DIP Episode 209 - Family Medicine Shelf Review Series 2

Okay, welcome. My name is Divine. I'm a resident. This is episode 209 of the Divine Intervention Podcast. In this podcast, I'm going to be continuing the Family Medicine Show for review. This is going to be part two. And really in this podcast, I'm going to be going over the psychiatry that's tested on the Family Medicine Show. Okay. So think of this as a Family Medicine Show for review, psychedition, basically, right? And I know some of you may be saying psych on the Family Medicine Show. Well, again, trust me, I've two people for these exams, right? So I kind of know what I'm talking about here. There is a fairly decent number of psych questions on the shelf. Really, if you understand what I talk about in this podcast, you should be pretty much set from the psych perspective on your Family Medicine Show. So I'm just going to jump right into it. I'm going to talk about like it on 90 different topics and then we'll be done. And obviously, I'm going to talk about it with a Family Medicine perspective, right? Not necessarily with the psychiatry, but with the perspective, if you may. So the first topic I'll talk about obviously is going to be depression, right? So make sure to press the solder. And again, the MDM will not write the question where they want you to think about the psychiatric diagnosis and not give you some kind of hint. They should think along those lines on the test, right? So the thing is depression, right?

Like, you know, they may give you like a screening-related question on your exam and they ask you to pick the best statement that helps you screen a person for depression, right? Basically, the questions you're using Family Medicine, you're just as the patient. Over the past two weeks, have you felt down? Have you felt depressed? Have you felt hopeless? Right? Or you can say over the past two weeks, have you had little, have you felt like little interest or have you had little pleasure in doing things? Basically, if the person says yes to any of these things, right? So, okay, I guess maybe let me see these questions again, right? So over the past two weeks, have you felt down depressed or hopeless, right? Or you can say over the past two weeks, have you felt little interest or pleasure in doing things? Again, if the patient says yes to any of these things, you need to kind of screen them, you know, sort of go down the diagnostic pathway for depression. The thing is, it's actually kind of high you to know that just in general, in internal medicine, like in medicine, in internal medicine, family medicine, in general, is this love for what I call gateway questions? You ask the gateway question. If the person is positive, because again, you don't have like copier amounts of time to spend with patients, right? So if a person is screens positive with a gateway question, you then go down like the big rabbit hole, right?

But if the person doesn't screen positive, then you don't need to go down the rabbit hole, right? So if the person answers yes to any of these questions, then you need to then apply CG caps to those people, right? And remember, CG caps is eight letters, right? So that means there must be a ninth thing that's included, right? And basically, right? So what does CG cap stand for? So the S is for sleep, right? The ice for loss of interest, the G is for guilt, right? The E is for low energy, right? Many times they put fatigue as low energy on nbim exams. And then concentration is the C is the appetite, please like the psychomodory tradition, right? And then the S is society and then the ninth thing, right? Is like low mood or any don't. Right? So basically, if the person has five or more, so if they have at least five of these nine symptoms for two or more weeks, right? They have they have a major depressive disorder, right? And the thing is, obviously, major depressive disorder, they are certain treatments which I'll talk about in a second. But if a person, right, you know, is like in danger of like harming themselves or harming other people immediately, you need to, you need to hospitalize the patient, even if it's against their kind of like desires, right? So you can hospitalize them. And if a person has like, you know, like major depressive disorder, they have like psychotic features, right? Or you know, they have like a suicide plan and stuff like that.

You do need to refer them to psychiatry on an nbim exam, okay? Like, you know, maybe you can hold them against their will in the hospital, but you need to consult psychiatry to treat the patient, right? That's kind of like beyond the purview of a family medicine or practice. And the thing is, if for example, the mbim gives you a question about a person that has like depressive-like symptoms, but they tell you that the kind of describe symptoms either like in the present moment in the question or like in the past, that you know, the person had like manic symptoms and you want to go ahead and make the diagnosis of bipolar disorder on that those circumstances, right? So again, bipolar disorder is just basically a person having like, mean, yeah, right? And then they have depressive episodes as well, right? I mean, it's called bipolar. Bipolar, the word bindings to polar means two poles, right? So it's like, you have elevated mood at one point and they have very depressed mood at the other point, right? And then there's some other like depression-related disorders you want to be able to recognize for your exam, right? So like, there's this one called like seasonal affective disorder, you may see on your test, right? It's basically like a subtype of depression. And for the most part, those people tend to have like the onset of symptoms like you know, brewing like the fall of the winter and then like when the season updates, the symptoms go away as well, right?

For the most part, you treat seasonal affective disorder SSR Is and phototherapy. I'll see that again. Seasonal affective disorder is treated with SSR Is and phototherapy, right? And then a major depressive disorder like condition that's not really major depressive disorder is just like, you know, like a grief kind of reaction, right? So they'll talk about a person that actually died, right? And you know, the person may have like depression, stout symptoms for like a transient period of time. But really, I'll say like a normal grief reaction usually on NBA meases. The person will just be sad, right? And the thoughts will focus around the person that died, right? If the person starts having like psychosis or hear someone speaking to them, like someone that like not the dead person, essentially like some other brother in some other state of country or whatever, speaking to them in their dreams or whatever, that's psychosis, right? That's psychosis. That's psychosis, right? And if the person is like completely bit down, like, you know, like almost like they're like in bed for days and days and days and on end doing nothing and they have like just really super bad guilt about the whole event, right? That's not a normal grief reaction, right? That's not a normal grief, that's not a normal grief reaction. You don't need to kind of like keep tabs on that on an exam, right?

And then another depression related disorder is like a pre-mentro dysphoric disorder, like PMDD, some people call it PMS, although PMDD is like a most severe form of PMS, essentially, but basically, right? These people will have like depressive style symptoms, anxiety style symptoms, and you know, they'll kind of be emotionally all over the place and typically starts about one week before the start having mencies and the symptoms go away like one week after mencies end. Typically for this people, you get like, you take like a symptom diary, right? That's actually the best way to make the diagnosis. You give them a symptom diary, they kind of check off boxes and then you have them come back into the office and then you can formally make the diagnosis and begin to proceed towards treatment. And then for your family medicine shelf, just kind of be careful, right? Some find some people can have like substance abuse issues and may present as depression or maybe hypothyroid. Remember typically when a person has depression or they want to go ahead and you know, just check your TSH to make sure they're not hypothyroid. If a person has cushion syndrome, again, remember, steroids can make a person's bringo waco, right? So, you know, you kind of want to be careful with that or people that just recently had like a stroke or a person that has Parkinson's, those people can have depression as a presentation, right?

And then don't forget, again, if a person is taking cortical steroids, it's really like IV cortical steroids, right? For like, like an exacerbation of some kind of rheumatologic disorder or autoimmune disorder, those things can trigger depression and also the drug interferon, right? So they can give you a patient with hep C that recently studied treatments and then has like depressive style symptoms. If you see that, you absolutely want to think about a like depression secondary to like a substance or something like that, okay? And again, they'll usually give you hints in the question that I'll tell you to maybe go ahead and do some kind of diagnostic testing for these other disorders, right? And in general, again, depression, you probably want to go ahead and start with an SSRI, right? On a name-be-em-exam. Although occasionally, they may give you like some patient specific factors or like some side effects that may lead you to go with one versus the other, right? So for example, like if a person has, you know, like a history of like really bad like cardiac disease, like they have a history of like CHF or like really bad hypertension and all that stuff, sexually is actually a pretty good drug for those people, right? So if a person has like, you know, really bad cardiovascular disease, sexually means probably the answer you want to go ahead with on your exam, right? And obviously, right?

If a person has like any kind of sexual dysfunction or they don't want to gain weight, they maybe want to lose weight or they want to quit smoking, bupropium is not a terrible choice for those people. Remember bupropium is an orapinephrine dopamine reoptic inhibitor, right? So, you know, it has fewer sexual side effects, doesn't cause weight gain, how to smoke incestation, right? Or remember, you don't want to give a bupropium, right? To people that have like bulimia or any of those things because they can have electrolyte imbalances that can set them up for seizures because bupropium lowers the seizures threshold, right? And then if a, remember that this drug metasapine, remember metasapine is actually an alpha-2 antagonist. If you remember from step-studying for step-1, the alpha-2 receptor is a G-pertine coupled receptor, it's an inhibitory G-pertine coupled receptor. So when you activate it, right? That decreases the release of caracolomins, but if you inhibit it, you will increase the release of caracolomins. So it's good in that setting, right? But remember that it actually causes sedation and weight gain, right? So if a person has major depressive disorder, right? And they have like in sub-like on-comitant in Somnia or they have weak loss, then metasapine is an excellent drug on imbim exams for those people. And then there is this anti-depressant known as people calling Paxel in the hospital, but it's paroxetine, that's an imbiosionanemia in exam.

You actually do not want to give it to a pregnant woman, that it's actually like pregnancy category D. So if a woman is pregnant, given paroxetine is not an awesome idea, basically you'll get the question wrong if you did that on an imbim exam, right? And the thing is, if for example you have a patient that you know has been placed on an anti-depressant and for like six to eight weeks, they don't appear to be responding, essentially your treatment options on an imbim exam is you can either increase the dose of the anti-depressant they're on, like titrate it to the maximum dose, or you can switch them to a different anti-depressant, or you can switch them to another class of anti- so you can switch from one anti SSR to another SSR, or you can switch to a completely different drug class like switching from like an SSR to an SNR, right? And the thing is one common question that pops up from students all the time, again I tutor tone of people, right? So, um, they say, oh, divine, um, how do I treat like a person's like first episode of depression? The thing is, when a person is having depression for the first time, you know, you go ahead and study them on an anti-depressant, and you know, basically like when you get to a dose that you know helps them kind of like have the symptoms go away, right? You kind of keep them on that dose for like, you know, like four to nine months roughly, and it should be fine.

But if a person after that first episode of depression then has another recurrence of depression, right? The thing is, um, so say for example, uh, or let, okay, let me give you a tritian principle. Let's say a person has depression the first time. You treat them for like four to nine months as I've talked about. And then let's see, the depression goes away even after they stop the drug, right? Let's see, the depression goes away for like six months, and then boom, they have a like another recurrence. The smart thing to typically do on an MBM exam is when you're treating them the second time, right? Again, if you notice them, it may be seen like some weird things, maybe like, oh, the wine stove is kind of weird. The thing is the family medicine shelf, as you probably have heard is kind of a weird shelf, right? So unfortunately, some of these bizarre things I feel that need to kind of talk about, right? Again, just my experience having like two to three than a ton of people, right? So the thing is, if a person has like their second recurrence of depression, like basically take their depression free interval after like the initial medication was stopped, right? And then double it, and that should be the length of time that you treat them for, right? So again, if for example, a person again, like the like after the first episode, the coach, three or four to nine months, and it didn't have symptoms for like six months, right? And then the depression comes back.

You want to treat them for like six to 12 months, essentially, right? Almost like double the time where they didn't have depressive symptoms. But here's another high-youth into them. If a person has depression, right? And you know, they get treated and the treatment is successful. But within like within less than a year after like the stop treatment, the symptoms come back. Typically, you want to go ahead and treat those people for life, essentially, with an anti-depressant. Another key rule there is if a person has like multiple like recurrences of depression, let's say like three or more, basically if a person has like three or more recurrences of depression, they also need to be placed on life, lifetime, anti-depressant therapy, right? So again, let me repeat that part because I feel like I'm not having very clear. Let's say a person comes in with depression, right? You treat them for four to nine months. You stop their medication. After you stop their medication, if within less than a year, their symptoms come back. Those people need to be placed on life long anti-depressant therapy. Alternatively, if a person has had like three or more recurrences of depression, they also need to be placed on lifetime anti-depressant therapy, right? And then don't forget this serotonin syndrome, right? Like again, especially people that have been treated for depression. Right? So people taking like SSR Is and maybe they have taken all the SSR Is or you know, like MAO Is.

In fact, they may make this a question. Representing a SSRI, they stop it and then like two, three days later, they start an MAOI. Those people are going to get serotonin syndrome. Remember, you usually need to wait for about two weeks for the SSRI to wash out before you start like an MAOI or TCM. So they don't get serotonin syndrome. So again, don't forget your serotonin educations, right? So your SSR Is, your MAO Is, right? Even a person that has Parkinson's, the MAO being inhibitors, right? So allegedly or essentially don't forget St. John's work, right? So if a person is taking like a hypersupplement on your exam, right? If a person is taking like trasodone or dextramethorfen or linesolid or remember, linesolid is a 50s inhibitor. If you remember that from step one, you use it to treat like VRE and MRSA. But it also has weak monominoxidys inhibitor properties. So you know, it can kind of cause problems, right? The dextramethorfen, right? So the person is being treated on SSRI and then they are taking like some kind of cough syrup. Remember, many cough syrup's ending DM. The DM literally stands for dextramethorfen that can trigger serotonin syndrome, right? Or tramadone, right? Again, a person taking like a pain medication or both spirulon. Remember, both spirulon is used to treat generalizing zed and disorder. It's a partial agony, it's a serotonin receptor, right? If a person even has like a hystero migraines, right?

Migraines, migraines, migraines, migraines, like your trip times, your so much trip time, those are serotonergic agents, right? If a person is getting or going to be, right? For like postpartum bleeding or whatever, right? Those things can all trigger serotonin syndrome. Those are all high offense to know, right? And how those serotonin syndrome present for the most part, those people will be, you know, they'll have like nausea, vomiting, they'll be flushing, they'll have diaphoresis, they'll have like increased diptendon reflexes, they'll have myoclonus, myoclonus that classic thing that shows up on exams. They can occasionally also have most rigidity and hyperthermia, right? But watch out for like that, myoclonus, the hyperreflexia and all that stuff, right? And again, before you start a person and an untidy person, just make sure they've not had a manic episode because typically an untidy person can precipitate media, you know, a person that has a hystrobipolar disorder, right? And again, when you're stopping an untidy person, you don't just stop it like, oh, you just say, oh, stop your medication this morning, no, don't do that, that's no predict, right? You need to taper their medication down over time, right? And again, if a person is going through a grief reaction, you typically do not need to treat with any kind of drug or anything of that sort. Okay, right? And then bipolar disorder, I've kind of talked about it, right?

Again, this will be, we'll have like manic, the thing is, if you notice, I'm not super, super, super, particular about criteria, that's more for your side shelf, but sorry, I didn't know it was wrong, I thought this morning, but the major thing to keep in mind is you just want to make sure that you're able to recognize these disorders, right? So, like, how many are present on an exam, right? The person will have like, you know, like an innovative mood, basically they'll feel like they're on top of the world, right? They may be having sex at more than normal rates, right? Or they can go like on a credit card spending spree, or they feel like they are over the world, you know, kind of having like these grandiose thoughts, they don't sleep much, maybe they are getting only 12 of sleep at night. You know, those are all things, and typically you would disrupt the social and occupational functioning. Those are all things that tell you that the person has a minion, right? Although, don't confuse minion, you'll examine it like a person going through like thyroid storm, or a person having like lupus, or again, a person having like a really steroids can really mess up a person's mind. Like a person taking corticosteroes can go super manic, right? So, again, those are just all things you want to subtly watch out for on your exam, right?

And for the most part, if a person has bipolar disorder, pretty much what you want to go ahead and do is, you know, go ahead and put them on a mostly, like lithium, you know, lithium is kind of like a big one. Don't forget your lithium side effects, right? So remember, lithium can cause like nephrogenic diabetes and sypidus, it can cause renal dysfunction, right? So, the nephrogenic di, right? So, the person will be like volume down, right? You'll have hypernatrhymia, you'll have low urinose malality, right? And remember, the lithium induced nephrogenic di, you should have like a myeloride or tram term because they'll block that in the channel at the level of the principal cell of the connective, though, that lithium uses to gain access to the principal cell to cause issues and scrub the signaling cascade of, of anti-diarrhytic hormone, right? And remember, lithium can also cause hypothyroidism, right? So, that's something to watch out for. And the thing is occasionally, on endemic exams, if a person is experiencing like all these like, you know, like bad lithium effects, one thing you can actually consider doing is to consider giving those people like some kind of anti-pynaptic drug, right? So, sometimes we leave it or not, you can give a peric acid for bipolar disorder again, careful in a person that's, you know, trying to get pregnant to at risk of becoming pregnant or a person that has liver disease, they shouldn't be on a peric acid, right?

And also, the second generation anti-psychotics actually pretty good for, for bipolar disorder and in-bemic exams as well, right? In fact, you can actually use those as first first line in place of lithium, right? Again, the in-bemic will kind of like set you up for like situations where either lithium is not an answer choice or a person is experiencing toxicities of lithium or a person has like chronic kidney disease to where it will not be prudent to give them lithium in the first place, right? So, again, don't forget SSRI scan on. That's why again, before you start a person on an untidy person, you need to just quiz them about like manic symptoms so that you don't trigger, you don't trigger media in those people, right? So, again, those are just things to keep in mind. And then the next topic I'll talk about generalizing X-rayed disorder. Basically, these people are just anxious about many things. It's usually is not just one thing. You know, there will be anxious about many many areas of their lives, how they'll pee, school fees, how they'll do this, how they'll do that, how they'll pass the exams. And, you know, they'll typically be like restless, they'll be able to concentrate, they'll be like very irritable, those people are like a light fuse, right? And they even have disturbances of sleep with all these symptoms, right?

And typically, when people have generalizing disorder, actually having generalizing disorder is like a risk factor for having like a comorbid psychiatric disorder. And for the most part, you know, you can treat GED with like, I mean, obviously you can treat them with most side disorders that are amenable to CBT, but typically your friends at the MBM want you to go with like a drug, right? So, you can give them like an SSRI, you can give them like an SNRI, right? And you can also give Bospiroin, right? Bospiroin is like a passion wagon, it's that serotonin, 5-HT, like serotonin receptors, right? So again, that's something to kind of watch out for. And again, if a person has a risk of like really bad substance abuse, it's probably not a pretty idea to put them on a benzodiazepine, right? And one thing I'll say is if a person is anxious over something that we infrequently encounter, let's say they are super anxious when they get into like an MRI scan or something like that, you're doing to put them on long-term therapy, you can just give them like a one-time dose of a benzodiaum for that event, right? If a person needs to fly, you again, give them a one-time benzodiaum for that event, right? That's not a contraindication on that those are circumstances because it's not like we're going to be an MRI scan every day of your life, right? So, just you know, kind of like a nice site story you want to keep in mind for your exams, right?

And then another thing you see on your test is like social anxiety disorder. Basically, these people kind of have like this fear or whenever they're like in a social situation or a situation where they have to perform, right? So they may have like symptoms like they may be blushing, maybe short of breath, or they may you know just feel just this generalized distress when they are in like social situations. And if a person has like this specific type like performance anxiety, like performance anxiety where they have to give a speech or whatever, typically the drug of choice is per per normal, right? They're non-selective beta blocker. Although remember if a person has like really bad like bronchospastic disease, like really bad asthma, really bad reactivary disease, you know, it's probably not a good idea to give those people a beta blocker because that can trigger a non-selective beta blocker like per per normal, because that can trigger their symptoms. Typically for those people you can go ahead and give them a benzo, right? And in generally for a person who has just chronic social anxiety disorder, not like all the have to give a speech, but they just have like this pervasive here of like social situations and everything. For the most part, you treat those people CBT and SSRI's long term, okay? CBT and SSRI's long term. And then you also want to be able to recognize a panic attack on your exam, right? So you know, typically how do panic attacks present, right?

Like, you know, the person will have like these politicians sweating, they'll feel short of breath, they'll have a feel of like losing control, feel of like dying, they can even have chest pain, they have chest pain, you want to make sure you get an EKG to make sure they are not like, you know, like having like an MI, right? You want to kind of roll that out. You know, they may have like abdominal pain, they may feel like headed, they may have all these like pastiges. Basically if you see that, that's a panic attack. And then if a patient keeps having all these things on a recurring basis, right? And they're happening, happening like unexpectedly and they are worried about getting like a future panic attack, then you, that's panic disorder, okay? So panic disorder is just a person having recurring panic attacks, right? And when you treat panic disorder, CBT and SSRI's, right? CBT and SSRI's, you need to give stab both together, right? So SSRI's, I kind of like your first line for the most part. And again, when a person is having like an acute, like they are cutely symptomatic, right? You can actually just give them a benzo for the acute symptoms, but again, you obviously don't want to put them on a benzo long term, right? That will not be a pretty thing to do on an MI exam. And then, so you can use it again if you are cutely symptomatic, you're going to kind of help them out there.

But again, long term benzo treatment for panic disorder, I promise you get that question all the way or test. So don't, don't do that, right? So now one other thing I want to talk about is like, you know, like somatic symptom disorder, right? I think back in the day it was called somatization disorder. Basically, these people have like, like I like the term, the term is very descriptive, somatic symptom disorder. They literally have like one real somatic symptom, right? And it's usually not like a terrible, terrible somatic symptom, right? But the thing is, the somatic symptom then causes them like a lot of distress in their lives and they think about it a lot, they piss every thing, they need a lot. They have all these like, you know, like lifestyle behaviors all centered around the somatic symptom, right? And once you see that think about somatic symptom disorder, I mean, according to the DSM, the typically we have these symptoms for like six months. And one classic thing that you put on your exam is that this person has had like all these medical evaluations and they've all been negative. And usually you've tried reassuring them and it doesn't do squat, right? Essentially, if you see somatic symptom disorder in your test, the way you treat it is they should have like regular office appointments with one physician, not multiple physicians, right? Because if you go to a different physician, a different physician, we give you your own heart tick, right?

So I mean, like if you watch TV and you watch like Skip and Shannon, right? Like, or even all these sports shows, right? People always have their heart ticks on fins. And by the way, if you watch basketball shows, the jump on ESPN is probably the like the best show in all of sports, but that's a different story for another day. But back to this, right? So basically, right? Regular office appointments regularly scheduled of if is appointments with one physician, okay? And then each time you see the patient, you just go ahead and reassure them that, you know, you've ruled out everything that's life threatening, right? And you know, you may maybe give them like some possible explanation for their symptom, but always tell them because again, they give all these behavioral questions on the family medicine shelf. Just tell them that you know, we've kind of ruled out of the life, all the life threatening stuff, right? And again, you may also select CBT as actually like correct therapy for somatic symptom disorder in your exam, right? And then some mimics of somatic symptom disorder you want to watch out for your exam, right? So if a person, you know, kind of like co-op to physical symptoms so that he can gain something like skip out from rotations or get out of jail or not have to appear in court, that's malingred on your test, right? Or if a patient, you know, so that's an example of a secondary gain, right? But if a person, you know, just loves that sick role, right?

They love like the attention they get from being sick. They're not necessarily doing it to get anything. They're just doing it because it makes them feel good on the inside, right? For like their own internal economy, for a primary gain, think about fact issues disorder under those circumstances. And obviously, for a person is like, you know, like making other people have symptoms like injecting, pooping to a person's blood stream and all that badness. That's what was previously known as Montchaussens, right? This, these on MBM is it's called a factitious disorder imposed on another, right? That's one thing to keep in mind. And then if a person's symptoms, you know, kind of revolve around the person having like abnormal motor symptoms or abnormal sensory symptoms like, oh, like one one limb is weak or whatever, right? And you were like, hmm, these symptoms don't seem to look alike to any part of the brain. And it doesn't seem to be explained by any like medical condition. And the person doesn't seem to be super worried about those symptoms, right? And it's usually like super accurate on set. It's really like in a very young person that you know, you're like, hmm, this person shouldn't really be having strokes at this age. They want to think about conversion disorder on that those are circumstances, right? And then one key thing you want to be able to do on your test is being able to differentiate between like, um, somatic symptom, the disorder and illness anxiety disorder.

Inhouse anxiety disorder was the thing that back in the day, people used to call a hypochondriasis. Um, basically, these people have like excessive worry, you know, about like their general health and they always worry like they always like super preoccupied with like health related activities. If you see that, think about illness anxiety disorder. So these people, they're just anxious about illness. They don't actually have like an actual symptom, right? So somatic symptom disorder, they have an actual symptom, the blood out of proportion, people that have illness anxiety disorder, they have no symptoms. What do you think they have problems, right? So that's the way to kind of keep those two things straight on an in-beaming example. And then again, like I said, in the USML and the military podcast, then obviously if you have not listened to that podcast and you're going to be taking like, even your shelf exams or like step two, seek your step three or step one, you're just doing yourself a huge, huge, huge disservice, right? The thing is literally, it's I'm not telling you like secret information. It's literally in the USML like content outline that they are going to have an emphasized focus on geriatric related questions and military related questions.

I've made a podcast on the military, I've made one podcast on a geriatrics and god, really, I'm going to make even more podcasts on geriatrics because there's some stuff I think I may want to talk about with like palliative care and stuff that's kind of high-yield for the exam. You better listen to those podcasts. If you don't, I promise you, you will regret it on your exam. Again, I'm not saying this out of any like self-promotion. I'm literally saying this for like your own personal interest, right? So just something to keep in mind, right? And then another side disorder, I want to recognize on your exam again, just kind of beast off of the military, PTSD, I kind of talked about it, not seeming that military podcast. But basically, right, again, for family medicine shelf, PTSD, right? Like this person will have like some kind of history of trauma, right? Like they were in a major, like maybe it's a firefighter or a person that was like in the military in a war zone or whatever. And all their bodies were killed in battle or something like that, right? And then they keep experiencing those traumatic events, right? Like they keep having like all these flashbacks. And then they try to avoid any stimulus that may be associated with the trauma, the experience that are back in the day, right? And then they get like this, you know, like hyper, like hyper arousal whenever they're exposed to this stimuli, you know, kind of think about that. Think about PTSD on little circumstances.

And usually for person, actually has PTSD, we're going to go ahead and screen them for like some comorbid side disorders, right? And you also want to screen them for like being like abuse that home, right? So those are just things you want to keep at the back of your mind. And really for the most part, PTSD, you treat it with an SSRI, right? You can treat it like sexually in peroxatine. But CBT is absolutely important. I'll say that again, CBT is absolutely important for people that have PTSD. And if a person has PTSD and they're having all these nightmares, Prasocin is actually the drug of choice for the nightmares in PTSD. Now, here's one thing I'm going to tell you, just this is one of those like almost like, oh, Apple green buyer fringes on congruence team. Whoever is listening to the podcast, I am begging you, please, please, please, never pick benzos as any kind of basically if you have a PTSD question, benzos will be the wrong answer. Never ever in your life, pick benzos as treatment for any PTSD, whatever, right? Benzos and PTSD bad, bad, bad, bad, bad, bad, bad, bad, bad, bad, bad, bad, if you do that on your test, I can pretty much again guarantee you you will get the question wrong, right? Now, this is going to wrap this up real quick, right? So let's talk about OCD, right? Again, OCD, basically look, literally look at the name, right? Obsessive, Compulsive, The Soder, right? Not obsessive, Compulsive Personality, The Soder.

That's a different psychiatric diagnosis. Here I'm talking about OCD, Obsessive, Compulsive, The Soder. Basically, these people have one, they can either have the obsession or they can have the compulsion or they can have both, right? And you don't need the compulsion, you just need the obsession to meet the diagnosis, right? So, but if you have both, I mean, obviously that's that's great, but yeah, you don't need, you don't need both to meet the diagnosis, right? So what is an obsession? An obsession is, you know, kind of like an intrusive thought, like a persistent idea, like a persistent impulse, or like images that kind of float around in a person's mind that you know, they are typically like not ideal thoughts, right? And because like the person like big amounts of distress, big amounts of anxiety, right? And then compulsion is typically the things that you do to relieve the anxiety as well as the obsession, right? So they are like repetitive behaviors like washing your hands multiple times, checking something. I feel like the mantra of checking something multiple times is very pervasive, or they may be exams, right? Or like keeping things in a certain order, or even sometimes it may not be like a physical act, maybe like a mental act, like counting something over and over again in their minds, or repeating something over and over again in their minds, like, you know, like a mental thing, that's that video compulsion, right?

And typically the people, like the people that have OCD recognized that what they are doing is unreasonable, right? They recognize it on, as like, wow, this thing is actually unreasonable, and for the most part, how do you treat OCD? Again, CBT, right? CBT, and the CBT occasion, it may ask for specifics on the exam, you may want to do things like exposure and response prevention, right? You expose them to the thing that triggers those intrusive thoughts and you kind of prevent them from responding to that stuff, right? And then you can treat it with an SSRI, right? You can also exclude me from me, exclude me from me is actually a second line for treating an OCD, or you can use a lens of pain, and one, the one that I teach people that I tutor all the time for OCD is like OCD, like literally the term OCD, right? Just read it backwards, the D for anti-D present, like an SSRI, the C for clomic, I mean that second line, the O4 lens that being that's third line, right? But again, OCD, you always want to add CBT to those people's treatment regimen, right? And then don't forget you're eating the sodders, please folks, you got to know you're eating the sodders, they shop a lot on the exam, right? So on a rexion of OSA, the presence of BMI will be less than 18.5, that's a given, right? And on a rexion of OSA, again, you know either like vomita ton, right? Or the restricting, they don't eat much food and all that stuff, right?

So you know, they'll have like a super low BMI, again don't forget the magic number 18.5, usually these patients will have like this feel of gaining weight, they'll have like a distorted body image, they may actually have even an area, and they may even say, they may even give you an anorexia question and make it a risk factor question. Remember people that have an a rexion of OSA, they have super high risk of osteoporosis, right? Because again, when you have low levels of estrogen, there's this mechanism of described, admising many podcasts about like how estrogen increases the amount of osteoportagring, and osteoportagring kind of binds up rank like end, so rank like end does not interact with the rank receptor, and you don't have like leaching of bone, right? So again, if you're not eating much, you're not going to have reproductive potential. So your estrogen your history checks is will shut down. So your estrogen will go down, and then the presence kind of screwed from that perspective, right? And then don't forget like bulimia, right? Don't forget bulimia bulimia, those people have normal weight or they'll be overweight, so the abema will be above 18.5, right? Basically, for persons abema is not less than 18.5 when an ambiemic exam, they don't have anorexia novosa end of story, okay? So the abema will be more than 18.5, and typically people that have bulimia on ambiemic exams, they tend to have more of these are compensatory behaviors, right?

So the vomit, they'll use diuretic, they use laxatives, or they'll start fasting to lose weight, or they'll engage in like excessive amounts of exercise. Again, usually the abema is, in fact, I'll say I don't think I've ever seen a bulimia actually, it's not a matter of I don't think I have never seen an ambiemic bulimia question, with a presence bema was not more than 18.5, okay? That's very high up to none. And again, I don't think ever seen an ambiemic question, we're pressing out anorexia novosa, and the abema was not less than 18.5, right? So again, just something to watch out for. And the thing is, on your ambiemic, they may actually try to integrate some other medical disorders that are almost like complications of these eating issues, right? So they can have really bad dental disease, because remember, when acid kind of wears away, I think you're in a mo, right? So you're kind of getting into trouble, like dental carries and all that badness. You may see calluses on the nursing of the fingers, that's like rustle sign, or they may like kind of tear their softicles, so they may have like a malarwized tear, they may even have a bare-haven syndrome from all the, again, all the MSS, they can have like all these electrolyte problems, right? So they love to give this thing, they may even give you like a question on arrows after describing a person like anorexia bulimia, whatever, right?

Obviously, the acrolyte is going to be low, the potassium is going to be low, and they're going to have a metabolic alkanosis, right? And again, all these things should make sense. If you're puking, puking, puking, stomach acid, you'll be hypoglyramic, because you're literally puking hydrochloric acid, and because your puking acid, you get a metabolic alkanosis with that, right? But, and the reason you get a metabolic alkanosis is if you're a big puker, right? I don't think that's a real world, but anyhow, it's my podcast, I can do whatever I want. So, you know, if you're a big puker, right? You'll be volume down, if you're volume down, your preload will go down, if your preload goes down, your credit card will go in the toilet, and obviously you stop perfusing your afternoon material appropriately.

So, your GG cells kind of freak out, the secret of tonal reigning, you convert adjudtence into adjudtence in one, that adjudtence in one will travel to the lungs, the pulmonary capillaries, the endothelial cells will convert the adjudtence in one to adjudtence in two, and in that adjudtence in two, we'll go to the zonal glomerulus of the adrenal cortex, you'll make a crap ton of ourosterone, and in that adjudtence in two, and in that adjudtence in two, we'll go to the zonal glomerulus of the adrenal cortex, you'll make a crap ton of ourosterone, and in that adjudtence in two, we'll go to the principal cell of the collecting duct, and spurs of that inech channel, so that sodium is going in, potassium is being dumped in the urine, so you get a hypochylemia, and then the adjudtence in one will also go to the alpha-intercalilated cell, and then you'll divide the proton pump, like you find on the urine site, so you puke out protons in your urine as well, right? So, you then get a contraction alkalosis with that, right?

So, that's something to keep at the back of your mind, and then the thing is, you want to be careful, again, you want to know these complications of like anorexia nervosa, for example, like these people can get super anemic, they can get osteophenic, they can get osteoporosis, they can become profoundly hypotensive, they can have these electrolyte abnormalities already described, and they can also get like dangerous cardiac arrhythmias, if a dangerous cardiac arrhythmias is actually one of the most common causes of death in people that have anorexia nervosa, right? And the thing is, when you start feeding these people, and again, actually having anorexia and severe symptoms is actually an indication for involuntary hospitalization, that's something you want to watch out for in your test, and again, when you start feeding these people, they are very high risk for like, refidian syndrome, right? So, they can actually get like, going to like a cardiac arrest, they can become delirious, right? And the thing that kills people in refidian syndrome is hypophosphatemia, that is a factor you want to burn into your brain forever, right? They can have hypophosphatemia, they can have hypokavemia, and they see, they're fine, why does this happen, why does this kill? Well, let me explain. The thing is, if your body has not seen food for a long time, you're very high-po insulinemic, right?

But when your body starts seeing food again, your body has almost like this insulin rebound, and insulin loves to drive electrolytes into cells. So, if it drives all your phosphate into cells, you can become profoundly high-pofolthosophytemic, then you will not have much ATP, and then you can go into cardiac arrest, right? And again, remember, insulin with glucose is one of the treatments for hypercalemia, right? So, you make sense that hypokillemia should be an electrolyte finding, and a person that's undergoing refidian syndrome, okay? So, again, just kind of keep those at the back of your mind, and then, phytonorexia nervosa for the most part, your first line treatment is CBT, okay? Drugs actually don't work for anorexia, I'll just tell you that right now, drugs do not work for anorexia, okay? I'll say that again, drugs do not work for anorexia. CBT is the treatment of choice for anorexia nervosa, right? But the thing is, if a person has bulimia nervosa, right? You actually treat them with CBT, and like an SSR, like anti-bipresence, right?

So, you can use like fluoxicine, fluoxicine is probably going to be the correct answer on your test, and then there's this tricyclic known as imipermin, imipermin is also ideal for people that have bulimia, but for the most part, fluoxicine is probably like the first thing you want to go with, because imipermin is a TCA, so obviously that's going to have some toxicity, and then one thing I want you to be able to differentiate on your test is between bulimia nervosa and binge eating disorder, right? Bulimia nervosa and binge eating disorder, the big difference is bulimia nervosa, those people eat a ton and they have compensatory behaviors. People that have binge eating disorder just binge eat, but they don't use, they don't have any compensatory behaviors, they just feel like guilty as crap over what they are doing. That's the way you differentiate bulimia nervosa from binge eating disorder, and again, remember that those two disorders will have people that have bmi's be done in 18.5, but on the right side of all said the bmi will be less than 18.5, and again, if a person has any of these eating disorders, they'll not prescribe bulpropion for those people, you give them bulpropion, you get the answer wrong on your test, and I would not want you to do that, right?

And then again, I promise I'm almost done here, just again, believe it or not, the test, the fair amount of psych on this exam, so I just want this to be like that one podcast releasing into it, like okay, I feel like I can answer any psych question I see. A schizophrenia won't be able to recognize it, right? So again, these people that have schizophrenia, you know, we have like weird logical thoughts, this organized speech, like their speech is kind of all over the place, so it's very like super incoherent, they have like this organized behavior, what do you mean? Like stay in one position for prolonged periods, that's kind of tonia. These are all like positive symptoms of schizophrenia, don't forgive your negative symptoms, right? So flat effect, right? Like those people are almost like not responsive to the environment, there's this thing called allogia, right? Where? You ask them a question, they give you like this super concrete responses, or their speech is very like muted, they don't really talk much, they're not getting much from them, or they have like evolution, where you know, they're trying to, it's almost like to get these people to initiate activities just not there, right?

You see all those things, those are negative symptoms, you see all these things in general, like I've described that's schizophrenia, but the most part is schizophrenia, studying one on an e-tipical first, so if they give you like a halloween period, or as an answer choice, and they give you a landsapine, go to landsapine, right? Go to an e-tipical landsapine, first like your landsapine, remember that can cause metabolic syndrome, respiratory, don't remember that can cause hyper-productinemia, and with thiaapine, remember that can cause cataracts, right? And remember our repeaters all, right? You know, those are all second generation landsapine, and then you can start with, and again, usually people that have schizophrenia want to go ahead and, you know, have them on board with a psychiatrist on an e-mimics app, and then I think the final thing I'll talk about today, and I'll be done with this is EDHD, EDHD usually kind of starts in a person's childhood, you know, you know, be inattentive, there'll be like super hyperactive in class, or they'll have like all these impulsive behaviors, and again, they'll have issues in two settings, right? The two settings are usually like 12-3 on e-mimics exams, either like at home, at work or in school, right? And if a person has like a history of substance abuse, or some other more disorder, they're very high risk of having concomitant EDHD, and but most by the way, you treat EDHD, you can use like stimulant, right?

Like you can use like methylphenid ED, you can use themphetamine, but one thing that your friends writing these are family medicine exams can try to do to you is they can tell you that all this person has a history of hypertension, or like barcadervascular disease, a person has those issues, then you know, it will not be a great idea to put them on like, amphetamine or like methylphenidate, or the drug you should maybe consider in those circumstances is like Adamoxetine. Adamoxetine is essentially an SNRI, so I'll spell that it's ATO M O X E T I N E Adamoxetine, right? So it's an SNRI, you can actually go ahead and use it for EDHD, in fact, becoming more and more common these days because it's not really a stimulant, okay? It's not really a stimulant. I mean, you could also try CBT, but that's not something you likely see on your test. So I think I'm going to go ahead and stop here. Yeah, pretty, I feel pretty confident that if you listen to this podcast, any side questions in your shelf, W, well, easily taking care of God willing, right? So as I do at the end of every podcast, right? So I do offer one or one tutoring and a large group tutoring for many exams, like pre-clinical med school exams, 30-ish-off exams, step one, step two CK, step two CS, if that's one thing I'm beginning to do more and more off because for whatever reason, more and more people are beginning to fail step two CS for whatever reason.

Step three, I tutor for that, if you're a medicine resident, I tutor for the internal medicine, in training exam, in internal medicine, shelf exams. I mean, sorry, the internal medicine, EBI, I'm board exam, and then I offer these booster courses, it's 20 hours for step one, and it's 15 hours for step two CK and step three, yeah, 15 hours for step two CK and step three, and basically it's, it's basically like, of course, I need you one on one, we can make like in one hour trenches or like in two hour trenches, and we just go over like most of the high-yield stuff that's routinely tested on these exams, like the most knows for these exams, in like a clinical veneer, rapid fire cure and e-format. And then if you, there's this thing I'm going to start doing, but I'm going to do it over Zoom in the future. So if you're interested in this, kind of let me know, I may have like sign ups and I'll give like specific dates where this will happen, so this will be all be online, where I will give like a very high-yield review of something to like a group of like 30, 40, 50 people, right? It'll be like a very small fee per person and we'll meet over Zoom, right? And I'll just kind of go through that material. And as we're going through those classes, I will kind of go over like test-taking strategies and high-yield things to keep in mind, for exams with those with those things. So just kind of watch out for that. It's going to be the beauty in like in a few days, right?

So just kind of be on the lookout for that. If you want to sign up, you'll be again a very small number no fee for each of the people that attend you, just be like a like a class literally, and you'll run for about an hour or two hours, but you'll be a very high-yield, rapid review of like a particular theme for a given exam. So if you're interested, again, just reach out to me and now give you some more information on that. And I'll probably make a podcast where I just kind of talk about what my dear is with that, right? And basically one other thing I will say is if you're met with a plan to residency, so like an ERS application, or a college student are planning to met school, so like an AMCA's application. Again, I do offer like one-on-one, I guess I'll call it consulting, like advice in for like rec letters, personal statement editing, editing applications, doing more interviews. Again, I've been on the admissions committee of a top-to-met school for like a year. So I've reviewed tons of high-quality applications, and essentially the vast majority of the people I've worked with in these processes give pretty much, all my study of first choices. I have a pretty good track record actually with applications. So feel free to reach out to me. I'm very particular about things, right? Probably almost particular to a fault, but I actually do a thankful life. I feel like I do a pretty good job going through people's applications and preparing them for the residency process.

Even if you have like a bad story, right? I can work with you and craft that story well to place you at an advantage, right? So again, if you need any of these things, or if you have a college body that needs to learn for like the MCAT or general chemistry or any chemistry, physics, biochemistry, histology, physiology, just reach out to me. Either reach out to me through the website, or you can send me an email at the Vine Intervention Podcasts with an SADN. So DIVIN, IN, T-E-R, V-E-N, T-I-O-N, P-O-D, C-A-S-T-S, at gmail.com, right? And then I'll give you some more information. And then one other thing I'll go ahead and say is please subscribe to the You Tube channel. I want to hit 1000 subscribers, hopefully before the end of the month. And please subscribe. This is all on Apple. It's on Spotify, on Google Play, all these podcasts. And then obviously there's the website where you can see the slides and everything. And also download the podcasts directly from there. So people have asked me questions about like, oh, DIVIN, could you put like your earlier episodes on Apple or whatever? I'll have to figure that out because I think Apple has like a limit on the number of podcasts you can place on their like on like on Apple podcasts. Because right now, I mean, this is the 209th episode, right? So I will kind of try to figure that out and kind of go from there. If anyone has any ideas, feel free to reach out to me. I'm always receptive to ideas.

So have a wonderful rest of your day. God bless you. And I will see you in the next podcast. Thank you.

Asking questions like, "Over the past two weeks, have you felt down, depressed, or hopeless?" or "Have you had little interest or pleasure in doing things?" (PHQ-9 style).

Sleep disturbance, Interest loss, Guilt, Low energy/Fatigue, Appetite change, Social withdrawal, Low mood, Concentration issues, and the ninth symptom. (Remember the mnemonic components.)

Bulimia involves binge eating plus compensatory behaviors (e.g., purging, excessive exercise). Binge Eating Disorder only involves binging without compensation.

SSR Is/SNR Is and Buspirone (Buspirone is a good drug choice to remember on exams).

Hypophosphatemia. This occurs due to insulin rebound driving phosphate into cells, leading to cardiac risk.

Benzodiazepines (Benzos). The transcript strongly warns against using them in this context.

Cognitive Behavioral Therapy (CBT), specifically Exposure and Response Prevention (ERP). Pharmacologically, SSR Is are first line; Clomipramine is a second-line option.

When the patient has coexisting hypertension or cardiovascular disease risk factors.

Somatic Symptom Disorder involves having one or more actual somatic symptoms; Illness Anxiety Disorder involves excessive worry about illness but no actual symptoms.

Paroxetine (Paraxilene). It is classified as Pregnancy Category D.

Nausea/vomiting, flushing, diaphoresis, increased deep tendon reflexes, and myoclonus.

Lifetime anti-depressant therapy.

Anorexia typically presents with a BMI < 18.5; Bulimia typically presents with a BMI > 18.5 (or normal weight).

Cognitive Behavioral Therapy (CBT), specifically Exposure and Response Prevention (ERP). Pharmacologically, SSR Is are first line; Clomipramine is a second-line option.

When the patient has coexisting hypertension or cardiovascular disease risk factors.

Somatic Symptom Disorder involves having one or more actual somatic symptoms; Illness Anxiety Disorder involves excessive worry about illness but no actual symptoms.

Paroxetine (Paraxilene). It is classified as Pregnancy Category D.

Nausea/vomiting, flushing, diaphoresis, increased deep tendon reflexes, and myoclonus.

Lifetime anti-depressant therapy.

Anorexia typically presents with a BMI < 18.5; Bulimia typically presents with a BMI > 18.5 (or normal weight).