion, you want to do standardized handoffs on NVME exams, right.

And the thing is, you may actually see answer choices that tell you that, oh, as you're conveying information, you want to use a lot of if then statements, right. So, oh, if for example, the patients, he might be in trouble, no seven, go ahead and give them a transmission of the patient become short of breath, get a chest, then get a chest X to rule out like pneumonia or P or whatever, right. So those are the things that make for a good patient hand off. Okay. You want to talk about like the key medications, key problems they have that may change while the person is off shift that you may need to act on. Um, um, labs you may have to follow on again, these are things you want to keep in mind with with patient handoffs. And then, um, I mean, if a medical error occurs, right, you obviously want to do this whole quality improvement business. Um, but the first thing you want to do when an error occurs, right, is to study the error. You want to analyze the error. Um, the big thing you want to keep in mind with like error analysis for NBM is these fish one diagrams, right, like the, the, the so called them ishikawa diagrams. We're essentially right, like if you look at kind of look like a fish, like the head of the fishes where you define the error, and then you keep asking questions, what contributed to this error? And then you say, oh, this thing contributed. And then when you say, okay, this is a thing that contributed, then you now work backwards again.

Okay, what contributed to this thing that contributed to the error, right? You essentially keep identifying factors, factors, factors, factors, factors, almost like the spines of a fish. That's why it's called a fish bone diagram. And then once you've identified an error, identified the causative factors and all that stuff, then if you want to like fix that error, right, that's what's known as quality improvement. The thing is for quality improvement, the higher thing you want to keep at the back of your mind is like the higher core principle, we want to keep at the back of your mind, for example, is something called the PDSA cycle, right. So like the PDSA cycle, the P just basically means like a plan, right. So you're like, okay, this is what we plan to learn. This is the intervention I want to implement in fixing this error, preventing this error. And then the two parties where you actually like, you know, do that thing, you maybe use like a small subset of patients, just to is almost like almost like doing a scientific experiment. And then the S, right, is like, okay, like you study the results of what you just did. And then the A is like, okay, maybe it's like act, right, like you refine your protocol you made or you're refining intervention, maybe like remove some things that you found to not be effective at some things where like, okay, this may make things more effective, right. And that's how essentially again, you fix your fixed year, right.

So like a PDSA cycle is like the backbone of quality improvement on MBA make sense. There is a lot more stuff relating to QI, but I'll say that this is probably the big thing you want to keep in mind for the USM L is. And then there are certain kinds of errors that people can make when they, especially when they have to like make diagnosis on MBA means, right. So like a clinician trying to make diagnosis, there are certain kinds of errors that your friends at the MBA me love to go after with. In like making like diagnostic decisions, right. So there are things you want to keep at the back of your mind, right. So for example, what if they give you a question about a physician that, you know, has. This physician has seen this. Let's say a patient presents with like cough, dyspnea and chest pain, right. And let's say this physician has seen that presentation before and that person that presented before had like had a pneumonia and then the physician just says, oh, yeah, that means since you have the same presentation and this is a new patient, you must have pneumonia as well. Even if the patient has a PE, what kind of air is that? That's an availability air. Okay. It's a kind of reasoning air. It's an availability air. Now what if you have a resident, you know, it comes on for a shift and let's see a patient was admitted like three hours ago. And you know what, let me even make it a little more vague because this is what the MBA me want to probably want to do to you on a test.

What if they give you a question about a patient, you know, this patient presents with like a certain set of symptoms that they've presented with similarly in the past at a different hospitalization. And let's say that different hospitalization, certain diagnosis that we made, let's say, oh, this patient has, I don't know, like paroxysymone, oxygenol, hemoglobin, right. And then the patient comes in this time similar presentation and you just immediately say, oh, yeah, this patient has PNH and you don't think about like a different shallow anything like that. What kind of bias, what kind of areas that call that's an anchoring air, that's an anchoring bias, okay, ANCH or RING, okay. That shows up very commonly on MDM exams. And then what if you get a question about like a resident, you know, he comes on for his shift and you know, he has this patient that was maybe like the attending before the attending left, the attending like quickly admitted a patient. And then handed that patient off to the resident. And then the resident just essentially goes and like everything the attending told the resident he blindly believes everything that attending mentioned like he doesn't even think like, oh, you know what, what maybe another thing that may be contributing to this patient's presentation sort of deal. That kind of bias is called like the blind obedience, it's kind of like obvious from the Trump is called the blind obedience bias.

Where is essentially like if someone that is more senior to you has told you something, you believe it who clients anchor without like thinking independently for yourself as a clinician. And then what if you get a question about a patient where this patient again, like a resident or a clinician patient presents call fever, chest pain. And you see like a chest takes a shot, consoled edition and boom, you're like, it's pneumonia, nothing else. And you don't consider like other things that may be on the differential that may present in a similar way. That's something called like a premature closure bias. We essentially just like you consider one thing and then you don't consider all the things right. That is a recipe for disaster, just saying this as a clinical pair, but that's actually a recipe for disaster as a clinician right. You may get into trouble in the future doing that they may be patients that may present in a common way, but find a common problem right premature closure gets you into those kinds of problems. So I will encourage you, yes, you know what the patient is having right like oh, this patient likely has this but try to consider other things that may be on your differential. Okay, because you may not be able to stand up in court if you get into those kinds of troubles.

Okay, now what if you get a question about in fact this is where this is one ear at the mbm he shines they use like certain like almost like analytic tools like like words that are released to certain analytic tools that people have never heard of before and then be freak out right when we see these things on exams really all you need to do is to be able to recognize these terms on an mbm right. So let's say for example they give you a question about a patient that you know is undergoing like intimate partner violence at home and then the ask like which of the following screening methods may be employed in detecting intimate partner violence in this patient right. The thing is they have three words you want to remember one word is hits okay the other word is heart so like H.A.R.K.

and then the third word is stat right these are the three things you want to keep in mind so hits stat and heart right the hits just means does your partner hurt you that's the H those your partner insult you that's the I those your partner like 13 you that's the T those your partner ever scream at you right that's the S right and then the heart is like oh like has your partner like you may leave it you at any point or are you afraid of your partner has this partner tried to like rep you as this partner like kick to you right that's again kind of like just a mnemonic and then like the stat just means like have you been slapped have you been threatened have you been like thrown around from one end of the room to another by your partner those are all things you can use to scream for.

intimate partner violence and then what if a patient what's he what if a patient you're trying to scream this patient for like alcohol abuse right what kind of tools what tools would you want to use to scream those patients on MB Ms so the thing is there's two of those things right but one is generally better than the other right so everyone knows the cage questionnaire have you tried to cut down I opener do you feel guilty do you feel annoyed when people ask about your drinking that's the cage questionnaire but the thing is there is also something called the audit C questionnaire that you can use the thing is if you see audit C and you see cage as answer choices on an MBM go with audit C audit C is better it has been better validated and it's going to be very effective in screening people for the use and abuse of of alcohol and I mean obviously ready for person is like an alcohol abuser there's certain high yield associations where you want to keep in mind on MB Ms right like they may have like a mega plastic anemia so the MCV may be high they'll have like elevated GGT that's a very high yield thing to give you mind on exams is the ALT ratio right maybe more than like two to one right and the thing is like what makes you classify your person as having like like drinking too much right basically if you're a lady or if you're more than 65 years old so like male female more than 65 years old if you consume more than like seven drinks in a week right or let's say like in one sitting you consume more than three drinks those people are at high risk of being like drinkers like like impaired like I think the term is like if I'm not mistaken I think it's called like at risk drinking and at risk drinker again more than 65 male or female or any female any sort right if you drink more than seven if you have more than seven drinks in a week more than three drinks in one sitting tha

t's at risk drinking for a guy you essentially double that number right like more than four change drinks in a week or more than four drinks in one sitting okay so what it see is better than cage okay again very high yield to know that and then the thing is remember right the different signs and symptoms of like alcohol draw those are things you want to keep at the back of your mind and the thing is like the alcoholic hallucinosis or the therium tremens obviously want to give those people benzos right on the that on that those are circumstances and the thing is in general before you employ the cage questionnaire of the audit see questionnaire with people you want to quantify how much they drink if a person does not drink extensively then it makes no sense to do the cage questionnaire of the audit see questionnaire on those people okay so you may get a question about a person that drinks and then the next best step in management we actually be to quantify their drinking as against the employing the cage questionnaire or the audit see questionnaire the cage audit see questionnaires are things you use after you know how much those people actually drink again you may see divine your these things are like come on these things are who cares I promise you these things are very very high yield to know for mbme to know for mbme exams okay now right also remember if a person is like an alcoholic they come into the eeg right you want to give them time in first before glucose and all that stuff right so that you don't precipitate like we're any key a cross-ochaof syndrome now one high yield thing that people often mess up on the examples is if a person is we drawing from alcohol like alcohol or they are delirious because they are we drawing from alcohol do not give those people anti-dopaminergic agents right you don't want to give them like an anti-psychotic anti-psychotics actua

lly increase the risk of seizure when you give it to people that we drain from alcohol in general if a person is delirious you can give an anti-psychotic but delirium from alcohol withdrawal is treated with benzodiazepines not anti-psychotics that's a very subtle detail that many people mess up but it's something you definitely want to know for your exams okay and I mean in general right if a person has if you so if you're worried about alcohol withdrawal you treat based on symptoms right you don't just empirically boom start a person on like alcohol withdrawal arrangements right you you you the presence of a symptom is what like should trigger you to start treating and then if a person right is addicted to opioids right things you may want to actually properly drink some water things you may want to do to help those people right you want to give them like buprenorphine or you can give them like suboxone that's like the combination of like buprenorphine and and aloxone right those are all things you can use to help people with with opioid dependence right and then if a person is going through a period withdrawal on your mbm is you want to go ahead and go with you want to go ahead and go with quantity as your treatment after scribe the mechanism and the pathophysiology behind that in like certain or podcasts that I have made so you can go and listen to those if you're if in any way interested or you can email me if you're having if you have any questions and then what if you what if you get a question about a patient that is trying to quit smoking what are certain things you can consider as treatment on an mbm exam right so what really one thing you can consider as treatment is like nicotine replacement therapy okay nicotine is so like nicotine gums lozenjis and all that stuff nicotine patches another thing you may actually want to consider your exam is also like bupro

pium right especially if a person has like comorbid depression um so like bupropium remember it's an NDRI right it's an neuropinephrine dopamine reoptic inhibitor that can actually also help with um smoking cessation and then another thing you could also consider is varanicling okay varanicling um works on nicotine receptors if I'm not mistaken I believe it's a partial nicotine receptor agonist it can actually help with a smoking cessation and the thing is of all these three the one that is the most effective is varanicling after varanicling the next most effective is bupropium after bupropium the one that's more if uh next is like the least effective of all these nicotine replacement but it works okay it's just varanicling works a lot better and in general if you if you combine um if you combine uh like instead of using just one thing if you say like oh nicotine replacement and bupropium those work more than using like one of those things uh alone and I'll just tell you this if you get an NV Me question and you see smoking cessation as an answer that is almost always the correct thing to do right and you may see like some novel NV Me questions about like e-cigarettes e-cigarettes are never the right answer okay you should never choose them to help with smoking cessation on an NV Me exam never ever choose e-cigarettes as um smoking cessation eats on NV Me exams okay so um let's see I know I've kind of uh talked about this in a prior podcast but let me just throw that in here because it's something I feel like I can talk about fairly quickly again again repetition repetition always helps right so what is the screening guideline for trippole well I hope you're telling me that uh you can do uh like an abdominal ultrasound for people between the ages of like 65 to 75 right if they've ever smoked right and the thing is one weird one although it kind of means the NV Me does this

to you um but if a person has actually never smoked they can actually still be eligible for triple screening if they have like a family history right they have like a family member that has a triple aid um you can also screen them with one time ultrasound between the ages of 65 to 75 and remember that this only applies to men you do not screen women for for triple ace and then um for osteoporosis right you want to screen people like women men are not screened for osteoporosis you want to screen like women um women that are more than 65 years old right you want to screen them if the T-score is less than negative 2.5 you go ahead and please them on a on a biswas funnit right and then remember that um um if a person is less than 65 and they have like certain like triggering conditions so let's say they've been on steroids for a long period of time or they have like an erection or a vosa right those kinds of people should be screened for osteoporosis even if they are less than 65 years of age um this is probably more for step three but if a person has a has a frax score it's like a score that estimates your risk of fracture within the next 10 years if your frax score is more than like 9.3 percent those people are also eligible for osteoporosis screening again even if they are less than the age of 65 and then um um um the HPV guidelines right obviously for HPV you want to go ahead and screen um let me just make it easy right from the age of 21 to 30 right you do you kill three years or if you want to again you want me kill life even easier you can see from the age of 21 to 65 you screen every three years okay but starting at age 30 you can do it every five years and this is actually what is preferred um you can essentially like at HPV called testing you do that every five years but if a person has like a minute efficiency disease so let's say they have HIV for example you

want to go ahead and screen them every year for with a pap smear and then colon cancer right classically you know hit the age of 50 you start screening um and I mean there are many and you do it every 10 years right although the thing is it's not always uh let me go ahead and let me go ahead and see this um it's not always every 10 years right so they are different means right so you can do like an annual FOBT like a FICAL ACOLT or BLOT test to screen for colon cancer you can do something called the FIT test like it's like an immunochemical test they call it like the FICAL immunochemical test you can also do that every year um another thing you can do is you can actually do like a colonoscopy every 10 years right that one everyone knows um and then you can actually do flexig right so like a flexible sigmaidoscopy like every five years or if you're combining like the flexig with the FIT tests that I mentioned earlier you can actually do that every 10 years like flexig plus like an annual FIT like you're doing the FIT test every year right if you're doing the FIT test every year then you can actually do the flexig every 10 years I'll be shot if the MBM is through that on an exam but again you never know um so those are kind of like the big ones um I mean like these days some people say you know what you can do CT colonography like every five years but uh that's no one I would expect for people to see on an MBM on an MBM exam and remember right if a family member has like colon cancer at the age of 53 right like a first degree relative then you start screening like 10 years earlier right like so you start screening at like the age of 43 basically um oh actually this is high up to no so say for example you get a question I just sort of realize my mistake now so let's say you get a question about a patient that you know they have a first degree relative at colon cancer at

53 here's the thing be then ask you when should you start screening like family members for colon cancer right they'll give you like the age of 40 as an answer to give the age of 43 as an answer the thing is you actually want to start screening at the age of 40 okay so if a person has a family member history of colon cancer you want to start screening 10 years earlier or at the age of 40 whichever comes first so one of these circumstances yeah family member 53 colon cancer but if you subtract 10 years that's 43 but 40 years comes before that so you go with that 40 year screening option again these are all high old things again in the heat of an exam these are things that are very simple that you can get correct if you know the information again okay so again I know it's annoying to think about these things to study for exams but again I promise you these are things you absolutely positively want to know for tests right and then um lung cancer right if a person has like a 30 pack year smoking history and uh let's assume even if the person has quit as long as the equit like less than 15 years ago um you do like a low dosity scan every year right um prostate cancer it's kind of something you kind of need to discuss between the physician and the patient um the only like absolute recommendation like oh everyone seems to agree on for prostate cancer is when you hit the age of 70 um screening for prostate cancer is not recommended past the age of 70 um and then one of the weird things with these pap smears right so if for example a lady has had like uh like a hysterectomy right for um let's say she had a hysterectomy for like a lyoma or something for a b9 reason then you don't need to do pap smears anymore like if you don't like a hysterectomy or move the cervix and all that stuff for b9 reason you don't need to do a pap smear anymore uh anymore but if a person had a hyster

ectomy for like endometrial hyperpleasure endometrial cancer or whatever you still need to do the you need still need to do um pap smears of the vaginal cough that's a very high yield thing you want to remember for the USMME exams and then for breast cancer right like USPSTFCS started 50 till you get to the age of 74 do it every two years um American cancer society says started 40 do it every year right so it kind of varies but in general if a woman is more than 40 years old you can screen her for breast cancer on the mbm exams and then if a person is like sexually active and they have an STI you want to go ahead and screen them for for ST Is right you want to go ahead and screen them for like chlamydia for gonorrhea for HIV the works but if a person is less than 21 you do not do a pap smear on those people okay that's a very that's very important to to keep in mind on on mbm exams and then like some key weird stuff with vaccines right so um um if you're a healthcare worker you should get the heavy vaccine right another again I'm not gonna tell you every single vaccine I'm just gonna tell you the ones that are more commonly tested on exams um the influenza vaccine right it's something that you want to do like every year right in the fall right so if a person comes in in April on an mbm exam the right answer would not be the vaccine it then begins in influenza right um T-dap right like the tetanus deothere and acerelepertosis vaccine right so most people should get like one T-dap dose and then every year they should get the t-d booster every 10 years okay but there's a weird exception to that if woman is pregnant and she's between like 27 to 36 weeks for every pregnancy she actually needs like a full T-dap between 27 and 36 weeks for every pregnancy that she has right and again the varicella vaccine or you don't want to give it to a kid that's less than one year old um

that's kind of how you to know um hbv again if it's a woman you can start as early as age 9 usually on mbm is the goal each 11 but you can do anywhere from age 9 to 26 for a woman uh for a guy you start at 11 right you can do it from like age 11 to like 21 but if you have a case of like uh men that have sex with other men you can actually do hbv vaccination up until the age of a 26 okay that's something that's kind of high or two to know and then they give you a question about like a military crew to her college to like a person like living in a dormitory going to college whatever you want to go ahead and give those people the meningococcal vaccine right you want to go ahead and give them the meningococcal vaccine and then remember right if a person has like if their spleen is gone for some reason you want to vaccinate them against uh encapsulated organisms right so like strep pneumo h flu my sermen ingitis uh sort of deal well if a person is going to be placed on aculisumab right remember aculisumab is uh monoclonal antibody against the c5 so it inhibits a terminal complement component remember that all the normal circumstances people that have terminal complement component to deficiencies they have a very high risk of uh recurring acural infections right so for a person has pne should put in the monoclonal aculisumab before starting monoclonal aculisumab you want to vaccinate them against an icereal meningitis and uh one weird thing they may throw on a test is they may say oh this person has an egg allergy should I give them the influenza vaccine um yes you should you should give them the influenza vaccine for prison has an egg allergy that is not a contraindication to get in the getting the influenza vaccine and again special populations like kids less than a year old pregnant women you don't know when they give them any kind of live vaccine right so what are like

the classic live vaccines that they sort of shuffle around on mbms right so things like I don't know like varicella for example right the mmr vaccine uh the yellow fever vaccine uh i think uh yet we i'm sure the herpes roster vaccine as well is something you don't want to give when an mbm to up again like a pregnant woman and then like the influenza vaccine like the intraniso one that's also a live at an uthead vaccine you don't want to give it to a pregnant woman on mbms and then um the pneumocococcal vaccine guidelines unfortunately uh things you want to keep in mind for your for your mbms right so um there are certain key constructs that they love to throne exams with these uh with these are pneumococcal vaccines right so if for example a person is more than 65 years old they do need the pneumococcal vaccine right like a normal person more than 65 they need a pneumococcal vaccine in fact the way try to when i'm tutoring people and tell them how to remember these pneumococcal vaccines remember it as is this person older than 65 or is this person less than 65 those are like the two big groups of people in general if you older than 65 you should get the pneumococcal vaccine and then there's there's this source of confusion for many people like oh divine which one do i give first do i give the pcv 13 or the ppsv 23 or whatever here's the deal okay remember the lower number should come first so you give the pcv 13 first and then like one year after you give pcv 13 you then slot in the ppsv 23 okay the thing is um in fact i'll talk about this at the end so that i don't jumble things out for people so that's the over 65 case pcv 13 first one year later ppsv 23 end of story okay now if a person is less than 65 they are not always eligible for the pneumococcal vaccine but they may be eligible for the pneumococcal vaccine right so for example if a person has like sickle cell

disease or person has like like phalacymia or a person has no spleen or a person has like something that could make the amino compromise right so let's see they have like HIV or they have like chronic kidney disease or they have like they are like on immunosuppressants because they've got in like some kind of transplant or person has like an immunodeficiency disorder or the person has like a hematologic malignancy Hodgkin's lymphoma leukemia lymphoma stuff like that or person has like nephrodix syndrome remember nephrodix syndrome actually makes people it's like a functional cause of immunodeficiency or if a person has like these are like super weird but the occasion is pop-up on this for a person has like a CSF leak or they have like a like a like a cochlear implant those people do need pneumococcal vaccination if they are less than six even if they are less than 65 right so and those people again symptoms they need PCV 13 and they need ppsv 23 okay that's again another big group you want to keep at the back of your mind now the third major group you want to keep at the back of your mind especially for the people that are less than 65 is if a person has like chronic disease and again kind of think of the major organs heart long liver right heart longer liver for person has chronic disease in any of those organs or they have like diabetes or the alcoholic so they smoke a ton right those people also need pneumococcal vaccination but here's one weird exception again I repeated again for person has like chronic disease or like the heart the lungs the liver okay or they smoke or they drink a ton or they have diabetes they do need pneumococcal vaccination but the only one you give those people is ppsv 23 you do not give them p pcv 13 and then this is something that is more for step three but there are certain people that after they get one dose of ppsv 23 they get another

dose of ppsv 23 like five years after the first ppsv 23 dose the general principle you want to remember here is if a person got their original ppsv 23 before the age of 65 then they should get another one five years later okay that's probably the only thing you want to keep at the back of your mind with exams and then again you want to kind of remember again this is like one of those weird things where you don't know it or you don't but you want to kind of remember like certain vaccines right so I've talked about like the high-year live-attenway-thead vaccines like the intranusal influenza or like MMR or like yellow fever or like varicella certain vaccines are inactivated right so like your T-dab vaccine is inactivated the injectable in freezer vaccine is inactivated right the pneumococcal HPV vaccine meningococcal vaccine hep A hep B vaccines those are all inactivated vaccines right so those are things you want to keep at the back of your mind for exams you want to know like oh is it live-attenway-thead is inactivated those are things that you occasionally throw throw on exams and then I think yeah I think I should probably go ahead and stop here this is going on not for like an hour plus but again I promise I promise you this podcast is floridly high yield for step two CK and for step three in fact if you're a medicine resident studying for like your intranusal exam this is I know that this is a floridly high yield podcast you're going to see things based on what I said tested on those on those exams so I do hope you get something from this as I said at the end of every podcast I draw for one on one tutoring for all the USML exams step one two CK two CSTEP three preclinical medical exams third year shelf exams the medicine internal medicine intranusal exam internal medicine board exam opportunity for all those things and then if you have like a college buddy that n

eeds to learn for like physics, gym camp, all-camp, bio camp, physiology, astrology I'd offer tutoring for all those things right and then if you're like a medicine applying to residency so like an ERAS application or a cholesterol and applying for med school like an amcass app I'd offer like one on one advice in consulting for those things like personal sleeping right in application prep stuff like that mocking interviews things like that again I have a lot of experience in these areas so reach out to me either send me an email divide intervention podcasts with an sadeandadjimeo.com or you can send me or you can reach out to me through the website so have a wonderful rest of your day God bless you I'll see you in the next episode thank you and actually one thing I want to say before I forget so a lot of people have requested that I put these podcasts on like a podcast app that I'm making easy to listen to I'm working on that I've tried multiple times in the past and failed basically but not getting something right doesn't mean I should probably shouldn't have used the term failed not getting something right doesn't mean you failed okay so I haven't gotten it right before but I'm gonna try again and there is someone that is helping me right now that will probably be able to make that happen so it will likely get on a podcast website sometime in the very near a podcast app sometime in the very near future so kind of watch out for that but in the meantime the thing you can do is you can subscribe to my podcast so that whenever I make a new post like a new podcast or something and I post it on the website you get an email or something okay so you can subscribe to my Word Press because my website is a Word Press beast website okay so I think that's all for now thank you for listening or bless you I'll see you next time thank you

H.A.R.K. (Hits, Insults, Tears, Screams).

AUDIT-C questionnaire, as it is better validated.

Protecting the patient from harm, protecting the general public from harm, or obeying the law.

Substituted Judgment Standard (acting based on what the person would have wanted).

Nicotine Replacement Therapy combined with Bupropion or Varenicline.

Age 40 (or 10 years prior to diagnosis, whichever is earlier).

Capacity can be determined by a physician; Competence is a legal determination.

MMR (Measles, Mumps, Rubella) vaccine and Yellow Fever vaccine.

Living Will (specific treatment instructions) + Health Care Power of Attorney (the designated decision-maker).

PPSV23 (Pneumovax 23).

Benzodiazepines are used for treatment; Anti-dopaminergic agents should be avoided.

"If/Then" statements (e.g., If the patient becomes short of breath, then get a CXR).

Capacity can be determined by a physician; Competence is a legal determination.

MMR (Measles, Mumps, Rubella) vaccine and Yellow Fever vaccine.

Living Will (specific treatment instructions) + Health Care Power of Attorney (the designated decision-maker).

PPSV23 (Pneumovax 23).

Benzodiazepines are used for treatment; Anti-dopaminergic agents should be avoided.

"If/Then" statements (e.g., If the patient becomes short of breath, then get a CXR).