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Board Bombs - 3 Critical Questions to Prepare you For Boards and Empower your Practice · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:05
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:06
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:07
  and
• 0:08
  Prep.
• 0:08
  These
• 0:09
  are
• 0:09
  called
• 0:09
  board
• 0:09
  bombs.
• 0:10
  They
• 0:11
  are
• 0:12
  exclusively
• 0:13
  designed
• 0:13
  to
• 0:14
  help
• 0:14
  you
• 0:14
  prepare
• 0:15
  for
• 0:15
  your
• 0:16
  NP
• 0:17
  board
• 0:17
  exams.
• 0:18
  So
• 0:18
  please
• 0:18
  enjoy.
• 0:19
  Let's
• 0:19
  get
• 0:19
  into
• 0:19
  the
• 0:19
  first
• 0:20
  question.
• 0:20
  A
• 0:20
  45
• 0:21
  year
• 0:21
  old
• 0:21
  woman
• 0:22
  started
• 0:22
  on
• 0:22
  amitriptyline
• 0:23
  for
• 0:23
  chronic
• 0:24
  neuropathic
• 0:24
  pain
• 0:25
  and
• 0:25
  depressive
• 0:26
  symptoms.
• 0:26
  Now,
• 0:27
  two
• 0:27
  weeks
• 0:27
  later,
• 0:27
  she
• 0:28
  reports
• 0:28
  dry
• 0:29
  mouth,
• 0:29
  constipation
• 0:30
  and
• 0:30
  blurred
• 0:30
  vision.
• 0:31
  These
• 0:31
  adverse
• 0:32
  effects
• 0:32
  are
• 0:32
  more
• 0:32
  likely
• 0:33
  due
• 0:34
  to
• 0:34
  the
• 0:34
  blockade
• 0:34
  of
• 0:35
  which
• 0:35
  receptor
• 0:36
  is
• 0:36
  it
• 0:36
  A,
• 0:37
  the
• 0:37
  alpha
• 0:37
  1
• 0:38
  adrenergic
• 0:39
  receptor?
• 0:39
  Is
• 0:40
  it
• 0:40
  B,
• 0:40
  the
• 0:41
  H1
• 0:42
  histamine
• 0:42
  receptor?
• 0:43
  Is
• 0:43
  it
• 0:43
  C,
• 0:44
  the
• 0:44
  muscarinic
• 0:45
  M1
• 0:45
  cholinergic
• 0:46
  receptor?
• 0:47
  Or
• 0:47
  is
• 0:47
  it
• 0:47
  D,
• 0:47
  the
• 0:48
  5ht2a
• 0:49
  receptor?
• 0:50
  So,
• 0:50
  amitriptyline.
• 0:51
  What
• 0:51
  med
• 0:51
  class
• 0:52
  are
• 0:52
  we
• 0:52
  in?
• 0:52
  We're
• 0:52
  in
• 0:53
  the
• 0:53
  TCA
• 0:54
  med
• 0:54
  class,
• 0:55
  right?
• 0:56
  That
• 0:56
  helps
• 0:56
  alone,
• 0:57
  right?
• 0:57
  The
• 0:57
  TCAs
• 0:58
  are
• 0:59
  known
• 1:00
  to
• 1:00
  cause
• 1:01
  dry
• 1:02
  mouth,
• 1:02
  constipation,
• 1:03
  blurred
• 1:04
  vision,
• 1:04
  even
• 1:04
  weight
• 1:04
  gain.
• 1:05
  It's
• 1:05
  really
• 1:05
  important
• 1:06
  we
• 1:06
  know
• 1:07
  what
• 1:07
  exactly
• 1:08
  it
• 1:08
  is
• 1:09
  blocking
• 1:10
  here
• 1:11
  because
• 1:11
  that's
• 1:12
  how
• 1:12
  you
• 1:12
  know
• 1:12
  the
• 1:13
  difference
• 1:13
  between
• 1:13
  a
• 1:13
  TCA
• 1:14
  and
• 1:15
  an
• 1:15
  SNRI
• 1:15
  or
• 1:16
  an
• 1:16
  ssri,
• 1:17
  right?
• 1:17
  It's
• 1:17
  all
• 1:17
  about
• 1:17
  receptor
• 1:18
  affinity.
• 1:19
  Which
• 1:19
  receptors
• 1:20
  are
• 1:20
  included
• 1:21
  in
• 1:21
  the
• 1:22
  angle
• 1:22
  of
• 1:22
  attack
• 1:22
  here.
• 1:23
  Or
• 1:23
  TCAs
• 1:24
  and
• 1:24
  Maois.
• 1:25
  They
• 1:25
  were
• 1:25
  effective
• 1:26
  and
• 1:27
  they
• 1:27
  changed
• 1:27
  a
• 1:27
  lot
• 1:28
  of
• 1:28
  lives,
• 1:28
  but
• 1:28
  they
• 1:28
  were
• 1:28
  somewhat
• 1:29
  dirtier.
• 1:29
  Right?
• 1:29
  They
• 1:30
  acted
• 1:30
  on
• 1:31
  more
• 1:31
  receptors
• 1:31
  and
• 1:32
  caused
• 1:32
  some
• 1:32
  more
• 1:32
  problems
• 1:33
  that
• 1:33
  we
• 1:34
  didn't
• 1:34
  really
• 1:35
  intend
• 1:35
  to
• 1:35
  worsen.
• 1:36
  So
• 1:36
  right
• 1:36
  off
• 1:36
  the
• 1:37
  bat,
• 1:37
  it
• 1:37
  really
• 1:37
  helps
• 1:38
  to
• 1:38
  know
• 1:38
  amitriptyline
• 1:39
  is
• 1:39
  in
• 1:39
  the
• 1:39
  TCA
• 1:40
  class
• 1:41
  if
• 1:41
  you're
• 1:42
  getting
• 1:42
  acclimated
• 1:43
  to
• 1:43
  your
• 1:43
  medications
• 1:44
  and
• 1:44
  you're
• 1:44
  not
• 1:44
  quite
• 1:45
  sure
• 1:45
  what
• 1:45
  we're
• 1:45
  even
• 1:45
  talking
• 1:46
  about.
• 1:47
  You
• 1:47
  don't
• 1:47
  know
• 1:47
  if
• 1:47
  this
• 1:47
  is
• 1:47
  an
• 1:47
  antipsychotic.
• 1:48
  You
• 1:48
  don't
• 1:48
  know
• 1:48
  if
• 1:49
  this
• 1:49
  is
• 1:49
  an
• 1:49
  Maoi.
• 1:50
  I
• 1:50
  know
• 1:50
  for
• 1:50
  me,
• 1:50
  the
• 1:51
  Maois
• 1:51
  and
• 1:51
  TCAs
• 1:52
  tripped
• 1:52
  me
• 1:53
  up
• 1:53
  in
• 1:53
  the
• 1:53
  beginning
• 1:53
  knowing
• 1:54
  the
• 1:54
  difference
• 1:54
  between
• 1:55
  the
• 1:55
  two.
• 1:55
  So
• 1:55
  step
• 1:55
  one,
• 1:56
  my
• 1:56
  friends,
• 1:56
  to
• 1:56
  feel
• 1:57
  more
• 1:57
  confident,
• 1:58
  right?
• 1:58
  As
• 1:58
  you
• 1:58
  read
• 1:58
  this
• 1:59
  question,
• 1:59
  become
• 1:59
  familiar
• 2:00
  with
• 2:00
  who's
• 2:01
  who
• 2:01
  in
• 2:01
  the
• 2:01
  zoo.
• 2:01
  What's
• 2:02
  a
• 2:02
  TCA
• 2:02
  and
• 2:03
  what's
• 2:03
  in
• 2:03
  the
• 2:03
  MAOI
• 2:04
  family?
• 2:04
  What's
• 2:05
  in
• 2:05
  the
• 2:05
  SSRI
• 2:06
  SNRI
• 2:07
  family?
• 2:07
  Because
• 2:08
  it
• 2:08
  matters,
• 2:08
  right?
• 2:09
  Sertraline
• 2:10
  doesn't
• 2:10
  sound
• 2:10
  that
• 2:11
  different
• 2:11
  than
• 2:11
  amitriptyline.
• 2:12
  And
• 2:12
  yet
• 2:12
  one
• 2:13
  is
• 2:13
  in
• 2:13
  the
• 2:13
  TCA
• 2:13
  class.
• 2:14
  One
• 2:14
  is
• 2:14
  in
• 2:14
  the
• 2:14
  SSRI
• 2:15
  class.
• 2:15
  Now,
• 2:16
  which
• 2:17
  receptor
• 2:17
  is
• 2:17
  this
• 2:17
  blocking?
• 2:18
  Alpha
• 2:18
  1
• 2:18
  adrenergic
• 2:19
  receptor.
• 2:20
  That's
• 2:20
  A.
• 2:21
  I
• 2:21
  don't
• 2:21
  think
• 2:21
  so.
• 2:21
  Because
• 2:22
  Alpha
• 2:22
  1
• 2:23
  usually
• 2:23
  causes
• 2:24
  orthostatic
• 2:25
  hypotension,
• 2:26
  some
• 2:26
  tachycardia,
• 2:27
  maybe
• 2:27
  dizziness,
• 2:28
  not
• 2:28
  really
• 2:28
  dry
• 2:29
  mouth
• 2:29
  or
• 2:29
  blurred
• 2:30
  vision.
• 2:30
  So
• 2:30
  we
• 2:30
  can
• 2:30
  scratch
• 2:31
  that
• 2:31
  off
• 2:32
  what
• 2:32
  about
• 2:32
  histamine?
• 2:33
  Does
• 2:33
  histamine
• 2:33
  cause
• 2:34
  constipation
• 2:35
  and
• 2:35
  blurred
• 2:35
  vision
• 2:35
  and
• 2:35
  dry
• 2:36
  mouth?
• 2:37
  Not
• 2:37
  specifically,
• 2:38
  no.
• 2:38
  It's
• 2:38
  more
• 2:38
  about
• 2:38
  sedation
• 2:40
  with
• 2:40
  histamine.
• 2:41
  So
• 2:42
  I'm
• 2:42
  not
• 2:42
  so
• 2:42
  sure
• 2:42
  about
• 2:43
  that
• 2:43
  either.
• 2:44
  Now,
• 2:44
  what
• 2:44
  about
• 2:45
  the
• 2:45
  muscarinic
• 2:46
  receptor?
• 2:47
  That
• 2:47
  sounds
• 2:48
  pretty
• 2:48
  accurate.
• 2:49
  Dry
• 2:49
  mouth,
• 2:49
  constipation
• 2:50
  and
• 2:50
  blurred
• 2:50
  vision.
• 2:51
  Let's
• 2:51
  put
• 2:51
  a
• 2:51
  pin
• 2:51
  in
• 2:52
  that
• 2:52
  one.
• 2:52
  And
• 2:52
  what
• 2:52
  about
• 2:53
  the
• 2:53
  5ht2a
• 2:54
  receptor?
• 2:54
  This
• 2:55
  is
• 2:55
  one
• 2:55
  of
• 2:55
  those
• 2:55
  questions
• 2:56
  on
• 2:56
  the
• 2:56
  quiz
• 2:57
  or
• 2:57
  test
• 2:57
  that
• 2:58
  it's
• 2:58
  just
• 2:58
  kind
• 2:58
  of
• 2:58
  loony
• 2:59
  bins.
• 2:59
  This
• 2:59
  is.
• 3:00
  Sometimes
• 3:00
  they
• 3:00
  just.
• 3:01
  I
• 3:01
  don't
• 3:02
  know
• 3:02
  if
• 3:02
  test
• 3:02
  makers
• 3:03
  get
• 3:03
  lazy
• 3:04
  and
• 3:04
  the
• 3:04
  last
• 3:05
  question
• 3:05
  is
• 3:05
  just
• 3:05
  whack
• 3:06
  a
• 3:06
  doodle.
• 3:06
  Where
• 3:06
  do
• 3:06
  you
• 3:07
  even
• 3:07
  get
• 3:07
  that
• 3:07
  from?
• 3:08
  They
• 3:08
  might
• 3:08
  as
• 3:08
  well
• 3:09
  have
• 3:09
  put
• 3:09
  option
• 3:09
  D
• 3:10
  tennis
• 3:10
  balls
• 3:10
  like
• 3:10
  it
• 3:11
  did
• 3:11
  just
• 3:11
  5ht2a.
• 3:13
  No,
• 3:13
  nothing
• 3:14
  you've
• 3:14
  ever
• 3:14
  read
• 3:14
  about
• 3:15
  5ht2a
• 3:16
  should
• 3:16
  ever
• 3:17
  suggest
• 3:17
  that
• 3:17
  it
• 3:17
  causes
• 3:18
  dry
• 3:18
  mouth,
• 3:18
  constipation
• 3:19
  or
• 3:19
  blurred
• 3:19
  vision.
• 3:20
  It
• 3:20
  just
• 3:20
  shouldn't
• 3:20
  even
• 3:21
  be
• 3:21
  the
• 3:21
  case.
• 3:22
  And
• 3:22
  so
• 3:23
  you
• 3:23
  can
• 3:23
  scrap
• 3:23
  that
• 3:23
  one.
• 3:24
  It's
• 3:24
  the
• 3:24
  tennis
• 3:24
  balls
• 3:25
  answer.
• 3:25
  Now,
• 3:26
  we
• 3:26
  do
• 3:26
  go
• 3:26
  over
• 3:26
  5ht
• 3:27
  2a
• 3:27
  a
• 3:28
  lot
• 3:28
  in
• 3:28
  previous
• 3:28
  episodes.
• 3:29
  Highly
• 3:29
  recommend
• 3:30
  you
• 3:30
  get
• 3:31
  familiar
• 3:31
  with
• 3:32
  that
• 3:32
  receptor.
• 3:32
  It's
• 3:33
  pretty
• 3:33
  fascinating
• 3:34
  when
• 3:34
  it
• 3:34
  is
• 3:34
  antagonized.
• 3:35
  It's
• 3:35
  pretty
• 3:36
  fascinating
• 3:36
  when
• 3:36
  it's
• 3:37
  activated
• 3:37
  too
• 3:38
  much
• 3:38
  like
• 3:38
  in
• 3:38
  SSRI
• 3:39
  administration
• 3:40
  and
• 3:41
  why
• 3:41
  we
• 3:41
  want
• 3:41
  to
• 3:41
  block
• 3:42
  it
• 3:42
  sometimes
• 3:42
  and
• 3:43
  what
• 3:43
  that
• 3:43
  can
• 3:43
  lead
• 3:43
  to.
• 3:44
  We'll
• 3:44
  probably
• 3:44
  do
• 3:44
  a
• 3:44
  whole
• 3:44
  episode
• 3:45
  on
• 3:45
  5ht2a.
• 3:46
  But
• 3:46
  for
• 3:47
  this
• 3:47
  question,
• 3:47
  it's
• 3:47
  wackadoodle.
• 3:48
  Don't
• 3:48
  pick
• 3:48
  it.
• 3:48
  Muscarinic
• 3:49
  cholinergic
• 3:50
  receptor
• 3:50
  is
• 3:51
  your
• 3:51
  answer.
• 3:51
  That
• 3:51
  C.
• 3:52
  And
• 3:52
  that
• 3:53
  is
• 3:53
  our
• 3:53
  45
• 3:53
  year
• 3:54
  old
• 3:54
  woman
• 3:54
  on
• 3:54
  Amitriptyline.
• 3:55
  It's
• 3:55
  a
• 3:55
  TCA
• 3:56
  causing
• 3:56
  dry
• 3:57
  mouth,
• 3:57
  constipation,
• 3:57
  blurred
• 3:58
  vision.
• 3:58
  A
• 3:59
  46
• 3:59
  year
• 3:59
  old
• 3:59
  woman
• 4:00
  is
• 4:00
  presenting
• 4:01
  with
• 4:01
  fatigue,
• 4:01
  weight
• 4:02
  gain,
• 4:02
  constipation
• 4:03
  and
• 4:04
  persistent
• 4:04
  low
• 4:04
  mood.
• 4:05
  She's
• 4:05
  been
• 4:06
  on
• 4:06
  sertraline
• 4:07
  for
• 4:07
  four
• 4:07
  months
• 4:07
  with
• 4:07
  minimal
• 4:08
  benefit.
• 4:09
  What
• 4:10
  is
• 4:10
  the
• 4:10
  most
• 4:10
  appropriate
• 4:11
  clinical
• 4:11
  action
• 4:11
  for
• 4:12
  the
• 4:12
  PMHNP?
• 4:13
  And
• 4:13
  we
• 4:13
  have
• 4:13
  a
• 4:13
  list
• 4:13
  of
• 4:14
  labs
• 4:14
  here.
• 4:14
  Her
• 4:15
  TSH
• 4:15
  is
• 4:15
  9.4.
• 4:17
  Her
• 4:17
  free
• 4:18
  T4
• 4:18
  is
• 4:19
  0.5.
• 4:20
  Her
• 4:20
  CBC
• 4:21
  and
• 4:21
  CMP
• 4:21
  are
• 4:22
  normal.
• 4:22
  For
• 4:23
  your
• 4:23
  boards.
• 4:23
  It's
• 4:24
  really
• 4:24
  important
• 4:24
  to
• 4:25
  have
• 4:25
  an
• 4:25
  idea
• 4:26
  of
• 4:26
  what
• 4:27
  abnormal
• 4:27
  lab
• 4:28
  values
• 4:28
  look
• 4:28
  like
• 4:28
  when
• 4:29
  you
• 4:29
  see
• 4:29
  them.
• 4:30
  Okay,
• 4:30
  Very
• 4:31
  important.
• 4:31
  No
• 4:32
  one
• 4:32
  is
• 4:32
  going
• 4:32
  to
• 4:33
  make
• 4:33
  you
• 4:33
  memorize
• 4:35
  every
• 4:35
  single
• 4:36
  lab
• 4:36
  value.
• 4:36
  But
• 4:36
  it
• 4:37
  really
• 4:37
  helps
• 4:37
  to
• 4:37
  know
• 4:38
  if
• 4:38
  an
• 4:38
  albumin
• 4:39
  of
• 4:39
  97
• 4:40
  is
• 4:40
  normal
• 4:41
  or
• 4:41
  not.
• 4:42
  It's
• 4:42
  clearly
• 4:42
  not.
• 4:43
  It's
• 4:43
  extremely
• 4:43
  high.
• 4:44
  Or
• 4:44
  a
• 4:44
  TSH
• 4:45
  value
• 4:45
  of
• 4:45
  9.
• 4:46
  Is
• 4:46
  that
• 4:46
  normal?
• 4:47
  Well,
• 4:47
  no,
• 4:47
  because
• 4:48
  the
• 4:48
  normal
• 4:48
  range
• 4:48
  is
• 4:48
  0.4
• 4:49
  to
• 4:49
  4.0.
• 4:51
  So
• 4:51
  again,
• 4:52
  for
• 4:52
  your
• 4:52
  exams,
• 4:53
  just
• 4:54
  for
• 4:54
  your
• 4:54
  clinical
• 4:54
  practice
• 4:55
  moving
• 4:55
  forward,
• 4:56
  not
• 4:56
  only
• 4:56
  do
• 4:56
  you
• 4:56
  want
• 4:56
  to
• 4:56
  have
• 4:57
  a
• 4:57
  familiarity
• 4:57
  with
• 4:58
  the
• 4:58
  families
• 4:59
  of
• 4:59
  your
• 5:00
  medications,
• 5:00
  what's
• 5:01
  different
• 5:01
  from
• 5:01
  Sertraline
• 5:02
  and
• 5:02
  Amitriptyline?
• 5:03
  Which
• 5:03
  families
• 5:04
  do
• 5:04
  they
• 5:04
  belong
• 5:04
  to?
• 5:04
  That's
• 5:05
  a
• 5:05
  huge
• 5:05
  first
• 5:05
  step
• 5:06
  to
• 5:06
  gaining
• 5:06
  mastery
• 5:07
  with
• 5:07
  your
• 5:07
  board
• 5:07
  questions.
• 5:08
  In
• 5:08
  addition
• 5:09
  to
• 5:09
  knowing
• 5:09
  Sertraline
• 5:10
  as
• 5:10
  Zoloft,
• 5:10
  that
• 5:10
  took
• 5:11
  us
• 5:11
  some
• 5:11
  time
• 5:11
  in
• 5:11
  school.
• 5:12
  Knowing
• 5:13
  Sertraline
• 5:13
  is
• 5:13
  Zoloft
• 5:14
  and
• 5:14
  Fluoxetine
• 5:15
  is
• 5:15
  Prozac.
• 5:15
  Right.
• 5:16
  So
• 5:17
  there's
• 5:17
  many
• 5:17
  layers
• 5:18
  you
• 5:18
  have
• 5:18
  to
• 5:18
  memorize
• 5:19
  before
• 5:19
  you
• 5:19
  go
• 5:19
  into
• 5:19
  these
• 5:20
  questions.
• 5:20
  So
• 5:21
  that
• 5:21
  by
• 5:21
  the
• 5:21
  time
• 5:21
  you
• 5:21
  look
• 5:21
  at
• 5:22
  this
• 5:22
  and
• 5:22
  see
• 5:22
  a
• 5:22
  TSH
• 5:23
  of
• 5:23
  9,
• 5:24
  you
• 5:24
  don't
• 5:24
  have
• 5:25
  to
• 5:25
  guess
• 5:25
  or
• 5:25
  wonder
• 5:25
  and
• 5:26
  you
• 5:26
  can
• 5:26
  say,
• 5:26
  okay,
• 5:26
  that's
• 5:27
  not
• 5:27
  normal.
• 5:27
  There's
• 5:28
  also
• 5:28
  a
• 5:28
  tip
• 5:28
  off
• 5:29
  in
• 5:29
  the
• 5:29
  question
• 5:30
  where
• 5:30
  the
• 5:30
  46
• 5:31
  year
• 5:31
  old
• 5:31
  woman
• 5:31
  has
• 5:32
  fatigue,
• 5:33
  weight
• 5:33
  gain,
• 5:33
  constipation
• 5:34
  and
• 5:35
  persistent
• 5:35
  low
• 5:35
  moods.
• 5:36
  Three
• 5:36
  out
• 5:36
  of
• 5:36
  four
• 5:36
  of
• 5:36
  those
• 5:37
  symptoms
• 5:37
  are
• 5:38
  more
• 5:38
  physical
• 5:38
  in
• 5:39
  nature.
• 5:39
  You
• 5:40
  can
• 5:40
  gain
• 5:40
  weight
• 5:40
  with
• 5:40
  depression,
• 5:41
  of
• 5:41
  course,
• 5:42
  you
• 5:42
  can
• 5:42
  be
• 5:42
  fatigued,
• 5:43
  of
• 5:43
  course,
• 5:44
  but
• 5:44
  three
• 5:44
  out
• 5:44
  of
• 5:45
  four
• 5:45
  of
• 5:45
  those
• 5:45
  seem
• 5:46
  to
• 5:46
  suggest
• 5:46
  some
• 5:46
  kind
• 5:46
  of
• 5:46
  physical
• 5:47
  problem.
• 5:47
  So
• 5:47
  immediately
• 5:48
  you're
• 5:48
  seeing
• 5:49
  thyroid
• 5:49
  levels.
• 5:49
  Even
• 5:49
  if
• 5:50
  you
• 5:50
  don't
• 5:50
  really
• 5:50
  know
• 5:50
  what
• 5:51
  the
• 5:51
  thyroid
• 5:51
  level
• 5:51
  is,
• 5:52
  normal
• 5:53
  values
• 5:53
  are.
• 5:53
  This
• 5:54
  should
• 5:54
  tip
• 5:54
  you
• 5:54
  off
• 5:54
  that
• 5:55
  this
• 5:55
  might
• 5:55
  be
• 5:55
  a
• 5:56
  thyroid
• 5:56
  problem.
• 5:57
  So
• 5:57
  what
• 5:57
  is
• 5:57
  the
• 5:58
  most
• 5:58
  appropriate
• 5:58
  clinical
• 5:59
  action
• 5:59
  for
• 5:59
  the
• 6:00
  pmhnp?
• 6:01
  A?
• 6:01
  Increase
• 6:01
  the
• 6:02
  Sertraline
• 6:02
  dose.
• 6:03
  Okay,
• 6:04
  we
• 6:04
  can
• 6:04
  talk
• 6:04
  about
• 6:04
  that.
• 6:05
  Maybe
• 6:06
  that
• 6:06
  might
• 6:06
  help
• 6:06
  with
• 6:06
  fatigue.
• 6:07
  Sertraline
• 6:08
  is
• 6:08
  more
• 6:08
  dopaminergic.
• 6:09
  At
• 6:09
  higher
• 6:10
  doses
• 6:10
  it
• 6:10
  is
• 6:11
  more
• 6:11
  activating.
• 6:12
  It
• 6:12
  might
• 6:12
  help
• 6:12
  the
• 6:12
  persistent
• 6:13
  low
• 6:13
  mood.
• 6:13
  Maybe
• 6:14
  we'll
• 6:14
  put
• 6:14
  a
• 6:14
  maybe
• 6:14
  in
• 6:15
  that.
• 6:15
  Is
• 6:15
  it
• 6:16
  B,
• 6:17
  Recognize
• 6:17
  likely
• 6:18
  hypothyroidism
• 6:19
  and
• 6:19
  coordinate
• 6:20
  initiation
• 6:20
  of
• 6:20
  thyroid
• 6:21
  replacement
• 6:21
  therapy.
• 6:22
  Let's
• 6:22
  definitely
• 6:22
  consider
• 6:23
  that
• 6:23
  these
• 6:23
  are
• 6:24
  weird
• 6:24
  thyroid
• 6:24
  levels.
• 7:19
  Of
• 7:20
  course,
• 7:20
  I'm
• 7:21
  assuming
• 7:21
  you
• 7:21
  don't
• 7:21
  know
• 7:21
  that
• 7:22
  or
• 7:22
  I
• 7:22
  don't
• 7:22
  know
• 7:22
  that.
• 7:23
  We're
• 7:23
  trying
• 7:23
  to
• 7:23
  critically
• 7:24
  think
• 7:24
  without
• 7:25
  more
• 7:25
  knowledge,
• 7:26
  but
• 7:26
  let's
• 7:26
  just
• 7:26
  say.
• 7:27
  Okay,
• 7:27
  that
• 7:27
  sounds
• 7:27
  like
• 7:27
  a
• 7:27
  reasonable
• 7:28
  question.
• 7:29
  There's
• 7:29
  some
• 7:29
  tip
• 7:30
  off
• 7:30
  with
• 7:30
  thyroid
• 7:30
  in
• 7:31
  this
• 7:31
  question.
• 7:31
  Option
• 7:32
  C
• 7:32
  is
• 7:32
  switch
• 7:32
  to
• 7:33
  Duloxetine
• 7:33
  or
• 7:34
  Cymbalta.
• 7:34
  I
• 7:35
  don't
• 7:35
  know
• 7:36
  really
• 7:36
  how
• 7:36
  that
• 7:37
  would
• 7:37
  help
• 7:37
  in
• 7:37
  this
• 7:37
  case
• 7:38
  by
• 7:38
  switching
• 7:38
  to
• 7:38
  Cymbalta.
• 7:39
  There's
• 7:40
  nothing
• 7:41
  that
• 7:41
  compelling
• 7:42
  other
• 7:43
  than
• 7:43
  the
• 7:43
  fact
• 7:43
  that
• 7:43
  maybe
• 7:44
  she's
• 7:44
  still
• 7:44
  depressed
• 7:45
  that
• 7:45
  you'd
• 7:45
  want
• 7:45
  to
• 7:45
  switch
• 7:46
  to
• 7:46
  an
• 7:46
  snri.
• 7:46
  So
• 7:47
  it's
• 7:47
  kind
• 7:47
  of
• 7:47
  a
• 7:47
  tricky
• 7:48
  one.
• 7:48
  But
• 7:48
  there's
• 7:49
  not
• 7:49
  a
• 7:49
  whole
• 7:49
  lot
• 7:49
  in
• 7:49
  the
• 7:49
  question
• 7:50
  that
• 7:50
  would
• 7:50
  suggest
• 7:51
  Cymbalta
• 7:51
  as
• 7:52
  your
• 7:52
  solution
• 7:52
  here.
• 7:52
  Any
• 7:53
  more
• 7:53
  than
• 7:53
  increasing
• 7:53
  the
• 7:54
  sertraline
• 7:55
  dose
• 7:55
  and
• 7:55
  then
• 7:56
  adding
• 7:56
  T3
• 7:57
  augmentation
• 7:58
  immediately
• 7:58
  is
• 7:58
  D.
• 7:59
  And
• 7:59
  that
• 7:59
  might
• 7:59
  throw
• 7:59
  some
• 7:59
  people
• 8:00
  off
• 8:00
  too.
• 8:01
  Think
• 8:01
  about
• 8:01
  it
• 8:01
  for
• 8:01
  a
• 8:01
  moment.
• 8:02
  I'll
• 8:02
  give
• 8:02
  you
• 8:02
  a
• 8:02
  moment.
• 8:03
  But
• 8:03
  the
• 8:03
  answer,
• 8:03
  my
• 8:04
  friends,
• 8:04
  is
• 8:05
  to
• 8:05
  is
• 8:06
  actually
• 8:06
  B,
• 8:07
  recognize
• 8:07
  likely
• 8:07
  hypothyroidism
• 8:09
  and
• 8:09
  coordinate
• 8:09
  initiation
• 8:10
  of
• 8:10
  thyroid
• 8:10
  replacement
• 8:11
  therapy.
• 8:11
  Now,
• 8:12
  some
• 8:12
  clinics,
• 8:13
  the
• 8:13
  PMH
• 8:14
  and
• 8:14
  P
• 8:14
  is
• 8:14
  not
• 8:14
  going
• 8:14
  to
• 8:14
  be
• 8:15
  the
• 8:15
  one
• 8:15
  correcting
• 8:15
  the
• 8:15
  thyroid.
• 8:16
  Depending
• 8:16
  on
• 8:17
  your
• 8:17
  scope,
• 8:17
  your
• 8:18
  state,
• 8:18
  your
• 8:18
  practice,
• 8:19
  you
• 8:19
  either
• 8:19
  will
• 8:20
  or
• 8:20
  will
• 8:20
  not
• 8:20
  prescribe
• 8:21
  levothyroxine.
• 8:22
  The
• 8:23
  broader
• 8:23
  point
• 8:24
  of
• 8:24
  this
• 8:24
  question
• 8:25
  is
• 8:25
  that
• 8:26
  we're
• 8:26
  looking
• 8:26
  at
• 8:26
  a
• 8:27
  hypothyroid
• 8:28
  picture.
• 8:28
  We're
• 8:29
  seeing
• 8:29
  fatigue,
• 8:30
  weight
• 8:30
  gain,
• 8:30
  constipation,
• 8:31
  low
• 8:31
  mood.
• 8:32
  Increasing
• 8:32
  the
• 8:32
  sertraline
• 8:33
  may
• 8:33
  help
• 8:33
  a
• 8:34
  lot
• 8:34
  of
• 8:34
  those
• 8:34
  things,
• 8:34
  but
• 8:34
  it's
• 8:35
  not
• 8:35
  the
• 8:36
  primary
• 8:36
  problem
• 8:36
  here.
• 8:37
  The
• 8:37
  primary
• 8:37
  manifestation
• 8:38
  of
• 8:38
  these
• 8:38
  symptoms
• 8:39
  is
• 8:39
  not
• 8:39
  a
• 8:40
  worsening
• 8:40
  depression
• 8:41
  or
• 8:41
  a
• 8:41
  lower
• 8:42
  Zoloft
• 8:42
  dose.
• 8:42
  It's
• 8:43
  an
• 8:43
  underactive
• 8:43
  thyroid.
• 8:44
  Always
• 8:44
  get
• 8:44
  to
• 8:45
  the
• 8:45
  root
• 8:45
  of
• 8:45
  your
• 8:45
  questions,
• 8:46
  right?
• 8:46
  It's
• 8:47
  not
• 8:47
  enough
• 8:47
  to
• 8:47
  just
• 8:47
  say
• 8:48
  let's
• 8:48
  increase
• 8:49
  the
• 8:49
  Zoloft.
• 8:49
  That
• 8:49
  could
• 8:50
  work
• 8:50
  just
• 8:50
  fine.
• 8:51
  And
• 8:51
  don't
• 8:51
  get
• 8:51
  too
• 8:52
  caught
• 8:52
  up
• 8:52
  with
• 8:52
  the
• 8:53
  rabbit
• 8:53
  holes
• 8:53
  right
• 8:54
  of
• 8:54
  the
• 8:54
  duloxetine.
• 8:55
  It's
• 8:55
  like,
• 8:55
  well,
• 8:56
  that's
• 8:56
  kind
• 8:56
  of
• 8:56
  just
• 8:56
  a
• 8:56
  red
• 8:56
  herring
• 8:57
  to
• 8:57
  throw
• 8:57
  you
• 8:57
  off.
• 8:58
  I
• 8:58
  wouldn't
• 8:58
  get
• 8:59
  too
• 8:59
  sucked
• 8:59
  into
• 9:00
  that
• 9:00
  either.
• 9:00
  Right
• 9:01
  now
• 9:02
  adding
• 9:02
  T3,
• 9:03
  that's
• 9:03
  a
• 9:03
  tricky
• 9:03
  one.
• 9:04
  You
• 9:04
  may
• 9:04
  not
• 9:04
  see
• 9:05
  the
• 9:05
  tricky
• 9:06
  curve
• 9:06
  balls
• 9:06
  on
• 9:06
  there
• 9:06
  as
• 9:07
  often,
• 9:07
  but
• 9:07
  that's
• 9:07
  usually
• 9:07
  an
• 9:08
  augmentation
• 9:08
  strategy
• 9:09
  for
• 9:09
  more
• 9:10
  of
• 9:10
  a
• 9:10
  normal
• 9:10
  thyroid
• 9:11
  in
• 9:11
  a
• 9:12
  treatment
• 9:12
  resistant
• 9:12
  depressive
• 9:13
  episode.
• 9:14
  But
• 9:14
  it's
• 9:15
  not
• 9:15
  really
• 9:15
  there
• 9:15
  for
• 9:15
  correcting
• 9:16
  low
• 9:16
  T4
• 9:17
  in
• 9:17
  primary
• 9:17
  hypothyroidism.
• 9:18
  That's
• 9:19
  not
• 9:19
  something
• 9:19
  you
• 9:19
  really
• 9:20
  need
• 9:20
  to
• 9:20
  know
• 9:20
  right
• 9:20
  now.
• 9:20
  But
• 9:21
  the
• 9:21
  bottom
• 9:21
  line
• 9:21
  is
• 9:22
  hypothyroidism
• 9:23
  can
• 9:23
  mimic
• 9:24
  depression.
• 9:24
  And
• 9:25
  it's
• 9:25
  important
• 9:25
  you
• 9:26
  don't
• 9:26
  just
• 9:26
  add
• 9:27
  antidepressant
• 9:28
  medication
• 9:29
  onto
• 9:29
  this
• 9:29
  stuff
• 9:29
  when
• 9:30
  you're
• 9:30
  dealing
• 9:30
  with
• 9:30
  a
• 9:30
  hypothyroid.
• 9:31
  So
• 9:32
  definitely
• 9:32
  be
• 9:32
  familiar
• 9:33
  not
• 9:33
  just
• 9:34
  with
• 9:34
  what
• 9:34
  a
• 9:34
  TS
• 9:35
  the
• 9:35
  high
• 9:36
  TSH
• 9:36
  could
• 9:36
  mean,
• 9:37
  but
• 9:37
  magnesium
• 9:38
  and
• 9:38
  calcium
• 9:39
  and
• 9:39
  sodium
• 9:40
  levels.
• 9:41
  Be
• 9:42
  familiar
• 9:42
  with
• 9:43
  what
• 9:44
  psychiatric
• 9:45
  symptoms
• 9:46
  can
• 9:46
  look
• 9:46
  like
• 9:47
  so
• 9:47
  that
• 9:47
  you're
• 9:47
  not
• 9:48
  masking
• 9:49
  something
• 9:49
  or
• 9:49
  not
• 9:50
  getting
• 9:50
  to
• 9:50
  the
• 9:50
  root
• 9:50
  of
• 9:50
  a
• 9:51
  problem.
• 9:51
  Now
• 9:52
  question
• 9:52
  three,
• 9:52
  our
• 9:52
  last
• 9:53
  question
• 9:53
  in
• 9:53
  board
• 9:53
  bombs,
• 9:54
  a
• 9:55
  34
• 9:55
  year
• 9:55
  old
• 9:56
  patient
• 9:56
  returns
• 9:56
  one
• 9:56
  month
• 9:57
  after
• 9:57
  starting
• 9:57
  sertraline
• 9:58
  50
• 9:58
  and
• 9:59
  reports
• 9:59
  decreased
• 10:00
  libido
• 10:00
  and
• 10:01
  difficulty
• 10:01
  achieving
• 10:02
  climax,
• 10:03
  which
• 10:03
  is
• 10:03
  the
• 10:03
  most
• 10:04
  appropriate
• 10:04
  next
• 10:05
  step.
• 10:05
  And
• 10:05
  I
• 10:06
  used
• 10:06
  a
• 10:06
  very
• 10:06
  appropriate
• 10:07
  word,
• 10:07
  I
• 10:07
  used
• 10:07
  the
• 10:07
  word
• 10:08
  climax.
• 10:09
  So
• 10:10
  do
• 10:10
  you
• 10:10
  do
• 10:10
  A,
• 10:11
  do
• 10:11
  you
• 10:11
  continue
• 10:11
  sertraline
• 10:12
  and
• 10:12
  reassure
• 10:12
  the
• 10:12
  patient?
• 10:13
  B,
• 10:14
  switch
• 10:14
  to
• 10:14
  bupropion,
• 10:15
  C,
• 10:16
  add
• 10:16
  a
• 10:16
  low
• 10:16
  dose
• 10:17
  MAOI
• 10:17
  Or
• 10:18
  D,
• 10:18
  immediately
• 10:19
  discontinue
• 10:19
  sertraline
• 10:20
  and
• 10:20
  start
• 10:20
  imipramine.
• 10:21
  Okay.
• 10:22
  Another
• 10:22
  question
• 10:22
  where
• 10:23
  it
• 10:23
  really
• 10:23
  helps
• 10:24
  to
• 10:24
  be
• 10:24
  familiar
• 10:24
  with
• 10:25
  the
• 10:25
  names
• 10:25
  of
• 10:25
  your
• 10:25
  medications.
• 10:26
  That's
• 10:26
  why
• 10:26
  I
• 10:26
  say
• 10:27
  to
• 10:27
  prep
• 10:27
  for
• 10:28
  your
• 10:28
  boards.
• 10:28
  Be
• 10:29
  super
• 10:29
  familiar
• 10:30
  with
• 10:30
  brand
• 10:30
  names
• 10:30
  versus
• 10:31
  generic
• 10:31
  names
• 10:31
  versus
• 10:32
  the
• 10:32
  families
• 10:32
  of
• 10:32
  medications.
• 10:33
  Here
• 10:34
  you
• 10:34
  have
• 10:34
  Sertraline.
• 10:35
  We
• 10:36
  know
• 10:36
  that.
• 10:36
  Zoloft,
• 10:36
  we
• 10:37
  know
• 10:37
  that's
• 10:37
  an
• 10:37
  ssri.
• 10:38
  We
• 10:38
  know
• 10:38
  that
• 10:38
  it
• 10:38
  causes
• 10:39
  libido
• 10:39
  issues.
• 10:40
  What
• 10:40
  do
• 10:40
  you
• 10:40
  do
• 10:40
  here?
• 10:41
  Increasing
• 10:41
  the
• 10:41
  sertraline
• 10:42
  or
• 10:42
  continuing
• 10:43
  it?
• 10:43
  A.
• 10:44
  And
• 10:44
  reassuring
• 10:44
  the
• 10:45
  patient
• 10:45
  is
• 10:45
  not
• 10:45
  really
• 10:46
  that
• 10:46
  great
• 10:47
  of
• 10:47
  an
• 10:47
  idea
• 10:47
  because
• 10:48
  some
• 10:48
  of
• 10:48
  these
• 10:49
  sexual
• 10:49
  side
• 10:49
  effects
• 10:49
  are
• 10:50
  dose
• 10:50
  dependent.
• 10:51
  Either
• 10:51
  increasing
• 10:52
  it
• 10:52
  or
• 10:52
  continuing
• 10:53
  it
• 10:53
  doesn't
• 10:53
  necessarily
• 10:54
  help
• 10:54
  with
• 10:54
  sexual
• 10:55
  side
• 10:55
  effects.
• 10:55
  It
• 10:55
  actually
• 10:55
  doesn't
• 10:56
  go
• 10:56
  away
• 10:56
  in
• 10:57
  two
• 10:57
  weeks.
• 10:57
  A
• 10:57
  lot
• 10:58
  of
• 10:58
  your
• 10:58
  side
• 10:58
  effects
• 10:58
  go
• 10:58
  away,
• 10:59
  not
• 10:59
  all
• 10:59
  of
• 10:59
  them.
• 11:00
  And
• 11:00
  sexual
• 11:00
  side
• 11:01
  effects
• 11:01
  can
• 11:01
  sometimes
• 11:01
  linger
• 11:02
  well
• 11:02
  beyond
• 11:03
  two
• 11:03
  weeks
• 11:03
  even
• 11:03
  after
• 11:04
  you
• 11:04
  discontinue
• 11:04
  the
• 11:05
  meds.
• 11:05
  Just
• 11:05
  reassuring
• 11:06
  your
• 11:06
  patient
• 11:06
  is
• 11:07
  not
• 11:07
  going
• 11:07
  to
• 11:07
  build
• 11:07
  rapport
• 11:08
  if
• 11:08
  you
• 11:08
  say
• 11:09
  everything's
• 11:09
  going
• 11:09
  to
• 11:09
  be
• 11:09
  okay,
• 11:10
  and
• 11:10
  then
• 11:10
  three
• 11:10
  months
• 11:11
  later,
• 11:11
  they
• 11:11
  still
• 11:12
  have
• 11:12
  this
• 11:12
  problem.
• 11:12
  So
• 11:13
  I
• 11:13
  don't
• 11:13
  like
• 11:13
  option
• 11:14
  A
• 11:14
  at
• 11:14
  all
• 11:14
  right
• 11:14
  away.
• 11:15
  Switch
• 11:15
  to
• 11:15
  bupropion.
• 11:16
  We
• 11:16
  can
• 11:17
  definitely
• 11:17
  consider
• 11:17
  switch
• 11:18
  to
• 11:18
  bupropion
• 11:18
  as
• 11:19
  an
• 11:19
  answer.
• 11:20
  Add
• 11:20
  a
• 11:20
  low
• 11:20
  dose
• 11:20
  maoi.
• 11:21
  That
• 11:21
  is
• 11:22
  up
• 11:22
  there
• 11:22
  with
• 11:22
  one
• 11:23
  of
• 11:23
  the
• 11:23
  worst
• 11:24
  ideas
• 11:24
  that
• 11:25
  you
• 11:25
  could
• 11:25
  think
• 11:25
  about
• 11:25
  right
• 11:26
  now.
• 11:26
  If
• 11:26
  you
• 11:27
  think
• 11:27
  that
• 11:27
  adding
• 11:27
  a
• 11:28
  low
• 11:28
  dose
• 11:28
  MAOI
• 11:29
  is
• 11:29
  a
• 11:29
  good
• 11:29
  idea,
• 11:30
  you
• 11:30
  got
• 11:30
  to
• 11:30
  hit
• 11:30
  the
• 11:31
  books,
• 11:31
  my
• 11:31
  friend,
• 11:31
  because
• 11:32
  that
• 11:32
  is
• 11:33
  definitely
• 11:33
  not
• 11:33
  the
• 11:33
  path
• 11:34
  we
• 11:34
  want
• 11:34
  to
• 11:34
  go
• 11:34
  down.
• 11:35
  There's
• 11:35
  all
• 11:35
  kinds
• 11:35
  of
• 11:35
  dietary
• 11:36
  restrictions
• 11:36
  with
• 11:37
  MAO
• 11:37
  eyes.
• 11:37
  You
• 11:38
  have
• 11:38
  serotonin
• 11:39
  syndrome
• 11:39
  risks.
• 11:39
  You
• 11:39
  add
• 11:39
  that
• 11:40
  onto
• 11:40
  sertraline,
• 11:41
  it's
• 11:41
  a
• 11:41
  mess.
• 11:41
  There's
• 11:42
  no
• 11:42
  evidence
• 11:43
  to
• 11:43
  suggest
• 11:43
  that
• 11:43
  would
• 11:44
  make
• 11:44
  any
• 11:44
  sense
• 11:44
  right
• 11:45
  now.
• 11:45
  And
• 11:46
  immediately
• 11:46
  discontinue
• 11:47
  sertraline
• 11:47
  and
• 11:47
  start
• 11:48
  imipramine
• 11:48
  again.
• 11:49
  Imipramine,
• 11:50
  what
• 11:50
  are
• 11:50
  we
• 11:50
  talking
• 11:50
  about?
• 11:50
  It's
• 11:51
  a
• 11:51
  tca.
• 11:52
  Why
• 11:52
  would
• 11:52
  that
• 11:52
  help?
• 11:53
  I
• 11:53
  think
• 11:53
  it
• 11:53
  would
• 11:53
  worsen
• 11:54
  sexual
• 11:54
  dysfunction.
• 11:54
  At
• 11:55
  best,
• 11:55
  it
• 11:55
  would
• 11:55
  do
• 11:55
  nothing.
• 11:56
  A
• 11:56
  lot
• 11:56
  of
• 11:56
  the
• 11:56
  boards
• 11:57
  here
• 11:57
  is
• 11:57
  just
• 11:58
  understanding
• 12:00
  what
• 12:00
  does
• 12:00
  that
• 12:00
  mean?
• 12:00
  Because
• 12:01
  I
• 12:01
  know
• 12:01
  when
• 12:01
  I
• 12:02
  took
• 12:02
  my
• 12:02
  courses
• 12:03
  or
• 12:03
  my
• 12:03
  exams,
• 12:04
  a
• 12:04
  new
• 12:05
  medication
• 12:05
  would
• 12:05
  pop
• 12:06
  up
• 12:06
  and
• 12:06
  I
• 12:06
  would
• 12:06
  say,
• 12:06
  wait
• 12:07
  a
• 12:07
  minute,
• 12:07
  what
• 12:07
  is
• 12:07
  that?
• 12:07
  And
• 12:08
  it
• 12:08
  would
• 12:08
  psych
• 12:08
  me
• 12:08
  out,
• 12:09
  right?
• 12:09
  And
• 12:09
  I'd
• 12:09
  be
• 12:09
  like,
• 12:09
  well,
• 12:10
  maybe
• 12:10
  that
• 12:10
  is
• 12:10
  a
• 12:10
  med
• 12:11
  we
• 12:11
  need
• 12:11
  to
• 12:12
  start.
• 12:12
  And
• 12:12
  maybe
• 12:13
  it's
• 12:13
  not
• 12:13
  bupropion.
• 12:14
  But
• 12:14
  my
• 12:14
  friends,
• 12:15
  bupropion
• 12:15
  is
• 12:16
  the
• 12:16
  answer.
• 12:17
  Option
• 12:17
  B,
• 12:18
  an
• 12:19
  ndri.
• 12:20
  Increasing
• 12:20
  dopamine,
• 12:21
  norepinephrine.
• 12:22
  Enhances
• 12:22
  dopaminergic
• 12:23
  tone.
• 12:23
  Reduce
• 12:23
  reverses
• 12:24
  sexual
• 12:24
  inhibition.
• 12:25
  Switching
• 12:25
  or
• 12:26
  augmenting
• 12:26
  with
• 12:26
  Bupropion
• 12:27
  is
• 12:27
  the
• 12:27
  best
• 12:28
  evidence
• 12:28
  based.
• 12:28
  Next
• 12:29
  step
• 12:29
  here.
• 12:30
  I
• 12:30
  hope
• 12:30
  you
• 12:30
  recognize
• 12:31
  that.
• 12:31
  Again,
• 12:31
  think
• 12:31
  neurotransmitters.
• 12:33
  Remember
• 12:33
  that
• 12:33
  your
• 12:34
  SSRIs
• 12:34
  can
• 12:34
  often
• 12:35
  dampen
• 12:35
  dopamine.
• 12:35
  They
• 12:36
  can
• 12:36
  worsen
• 12:36
  sexual
• 12:37
  side
• 12:37
  effects
• 12:38
  in
• 12:38
  that
• 12:38
  sense
• 12:38
  to
• 12:39
  worsen
• 12:39
  your
• 12:40
  ability
• 12:40
  to
• 12:40
  experience
• 12:40
  emotions
• 12:41
  and
• 12:41
  all
• 12:41
  that
• 12:42
  jazz.
• 12:42
  So
• 12:43
  think
• 12:43
  neurotransmitters.
• 12:44
  That's
• 12:44
  how
• 12:44
  you
• 12:44
  get
• 12:45
  out
• 12:45
  of
• 12:45
  these
• 12:45
  traps.
• 12:45
  Think
• 12:46
  neurotransmitters.
• 12:47
  Dopamine
• 12:47
  is
• 12:48
  the
• 12:48
  one
• 12:48
  there.
• 12:48
  Option
• 12:49
  B
• 12:49
  I
• 12:49
  hope
• 12:50
  you
• 12:50
  enjoyed
• 12:50
  Bored
• 12:50
  Bombs,
• 12:51
  my
• 12:51
  friends.
• 12:51
  Please
• 12:52
  become
• 12:52
  Patreon
• 12:52
  members.
• 12:53
  You
• 12:53
  get
• 12:54
  early
• 12:54
  episodes
• 12:55
  dropped
• 12:55
  to
• 12:55
  you
• 12:55
  and
• 12:55
  no
• 12:56
  one
• 12:56
  else
• 12:56
  does.
• 12:56
  You
• 12:57
  get
• 12:57
  bonus
• 12:57
  episodes
• 12:58
  that
• 12:58
  no
• 12:58
  one
• 12:59
  else
• 12:59
  does.
• 12:59
  You
• 13:00
  get
• 13:00
  slide
• 13:00
  decks
• 13:01
  full
• 13:01
  of
• 13:01
  beautiful
• 13:01
  information
• 13:02
  about
• 13:02
  affinity
• 13:03
  and
• 13:04
  occupancy
• 13:05
  and
• 13:06
  inverse
• 13:06
  agonists
• 13:07
  and
• 13:07
  all
• 13:08
  these
• 13:08
  really
• 13:08
  good
• 13:08
  things
• 13:09
  at
• 13:09
  your
• 13:09
  fingertips
• 13:10
  for
• 13:11
  helping
• 13:11
  you,
• 13:11
  empower
• 13:12
  you
• 13:12
  in
• 13:12
  your
• 13:12
  practice,
• 13:13
  empower
• 13:13
  you
• 13:14
  in
• 13:14
  your
• 13:15
  everyday.
• 13:15
  And
• 13:16
  so
• 13:16
  that's
• 13:16
  really
• 13:18
  why
• 13:18
  you
• 13:18
  should
• 13:18
  become
• 13:18
  a
• 13:18
  Patreon
• 13:19
  member
• 13:19
  to
• 13:20
  have
• 13:20
  these
• 13:20
  beautiful
• 13:21
  slide
• 13:21
  decks
• 13:21
  communicate
• 13:22
  about
• 13:23
  what
• 13:23
  episodes
• 13:23
  you
• 13:23
  want
• 13:24
  to
• 13:24
  see
• 13:24
  next,
• 13:24
  what
• 13:24
  you're
• 13:25
  having
• 13:25
  trouble
• 13:25
  with.
• 13:26
  It's
• 13:26
  a
• 13:26
  great
• 13:26
  idea.
• 13:26
  And
• 13:27
  if
• 13:27
  nothing
• 13:27
  else,
• 13:27
  my
• 13:27
  friends,
• 13:28
  we'd
• 13:28
  love
• 13:28
  you
• 13:28
  to
• 13:28
  help
• 13:29
  us
• 13:29
  by
• 13:29
  just
• 13:29
  giving
• 13:30
  us
• 13:30
  five
• 13:30
  stars
• 13:31
  on
• 13:31
  Apple.
• 13:31
  That
• 13:31
  goes
• 13:32
  a
• 13:32
  long
• 13:32
  way
• 13:32
  if
• 13:32
  you
• 13:32
  write
• 13:33
  a
• 13:33
  little
• 13:33
  comment.
• 13:33
  Thanks
• 13:34
  for
• 13:34
  tuning
• 13:34
  in.
• 13:34
  It's
• 13:35
  always
• 13:35
  a
• 13:35
  pleasure.
• 13:35
  I
• 13:36
  hope
• 13:36
  you
• 13:36
  enjoyed
• 13:36
  this
• 13:37
  episode
• 13:37
  of
• 13:37
  Bored
• 13:38
  Bombs.
• 13:39
  Until
• 13:39
  next
• 13:39
  time,
• 13:39
  my
• 13:40
  friends,
• 13:40
  take
• 13:40
  care.
• 13:41
  Signing
• 13:41
  off.