Latest / Pearls and Prep / Bonus Episode: Brief, High-Yield Psych Case. A Board Question You Can’t Miss.

Transcript

Bonus Episode: Brief, High-Yield Psych Case. A Board Question You Can’t Miss. · 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
• 0:08
  and
• 0:08
  Prep.
• 0:08
  This
• 0:08
  is
• 0:08
  NPZ
• 0:09
  here,
• 0:10
  your
• 0:10
  preceptor
• 0:10
  in
• 0:11
  your
• 0:11
  pocket,
• 0:11
  the
• 0:11
  go
• 0:11
  to
• 0:12
  place
• 0:12
  for
• 0:12
  pearls
• 0:13
  that
• 0:13
  prep
• 0:14
  you
• 0:14
  to
• 0:14
  practice.
• 0:15
  Well.
• 0:16
  Knock,
• 0:16
  knock,
• 0:16
  knock.
• 0:17
  You
• 0:18
  have
• 0:18
  a
• 0:18
  68
• 0:19
  year
• 0:19
  old
• 0:19
  woman
• 0:20
  with
• 0:20
  atrial
• 0:21
  fibrillation
• 0:22
  at
• 0:22
  your
• 0:22
  door
• 0:23
  in
• 0:23
  the
• 0:23
  outpatient
• 0:24
  clinic.
• 0:25
  She's
• 0:25
  on
• 0:25
  Apixaban,
• 0:26
  5
• 0:27
  milligrams
• 0:27
  twice
• 0:28
  daily.
• 0:29
  And
• 0:29
  she
• 0:29
  has
• 0:30
  new
• 0:30
  onset
• 0:30
  depression.
• 0:31
  Her
• 0:31
  husband
• 0:32
  passed
• 0:32
  away
• 0:32
  three
• 0:33
  months
• 0:33
  ago.
• 0:34
  She's
• 0:34
  in
• 0:34
  tears.
• 0:35
  She's
• 0:35
  tried
• 0:36
  therapy,
• 0:36
  but
• 0:36
  she
• 0:36
  wants
• 0:37
  medications.
• 0:38
  Okay.
• 0:39
  Her
• 0:39
  PHQ9
• 0:39
  score
• 0:40
  is
• 0:40
  18.
• 0:40
  She
• 0:40
  has
• 0:41
  low
• 0:41
  energy.
• 0:41
  She's
• 0:42
  sleeping
• 0:42
  a
• 0:42
  lot,
• 0:43
  about
• 0:43
  12
• 0:43
  hours
• 0:43
  a
• 0:44
  day.
• 0:44
  And
• 0:45
  her
• 0:45
  appetite's
• 0:46
  actually
• 0:46
  increased.
• 0:46
  She's
• 0:47
  binging
• 0:47
  on
• 0:47
  Haagen
• 0:48
  Dazs.
• 0:49
  I'm
• 0:49
  more
• 0:49
  of
• 0:49
  a
• 0:49
  Ben
• 0:49
  and
• 0:49
  Jerry's
• 0:50
  fan.
• 0:50
  And
• 0:51
  she's
• 0:51
  feeling
• 0:51
  a
• 0:51
  little
• 0:51
  worthless
• 0:52
  now.
• 0:53
  She
• 0:53
  has
• 0:53
  no
• 0:53
  history
• 0:54
  of
• 0:54
  bleeding
• 0:54
  disorders
• 0:55
  or
• 0:55
  seizures.
• 0:56
  Now,
• 0:56
  which
• 0:56
  of
• 0:56
  the
• 0:57
  following
• 0:57
  is
• 0:57
  the
• 0:58
  most
• 0:58
  appropriate
• 0:58
  antidepressant
• 0:59
  choice
• 0:59
  for
• 1:00
  this
• 1:00
  patient?
• 1:00
  Would
• 1:01
  you
• 1:01
  give
• 1:01
  her
• 1:02
  Zoloft?
• 1:04
  That's
• 1:04
  a,
• 1:05
  B,
• 1:05
  Lexapro,
• 1:06
  C,
• 1:07
  Prozac,
• 1:07
  or
• 1:08
  D.
• 1:09
  Wellbutrin?
• 1:10
  So
• 1:11
  what
• 1:11
  would
• 1:11
  you
• 1:11
  do
• 1:11
  here,
• 1:12
  my
• 1:12
  friends?
• 1:14
  And
• 1:14
  the
• 1:15
  devil
• 1:15
  is
• 1:15
  in
• 1:15
  the
• 1:16
  details.
• 1:17
  So
• 1:18
  this
• 1:18
  is
• 1:18
  one
• 1:18
  of
• 1:18
  those
• 1:19
  questions
• 1:19
  that
• 1:20
  you
• 1:20
  may
• 1:20
  see
• 1:20
  on
• 1:20
  your
• 1:20
  boards,
• 1:21
  right?
• 1:22
  In
• 1:22
  where
• 1:22
  you
• 1:22
  have
• 1:22
  this
• 1:23
  kind
• 1:23
  of
• 1:24
  foreign
• 1:24
  medication
• 1:25
  you
• 1:25
  may
• 1:25
  not
• 1:25
  even
• 1:25
  understand
• 1:26
  or
• 1:26
  know
• 1:26
  about
• 1:27
  as
• 1:27
  a.
• 1:27
  As
• 1:27
  a
• 1:27
  new
• 1:27
  grad
• 1:28
  or
• 1:28
  someone
• 1:28
  preparing
• 1:29
  to
• 1:29
  practice.
• 1:29
  Right.
• 1:30
  A
• 1:30
  Pixaban.
• 1:31
  Okay.
• 1:32
  It's
• 1:32
  like,
• 1:32
  what
• 1:32
  on
• 1:32
  earth
• 1:33
  is
• 1:33
  that?
• 1:33
  Okay,
• 1:34
  but
• 1:34
  there
• 1:34
  are
• 1:34
  certain
• 1:35
  clues
• 1:35
  in
• 1:36
  here
• 1:36
  that
• 1:37
  are
• 1:37
  alluding
• 1:38
  to
• 1:38
  what
• 1:38
  it
• 1:38
  might
• 1:38
  do
• 1:40
  in
• 1:40
  a
• 1:40
  sneaky
• 1:41
  way.
• 1:41
  You
• 1:41
  know
• 1:41
  how
• 1:41
  these
• 1:41
  questions
• 1:42
  can
• 1:42
  get
• 1:42
  really
• 1:42
  sneaky
• 1:43
  on
• 1:43
  the
• 1:43
  boards
• 1:44
  or
• 1:44
  on
• 1:44
  your
• 1:44
  final
• 1:44
  exams?
• 1:45
  So
• 1:45
  there's
• 1:46
  something
• 1:46
  alluding
• 1:47
  to
• 1:47
  bleeding
• 1:48
  disorders
• 1:48
  or
• 1:48
  seizures.
• 1:49
  That's
• 1:49
  kind
• 1:49
  of
• 1:49
  a
• 1:49
  weird
• 1:50
  closing
• 1:51
  statement
• 1:51
  in
• 1:51
  your,
• 1:51
  in
• 1:52
  your
• 1:52
  opener
• 1:53
  here.
• 1:54
  But
• 1:54
  you
• 1:54
  do
• 1:54
  know
• 1:55
  she
• 1:55
  has
• 1:55
  atrial
• 1:55
  fibrillation.
• 1:56
  Okay.
• 1:57
  And
• 1:57
  this
• 1:58
  is
• 1:58
  where
• 1:58
  the
• 1:58
  pathophys
• 1:59
  class
• 2:00
  actually
• 2:00
  pays
• 2:00
  off
• 2:01
  in
• 2:01
  case
• 2:01
  you
• 2:01
  napped
• 2:02
  through
• 2:02
  it
• 2:03
  or
• 2:04
  you
• 2:04
  already
• 2:04
  threw
• 2:05
  your
• 2:05
  book
• 2:05
  in
• 2:05
  the
• 2:05
  chimney.
• 2:06
  Not
• 2:06
  a
• 2:06
  good
• 2:07
  idea.
• 2:07
  I
• 2:07
  don't
• 2:08
  recommend
• 2:08
  you
• 2:08
  do
• 2:08
  either
• 2:08
  of
• 2:08
  those
• 2:09
  things.
• 2:09
  I
• 2:09
  actually
• 2:09
  loved
• 2:09
  pathophys,
• 2:10
  but
• 2:11
  atrial
• 2:11
  fibrillation
• 2:12
  is
• 2:12
  kind
• 2:13
  of
• 2:13
  its
• 2:13
  own
• 2:13
  beast
• 2:13
  because
• 2:14
  with
• 2:14
  atrial
• 2:14
  fibrillation,
• 2:15
  you
• 2:16
  have
• 2:16
  the
• 2:16
  risk,
• 2:16
  of
• 2:17
  course,
• 2:17
  that
• 2:18
  your,
• 2:19
  your
• 2:19
  heart
• 2:20
  is
• 2:20
  not
• 2:21
  beating
• 2:22
  in
• 2:22
  a
• 2:22
  normal
• 2:22
  rhythm
• 2:23
  and
• 2:23
  it
• 2:23
  can
• 2:23
  actually
• 2:24
  lead
• 2:24
  to
• 2:25
  the
• 2:26
  formation
• 2:27
  of
• 2:27
  clots.
• 2:28
  Okay.
• 2:29
  And
• 2:30
  so
• 2:30
  apixaban
• 2:31
  is
• 2:31
  a
• 2:31
  direct
• 2:31
  oral
• 2:32
  anti
• 2:33
  coagulant.
• 2:34
  Good
• 2:34
  to
• 2:34
  know.
• 2:34
  Right.
• 2:35
  And
• 2:36
  so
• 2:36
  it
• 2:36
  kind
• 2:36
  of
• 2:37
  prevents
• 2:37
  thrombin
• 2:38
  generation
• 2:38
  and
• 2:38
  clot
• 2:39
  formation.
• 2:40
  It's
• 2:41
  first
• 2:41
  line
• 2:41
  therapy
• 2:41
  for
• 2:41
  stroke
• 2:42
  prevention
• 2:43
  in
• 2:43
  afib
• 2:44
  reduces
• 2:44
  stroke
• 2:45
  by
• 2:45
  55%.
• 2:46
  Okay?
• 2:47
  You
• 2:47
  don't
• 2:47
  need
• 2:47
  to
• 2:47
  know
• 2:47
  that
• 2:47
  much
• 2:48
  more.
• 2:48
  You
• 2:48
  don't
• 2:48
  need
• 2:48
  to
• 2:48
  know
• 2:48
  who
• 2:48
  invented
• 2:49
  it.
• 2:49
  You
• 2:50
  don't
• 2:50
  need
• 2:50
  to
• 2:50
  know
• 2:50
  whose
• 2:51
  grandmother
• 2:51
  is
• 2:51
  on
• 2:52
  this
• 2:52
  right
• 2:52
  now.
• 2:53
  But
• 2:53
  the
• 2:53
  grandmother
• 2:53
  at
• 2:54
  your
• 2:54
  door
• 2:54
  in
• 2:54
  the
• 2:55
  outpatient
• 2:55
  space
• 2:56
  is
• 2:56
  on
• 2:56
  this.
• 2:57
  And
• 2:58
  it's
• 2:58
  really
• 2:58
  important,
• 2:59
  you
• 2:59
  know?
• 2:59
  And
• 2:59
  you
• 3:00
  kind
• 3:00
  of
• 3:00
  stop
• 3:00
  in
• 3:00
  your
• 3:00
  tracks
• 3:01
  and
• 3:01
  go,
• 3:01
  wait
• 3:01
  a
• 3:01
  minute.
• 3:02
  Is
• 3:02
  there
• 3:02
  anything
• 3:02
  I
• 3:03
  need
• 3:03
  to
• 3:03
  know
• 3:03
  here?
• 3:03
  One
• 3:04
  of
• 3:04
  my
• 3:04
  golden
• 3:04
  rules
• 3:05
  in
• 3:05
  practice,
• 3:05
  my
• 3:06
  friends,
• 3:06
  is
• 3:07
  I
• 3:07
  always
• 3:07
  like
• 3:07
  to
• 3:08
  ask
• 3:08
  myself,
• 3:09
  what
• 3:09
  is
• 3:09
  the
• 3:09
  worst
• 3:10
  possible
• 3:10
  thing
• 3:11
  I
• 3:11
  could
• 3:12
  do
• 3:12
  here,
• 3:12
  and
• 3:13
  how
• 3:13
  do
• 3:13
  I
• 3:13
  not
• 3:13
  do
• 3:13
  that?
• 3:14
  Right?
• 3:14
  And
• 3:15
  so
• 3:15
  when
• 3:15
  I
• 3:15
  frame
• 3:16
  the
• 3:16
  question
• 3:16
  like
• 3:16
  that
• 3:17
  after
• 3:18
  seeing
• 3:18
  a
• 3:18
  patient
• 3:19
  or
• 3:19
  being
• 3:19
  in
• 3:19
  front
• 3:19
  of
• 3:19
  a
• 3:20
  patient,
• 3:20
  it
• 3:21
  allows
• 3:21
  me
• 3:21
  to
• 3:22
  really
• 3:22
  scrutinize,
• 3:22
  almost
• 3:23
  like
• 3:23
  a
• 3:23
  detective,
• 3:23
  like,
• 3:24
  what
• 3:24
  is.
• 3:24
  What
• 3:24
  is
• 3:25
  going
• 3:25
  on
• 3:25
  here?
• 3:26
  What
• 3:26
  do
• 3:26
  I
• 3:26
  have
• 3:26
  to
• 3:26
  be
• 3:27
  worried
• 3:27
  about?
• 3:28
  And
• 3:28
  certainly
• 3:28
  somebody
• 3:29
  with
• 3:29
  atrial
• 3:29
  fibrillation.
• 3:30
  I'd
• 3:30
  want
• 3:30
  to
• 3:31
  do
• 3:31
  a
• 3:31
  deeper
• 3:31
  dive
• 3:31
  and
• 3:32
  understand,
• 3:32
  like,
• 3:32
  what
• 3:33
  is
• 3:33
  the
• 3:33
  worst
• 3:33
  thing
• 3:33
  I
• 3:33
  could
• 3:34
  accidentally
• 3:34
  do
• 3:34
  here
• 3:35
  if
• 3:35
  I'm
• 3:35
  not
• 3:35
  paying
• 3:35
  attention.
• 3:36
  Okay?
• 3:37
  And
• 3:37
  so
• 3:38
  of
• 3:38
  all
• 3:38
  these.
• 3:39
  Of
• 3:39
  all
• 3:39
  these
• 3:39
  answers,
• 3:40
  right?
• 3:40
  Zoloft,
• 3:41
  Lexapro,
• 3:42
  Prozac,
• 3:43
  or.
• 3:44
  Or
• 3:44
  Wellbutrin,
• 3:46
  which
• 3:46
  one
• 3:47
  of
• 3:47
  these
• 3:47
  things
• 3:47
  is
• 3:47
  not
• 3:48
  like
• 3:48
  the
• 3:48
  other,
• 3:48
  Right?
• 3:49
  Well,
• 3:49
  right
• 3:49
  off
• 3:49
  the
• 3:49
  bat,
• 3:50
  we
• 3:50
  have
• 3:50
  three
• 3:50
  SSRIs,
• 3:51
  and
• 3:51
  then
• 3:51
  we
• 3:52
  have
• 3:52
  one
• 3:52
  NDRI.
• 3:53
  NDRI
• 3:53
  would
• 3:53
  be
• 3:54
  Wellbutrin.
• 3:54
  It's
• 3:54
  a
• 3:54
  norepinephrine
• 3:55
  dopamine
• 3:56
  reuptake
• 3:56
  inhibitor.
• 3:58
  Well,
• 3:58
  why
• 3:58
  do
• 3:58
  we
• 3:58
  have
• 3:58
  one?
• 3:59
  Dopamine,
• 3:59
  norepinephrine
• 4:00
  reuptake
• 4:01
  inhibitor,
• 4:01
  choice.
• 4:02
  And
• 4:02
  the
• 4:02
  rest
• 4:03
  are
• 4:03
  serotonergic.
• 4:04
  Well,
• 4:04
  that's
• 4:04
  interesting,
• 4:05
  because
• 4:05
  we're
• 4:05
  supposed
• 4:05
  to
• 4:05
  pick
• 4:05
  one
• 4:06
  that
• 4:06
  is
• 4:06
  good,
• 4:07
  one
• 4:07
  that
• 4:07
  is
• 4:07
  acceptable
• 4:08
  to
• 4:08
  the
• 4:08
  patient.
• 4:10
  Well,
• 4:11
  that's
• 4:12
  very
• 4:12
  interesting.
• 4:13
  Well,
• 4:13
  we
• 4:13
  know,
• 4:13
  right,
• 4:14
  when
• 4:14
  a
• 4:15
  patient
• 4:15
  is
• 4:15
  taking
• 4:15
  oral
• 4:16
  anticoagulants,
• 4:17
  right?
• 4:17
  So
• 4:17
  we're
• 4:18
  trying
• 4:18
  to
• 4:18
  bust
• 4:18
  up
• 4:18
  clots.
• 4:19
  There
• 4:19
  is
• 4:20
  a
• 4:20
  concern
• 4:21
  for
• 4:21
  bleeding,
• 4:23
  and
• 4:24
  one
• 4:24
  of
• 4:24
  the
• 4:25
  side
• 4:25
  effects
• 4:26
  or
• 4:27
  one
• 4:27
  of
• 4:27
  the
• 4:27
  contraindications
• 4:28
  with
• 4:29
  SSRIs
• 4:30
  is
• 4:30
  that
• 4:30
  they
• 4:30
  can
• 4:30
  increase
• 4:31
  bleeding
• 4:31
  risk
• 4:32
  with
• 4:32
  anticoagulants.
• 4:33
  Right?
• 4:34
  SSRIs
• 4:34
  deplete
• 4:35
  platelet
• 4:35
  serotonin,
• 4:36
  so
• 4:37
  they
• 4:37
  kind
• 4:37
  of
• 4:37
  make
• 4:37
  that
• 4:37
  clot
• 4:38
  formation.
• 4:38
  They
• 4:39
  kind
• 4:39
  of
• 4:39
  give
• 4:40
  it
• 4:40
  less
• 4:40
  glue
• 4:40
  to
• 4:41
  clot,
• 4:41
  and
• 4:42
  so
• 4:42
  bleeding
• 4:42
  can
• 4:43
  happen
• 4:43
  more
• 4:44
  frequently.
• 4:44
  That's
• 4:45
  a
• 4:45
  problem.
• 4:45
  Right?
• 4:46
  It
• 4:46
  can
• 4:46
  be
• 4:46
  harder
• 4:47
  to
• 4:47
  control
• 4:47
  bleeding.
• 4:48
  Patients
• 4:48
  can
• 4:49
  bruise
• 4:49
  easily.
• 4:49
  They
• 4:49
  can
• 4:50
  get
• 4:50
  nosebleeds.
• 4:50
  They
• 4:51
  can
• 4:51
  have
• 4:51
  bleeding
• 4:51
  gums,
• 4:52
  heavier
• 4:52
  periods,
• 4:53
  you
• 4:53
  know,
• 4:53
  if
• 4:54
  it's
• 4:54
  moderate.
• 4:54
  And
• 4:55
  if
• 4:55
  it's
• 4:55
  escalating,
• 4:56
  they
• 4:56
  might
• 4:56
  have
• 4:56
  black
• 4:56
  stools
• 4:57
  or
• 4:57
  fatigue
• 4:57
  and
• 4:57
  become
• 4:58
  anemic.
• 4:58
  Okay,
• 5:00
  um.
• 5:00
  That's
• 5:01
  a
• 5:01
  problem
• 5:01
  as
• 5:01
  well,
• 5:02
  right?
• 5:02
  Uh,
• 5:03
  they
• 5:04
  might.
• 5:05
  In
• 5:05
  the
• 5:05
  worst
• 5:06
  case
• 5:06
  scenario,
• 5:06
  your
• 5:07
  elderly
• 5:07
  patient
• 5:08
  falls,
• 5:09
  hits
• 5:09
  her
• 5:09
  head,
• 5:10
  and
• 5:10
  now
• 5:10
  there's
• 5:11
  an
• 5:11
  intra.
• 5:11
  Intracranial
• 5:12
  bleed
• 5:12
  because
• 5:13
  we
• 5:13
  prescribed
• 5:14
  Zoloft
• 5:15
  or
• 5:15
  Prozac
• 5:16
  when
• 5:16
  they
• 5:16
  were
• 5:17
  also
• 5:17
  on
• 5:17
  an
• 5:17
  anticoagulant.
• 5:19
  So
• 5:19
  with
• 5:19
  older
• 5:20
  patients,
• 5:20
  of
• 5:20
  course,
• 5:20
  there's
• 5:21
  many
• 5:21
  different
• 5:21
  patients
• 5:21
  you
• 5:22
  have
• 5:22
  to
• 5:22
  be
• 5:22
  careful
• 5:22
  with
• 5:23
  when
• 5:23
  it
• 5:23
  comes
• 5:23
  to
• 5:24
  bleeding
• 5:25
  risks.
• 5:25
  But
• 5:25
  with
• 5:26
  older
• 5:26
  patients,
• 5:26
  we're
• 5:27
  definitely
• 5:27
  concerned
• 5:27
  about
• 5:28
  the
• 5:28
  fall.
• 5:28
  And
• 5:29
  it's
• 5:29
  even
• 5:29
  worse
• 5:30
  if
• 5:30
  you,
• 5:30
  if
• 5:30
  you
• 5:30
  prescribe
• 5:31
  like
• 5:31
  a
• 5:31
  sedating
• 5:32
  ssri,
• 5:32
  God
• 5:33
  forbid
• 5:33
  you
• 5:33
  prescribe
• 5:33
  Paxil,
• 5:34
  which
• 5:35
  I
• 5:35
  think
• 5:35
  by
• 5:35
  the
• 5:36
  time
• 5:36
  you
• 5:36
  start
• 5:37
  practicing,
• 5:38
  I
• 5:38
  hope
• 5:39
  you
• 5:39
  all
• 5:39
  will
• 5:40
  have
• 5:40
  the
• 5:40
  intuition
• 5:41
  to
• 5:41
  go.
• 5:41
  Paxil
• 5:42
  is
• 5:42
  really
• 5:42
  not
• 5:43
  a
• 5:43
  good
• 5:43
  idea
• 5:43
  in
• 5:44
  older
• 5:44
  folks
• 5:45
  because
• 5:45
  especially
• 5:46
  if
• 5:46
  there's
• 5:46
  like
• 5:46
  a
• 5:47
  anticoagulant
• 5:48
  on
• 5:48
  board,
• 5:49
  because
• 5:49
  not
• 5:50
  only
• 5:50
  is
• 5:50
  there
• 5:51
  an
• 5:51
  increased
• 5:51
  risk
• 5:51
  of
• 5:51
  bleeding,
• 5:52
  but
• 5:52
  this
• 5:52
  is
• 5:52
  quite
• 5:53
  sedating.
• 5:54
  This
• 5:54
  patient
• 5:54
  that
• 5:55
  you're.
• 5:55
  That's
• 5:55
  at
• 5:55
  your
• 5:56
  clinic
• 5:56
  right
• 5:56
  now
• 5:56
  gained
• 5:57
  15
• 5:57
  pounds
• 5:57
  of
• 5:57
  weight.
• 5:57
  So
• 5:58
  Paxil's
• 5:58
  even
• 5:58
  worse.
• 5:59
  Now
• 5:59
  you're
• 6:00
  going
• 6:00
  to
• 6:00
  cause
• 6:00
  weight
• 6:00
  gain.
• 6:00
  Now
• 6:01
  you're
• 6:01
  going
• 6:01
  to
• 6:01
  cause
• 6:01
  a
• 6:01
  bleed
• 6:02
  risk,
• 6:03
  and
• 6:03
  the
• 6:03
  patient's
• 6:04
  going
• 6:04
  to
• 6:04
  be
• 6:04
  sedated
• 6:05
  and
• 6:05
  might
• 6:05
  fall
• 6:05
  and
• 6:06
  has
• 6:06
  a
• 6:06
  worse
• 6:06
  bleed
• 6:07
  risk.
• 6:07
  Right?
• 6:07
  So
• 6:08
  Paxil
• 6:08
  would
• 6:08
  be
• 6:08
  one
• 6:09
  of
• 6:09
  the
• 6:09
  worst
• 6:09
  things
• 6:09
  you
• 6:09
  could
• 6:10
  do,
• 6:10
  which.
• 6:11
  Which
• 6:11
  would
• 6:11
  be
• 6:12
  horrific.
• 6:12
  But,
• 6:13
  yeah.
• 6:13
  So
• 6:13
  Paxil's
• 6:14
  a
• 6:14
  bad
• 6:14
  idea,
• 6:14
  but
• 6:14
  sometimes
• 6:15
  you
• 6:15
  learn
• 6:16
  in
• 6:16
  school
• 6:17
  by
• 6:18
  understanding
• 6:18
  what
• 6:18
  the
• 6:19
  worst
• 6:19
  thing
• 6:19
  is.
• 6:19
  So
• 6:19
  you
• 6:20
  understand
• 6:20
  what
• 6:20
  the
• 6:20
  best
• 6:20
  thing
• 6:21
  is,
• 6:21
  right?
• 6:22
  And
• 6:23
  so,
• 6:23
  my
• 6:24
  friends,
• 6:25
  the
• 6:25
  answer
• 6:26
  today
• 6:26
  to
• 6:27
  this
• 6:27
  question
• 6:28
  is
• 6:28
  Wellbutrin.
• 7:24
  Because
• 7:25
  sure
• 7:26
  enough,
• 7:26
  Wellbutrin
• 7:27
  is
• 7:27
  the
• 7:28
  non
• 7:28
  serotonergic
• 7:29
  choice
• 7:30
  that
• 7:30
  will
• 7:30
  not
• 7:31
  lead
• 7:31
  to
• 7:31
  an
• 7:31
  increased
• 7:32
  risk
• 7:32
  of
• 7:33
  bleeding.
• 7:34
  Okay?
• 7:34
  It's
• 7:35
  also
• 7:35
  convenient
• 7:36
  for
• 7:36
  her
• 7:36
  particular
• 7:37
  symptoms,
• 7:37
  right?
• 7:38
  Her
• 7:38
  low
• 7:38
  energy,
• 7:39
  she's
• 7:39
  sleeping
• 7:40
  too
• 7:40
  much,
• 7:42
  she
• 7:42
  has
• 7:42
  an
• 7:42
  increased
• 7:42
  appetite,
• 7:43
  she's
• 7:43
  gaining
• 7:43
  weight.
• 7:44
  Wellbutrin
• 7:45
  typically
• 7:45
  is
• 7:45
  weight
• 7:45
  neutral.
• 7:46
  Some
• 7:46
  people
• 7:46
  even
• 7:46
  lose
• 7:47
  weight
• 7:47
  on
• 7:47
  Wellbutrin
• 7:48
  in
• 7:48
  my
• 7:48
  experience.
• 7:49
  But
• 7:49
  it
• 7:49
  certainly
• 7:50
  will
• 7:50
  give
• 7:50
  her
• 7:50
  that
• 7:50
  energy.
• 7:51
  Now
• 7:51
  you
• 7:51
  just
• 7:51
  have
• 7:51
  to
• 7:52
  make
• 7:52
  sure
• 7:52
  she
• 7:52
  has
• 7:52
  no
• 7:52
  seizure
• 7:53
  history.
• 7:53
  And
• 7:53
  of
• 7:53
  course,
• 7:54
  we
• 7:54
  proved
• 7:55
  that.
• 7:55
  And
• 7:55
  there's
• 7:56
  a
• 7:56
  little
• 7:56
  clue,
• 7:56
  my
• 7:56
  friend.
• 7:57
  See,
• 7:57
  when
• 7:57
  you
• 7:58
  put
• 7:58
  this
• 7:58
  all
• 7:58
  together,
• 7:58
  when
• 7:59
  you
• 7:59
  read
• 7:59
  the
• 7:59
  whole
• 7:59
  question,
• 7:59
  it
• 8:00
  really
• 8:00
  helps
• 8:00
  you
• 8:00
  gain
• 8:01
  mastery
• 8:01
  in
• 8:01
  your
• 8:01
  board
• 8:02
  questions,
• 8:02
  because
• 8:03
  the
• 8:03
  Wellbutrin
• 8:04
  here,
• 8:05
  right,
• 8:06
  it's
• 8:06
  like
• 8:06
  a
• 8:06
  clue
• 8:06
  at
• 8:07
  the
• 8:07
  end
• 8:07
  of
• 8:07
  your.
• 8:08
  At
• 8:08
  the
• 8:08
  end
• 8:08
  of
• 8:08
  this
• 8:09
  multiple
• 8:09
  choice
• 8:09
  question
• 8:10
  says
• 8:10
  she
• 8:10
  has
• 8:10
  no
• 8:10
  history
• 8:10
  of
• 8:11
  bleeding
• 8:11
  disorders
• 8:11
  or
• 8:12
  seizures.
• 8:12
  Usually
• 8:13
  questions
• 8:14
  don't
• 8:14
  just
• 8:14
  throw
• 8:14
  irrelevant
• 8:15
  information
• 8:15
  at
• 8:16
  you,
• 8:16
  okay?
• 8:16
  There's
• 8:16
  usually
• 8:17
  a
• 8:17
  reason
• 8:17
  they're
• 8:18
  telling
• 8:18
  you
• 8:18
  she
• 8:18
  has
• 8:18
  no
• 8:19
  History
• 8:19
  of
• 8:19
  seizures.
• 8:20
  That's
• 8:20
  the
• 8:20
  elbow
• 8:21
  nudge
• 8:21
  saying,
• 8:21
  hey,
• 8:21
  if
• 8:22
  you're
• 8:22
  going
• 8:22
  to
• 8:22
  consider
• 8:22
  Wellbutrin,
• 8:24
  it
• 8:24
  ain't
• 8:24
  a
• 8:24
  bad
• 8:24
  choice
• 8:25
  because
• 8:25
  she
• 8:25
  doesn't
• 8:25
  have
• 8:26
  a
• 8:26
  history
• 8:26
  of
• 8:26
  seizures.
• 8:27
  So
• 8:28
  absolutely
• 8:28
  the
• 8:28
  right
• 8:29
  thing
• 8:29
  to
• 8:29
  do
• 8:29
  here
• 8:30
  with
• 8:30
  your
• 8:30
  elderly
• 8:31
  fit
• 8:31
  patient
• 8:32
  is
• 8:32
  set
• 8:32
  her
• 8:32
  up
• 8:32
  for
• 8:32
  success,
• 8:33
  make
• 8:33
  sure
• 8:33
  she's
• 8:34
  safe,
• 8:34
  and
• 8:35
  avoid
• 8:35
  the
• 8:35
  SSRIs,
• 8:38
  because
• 8:38
  we
• 8:38
  don't
• 8:38
  want
• 8:39
  to
• 8:39
  impair
• 8:39
  platelet
• 8:40
  aggregation.
• 8:42
  And
• 8:42
  we,
• 8:43
  you
• 8:43
  know,
• 8:43
  remember
• 8:44
  that
• 8:44
  platelets
• 8:44
  themselves
• 8:45
  cannot
• 8:45
  synthesize
• 8:46
  serotonin,
• 8:47
  okay?
• 8:47
  They
• 8:48
  rely
• 8:48
  entirely
• 8:49
  on
• 8:49
  the
• 8:49
  uptake
• 8:50
  from
• 8:50
  plasma
• 8:50
  via
• 8:51
  SS,
• 8:51
  the.
• 8:51
  The
• 8:52
  SSRI
• 8:52
  via
• 8:53
  the
• 8:53
  serotonin
• 8:53
  transporter,
• 8:54
  okay?
• 8:55
  Which
• 8:55
  SSRIs
• 8:56
  block,
• 8:56
  okay?
• 8:57
  So
• 8:58
  that's
• 8:58
  a
• 8:58
  big
• 8:58
  issue.
• 8:59
  So
• 8:59
  remember,
• 8:59
  platelets
• 9:00
  are
• 9:00
  very
• 9:00
  needy.
• 9:02
  They're
• 9:02
  very
• 9:02
  needy
• 9:03
  for
• 9:04
  serotonin.
• 9:05
  And
• 9:05
  the
• 9:05
  SSRI
• 9:06
  really
• 9:06
  stops
• 9:07
  the
• 9:07
  show.
• 9:07
  And
• 9:08
  that's
• 9:08
  a
• 9:08
  major
• 9:08
  problem.
• 9:10
  So
• 9:10
  we
• 9:10
  wanna
• 9:10
  just
• 9:11
  keep
• 9:11
  that
• 9:11
  in
• 9:11
  mind.
• 9:12
  We
• 9:12
  don't
• 9:12
  want
• 9:13
  intracranial
• 9:13
  hemorrhages,
• 9:14
  GI
• 9:14
  bleeding,
• 9:15
  any
• 9:15
  major
• 9:15
  bleeds
• 9:15
  at
• 9:16
  all.
• 9:16
  And
• 9:16
  look
• 9:16
  out
• 9:17
  for
• 9:17
  warfarin,
• 9:17
  right?
• 9:18
  Look
• 9:18
  out
• 9:18
  for
• 9:19
  all
• 9:19
  these
• 9:19
  other
• 9:20
  medications
• 9:20
  out
• 9:20
  there.
• 9:20
  There's
• 9:21
  a
• 9:21
  lot
• 9:21
  of
• 9:21
  oral
• 9:21
  anticoagulants
• 9:22
  I
• 9:22
  highly
• 9:23
  recommend
• 9:23
  you
• 9:24
  get
• 9:24
  familiar
• 9:24
  with.
• 9:24
  Cause
• 9:25
  I'll
• 9:25
  tell
• 9:25
  you
• 9:25
  something,
• 9:25
  my
• 9:25
  friends,
• 9:26
  pharmacology,
• 9:27
  at
• 9:27
  least
• 9:28
  in
• 9:28
  my
• 9:28
  experience
• 9:28
  at
• 9:28
  school,
• 9:29
  was
• 9:29
  challenging
• 9:30
  because
• 9:30
  there's
• 9:30
  a
• 9:30
  lot
• 9:31
  of
• 9:31
  medications.
• 9:31
  The
• 9:32
  mnemonics
• 9:32
  weren't
• 9:33
  great.
• 9:33
  You're
• 9:34
  memorizing
• 9:34
  20
• 9:35
  different
• 9:35
  skin,
• 9:35
  you
• 9:36
  know,
• 9:36
  dermatological
• 9:37
  medications,
• 9:39
  20
• 9:39
  different
• 9:39
  anticoagulants.
• 9:40
  It
• 9:41
  can
• 9:41
  be
• 9:41
  kind
• 9:41
  of
• 9:41
  blurry
• 9:41
  and
• 9:42
  scary.
• 9:42
  And
• 9:42
  I
• 9:42
  will
• 9:43
  say
• 9:43
  one
• 9:43
  thing
• 9:43
  that
• 9:44
  you
• 9:44
  really
• 9:44
  could,
• 9:45
  one
• 9:45
  thing
• 9:46
  that
• 9:46
  would
• 9:46
  really
• 9:46
  prepare
• 9:46
  you
• 9:47
  before
• 9:47
  you
• 9:47
  go
• 9:47
  into
• 9:47
  practice
• 9:48
  is
• 9:49
  memorizing
• 9:50
  some
• 9:51
  of
• 9:51
  the
• 9:51
  most
• 9:52
  relevant
• 9:53
  medications
• 9:54
  that
• 9:55
  are
• 9:55
  medical,
• 9:56
  that
• 9:56
  can
• 9:56
  interfere,
• 9:57
  that
• 9:57
  psychiatric
• 9:57
  medications
• 9:58
  can
• 9:58
  interfere
• 9:59
  with.
• 9:59
  Right?
• 10:00
  So
• 10:00
  I
• 10:00
  don't
• 10:00
  know
• 10:01
  if
• 10:01
  you
• 10:01
  want
• 10:01
  to
• 10:01
  consult
• 10:01
  open
• 10:02
  evidence.
• 10:02
  It's
• 10:02
  a
• 10:02
  really
• 10:03
  great
• 10:04
  AI
• 10:04
  tool
• 10:04
  that's
• 10:05
  backed
• 10:05
  by,
• 10:06
  you
• 10:07
  know,
• 10:07
  JAMA
• 10:08
  and
• 10:08
  the
• 10:08
  BMJ
• 10:09
  and
• 10:09
  all
• 10:09
  kinds
• 10:09
  of
• 10:09
  really
• 10:10
  good
• 10:10
  evidence
• 10:10
  based
• 10:10
  literature.
• 10:11
  But
• 10:11
  that's
• 10:12
  kind
• 10:12
  of
• 10:12
  an
• 10:12
  AI
• 10:12
  that's
• 10:13
  backed
• 10:13
  specifically
• 10:14
  by
• 10:14
  peer
• 10:14
  reviewed
• 10:15
  literature.
• 10:15
  And
• 10:16
  ask
• 10:16
  it,
• 10:17
  you
• 10:17
  know,
• 10:17
  throw
• 10:17
  it
• 10:17
  a
• 10:17
  few
• 10:17
  prompts
• 10:18
  and
• 10:18
  give
• 10:18
  me
• 10:18
  the
• 10:18
  20
• 10:19
  most
• 10:19
  high
• 10:19
  yield
• 10:21
  medications
• 10:22
  that
• 10:23
  people
• 10:23
  may
• 10:23
  be
• 10:24
  on
• 10:24
  that
• 10:24
  psych,
• 10:25
  NPS
• 10:25
  or
• 10:25
  psychiatrists
• 10:27
  may
• 10:27
  not
• 10:27
  be
• 10:27
  as
• 10:27
  acutely
• 10:28
  familiar
• 10:28
  with
• 10:29
  when
• 10:29
  they
• 10:29
  graduate
• 10:30
  to
• 10:30
  ensure
• 10:30
  that
• 10:31
  I'm
• 10:31
  being
• 10:31
  very
• 10:31
  vigilant
• 10:32
  about
• 10:33
  anything
• 10:33
  that's
• 10:33
  coming
• 10:34
  into
• 10:34
  my
• 10:35
  clinic,
• 10:35
  right?
• 10:35
  Just
• 10:36
  to
• 10:36
  get
• 10:36
  a
• 10:36
  brush
• 10:36
  up.
• 10:36
  They
• 10:37
  call
• 10:37
  this
• 10:37
  practice
• 10:37
  for
• 10:37
  a
• 10:38
  reason.
• 10:38
  It
• 10:38
  didn't
• 10:39
  occur
• 10:39
  to
• 10:39
  me
• 10:40
  for
• 10:40
  a
• 10:40
  couple
• 10:41
  of
• 10:41
  years
• 10:41
  until
• 10:41
  I
• 10:41
  graduated.
• 10:43
  What
• 10:43
  practice
• 10:44
  really
• 10:44
  means,
• 10:44
  right?
• 10:45
  When
• 10:45
  you're
• 10:45
  Practicing
• 10:45
  an
• 10:46
  instrument,
• 10:46
  you're
• 10:47
  getting
• 10:47
  better
• 10:47
  every
• 10:47
  time.
• 10:48
  That
• 10:48
  means
• 10:48
  that
• 10:48
  it
• 10:49
  requires
• 10:49
  a
• 10:49
  daily
• 10:49
  discipline
• 10:50
  to
• 10:50
  improve,
• 10:50
  to
• 10:51
  research,
• 10:51
  to
• 10:52
  refine.
• 10:52
  Don't
• 10:53
  be
• 10:54
  self
• 10:54
  conscious
• 10:54
  or
• 10:54
  insecure
• 10:55
  if
• 10:55
  you
• 10:55
  don't
• 10:56
  remember
• 10:56
  every,
• 10:56
  the
• 10:57
  name
• 10:57
  of
• 10:57
  every
• 10:57
  oral
• 10:57
  anti
• 10:58
  coagulant
• 10:58
  off
• 10:58
  the
• 10:59
  top
• 10:59
  of
• 10:59
  your
• 10:59
  head.
• 10:59
  Especially
• 11:00
  with
• 11:00
  the,
• 11:00
  considering
• 11:01
  the
• 11:01
  fact
• 11:01
  that
• 11:01
  there's
• 11:02
  new
• 11:02
  ones
• 11:02
  that
• 11:02
  come
• 11:02
  out
• 11:03
  all
• 11:03
  of
• 11:03
  the
• 11:03
  time,
• 11:03
  there's
• 11:04
  new
• 11:04
  meds
• 11:04
  that
• 11:04
  come
• 11:04
  out
• 11:05
  all
• 11:05
  of
• 11:05
  the
• 11:05
  time.
• 11:05
  No
• 11:06
  one
• 11:06
  can
• 11:06
  keep
• 11:06
  track
• 11:06
  of
• 11:07
  all
• 11:07
  of
• 11:07
  that.
• 11:07
  But
• 11:08
  that's
• 11:08
  why
• 11:08
  we
• 11:08
  call
• 11:08
  this
• 11:08
  a
• 11:09
  practice
• 11:09
  every
• 11:09
  day.
• 11:10
  We,
• 11:10
  we
• 11:10
  have,
• 11:11
  you
• 11:11
  know,
• 11:11
  we,
• 11:11
  we
• 11:11
  have
• 11:12
  the
• 11:12
  discipline
• 11:13
  and
• 11:13
  the,
• 11:15
  you
• 11:15
  know,
• 11:15
  the,
• 11:15
  the
• 11:16
  persistence
• 11:16
  to,
• 11:17
  to,
• 11:17
  to
• 11:17
  get,
• 11:18
  get
• 11:18
  on
• 11:18
  the
• 11:18
  instrument
• 11:19
  and
• 11:19
  play
• 11:19
  and,
• 11:20
  and
• 11:20
  pretty
• 11:20
  soon
• 11:20
  we're
• 11:21
  really
• 11:21
  proud
• 11:21
  of
• 11:22
  the
• 11:22
  way
• 11:22
  we
• 11:22
  sound
• 11:23
  and
• 11:23
  we
• 11:23
  keep
• 11:23
  playing
• 11:24
  and
• 11:24
  performing
• 11:25
  and
• 11:25
  we're
• 11:25
  doing
• 11:25
  well.
• 11:26
  So
• 11:26
  think
• 11:26
  of
• 11:27
  it
• 11:27
  that
• 11:27
  way.
• 11:27
  My
• 11:27
  friends
• 11:28
  run
• 11:29
  these
• 11:29
  queries,
• 11:31
  find
• 11:31
  out
• 11:31
  the
• 11:31
  medications
• 11:32
  that
• 11:32
  you
• 11:32
  really
• 11:33
  need
• 11:33
  to
• 11:33
  be
• 11:33
  careful
• 11:33
  about.
• 11:34
  And
• 11:34
  I'll
• 11:34
  tell
• 11:34
  you,
• 11:35
  you
• 11:35
  might
• 11:35
  find
• 11:35
  your
• 11:36
  75
• 11:36
  year
• 11:36
  old
• 11:36
  patients
• 11:37
  are
• 11:37
  on
• 11:37
  30
• 11:37
  different
• 11:38
  medications.
• 11:39
  It
• 11:39
  can
• 11:39
  be
• 11:39
  very
• 11:39
  dizzying,
• 11:40
  it
• 11:40
  can
• 11:40
  be
• 11:40
  very
• 11:40
  overwhelming.
• 11:42
  It's
• 11:42
  very
• 11:42
  important.
• 11:42
  You
• 11:43
  have
• 11:43
  a
• 11:43
  working
• 11:43
  familiarity
• 11:44
  with
• 11:45
  some
• 11:45
  of
• 11:45
  the
• 11:45
  worst
• 11:45
  things
• 11:46
  that
• 11:46
  can
• 11:46
  happen
• 11:46
  in
• 11:46
  those
• 11:47
  populations.
• 11:47
  And
• 11:47
  it
• 11:48
  may
• 11:48
  not
• 11:48
  be
• 11:48
  always
• 11:48
  that
• 11:49
  simple.
• 11:49
  You
• 11:49
  might
• 11:49
  have
• 11:49
  a
• 11:50
  patient
• 11:50
  who
• 11:50
  comes
• 11:51
  into
• 11:51
  your
• 11:51
  office
• 11:51
  who
• 11:52
  not
• 11:52
  only
• 11:53
  is
• 11:54
  on,
• 11:55
  you
• 11:55
  know,
• 11:55
  not
• 11:55
  only
• 11:55
  has
• 11:56
  afib
• 11:56
  and,
• 11:57
  but,
• 11:57
  but
• 11:58
  also
• 11:58
  has
• 11:58
  seizures
• 11:59
  in
• 11:59
  her
• 11:59
  past.
• 11:59
  Well,
• 12:00
  now
• 12:00
  you
• 12:00
  can't
• 12:00
  give
• 12:00
  Wellbutrin.
• 12:01
  So
• 12:01
  what
• 12:01
  do
• 12:01
  you
• 12:02
  do
• 12:02
  then,
• 12:03
  right?
• 12:03
  Do
• 12:04
  you
• 12:04
  go
• 12:04
  to
• 12:04
  psychotherapy?
• 12:05
  Is
• 12:05
  this
• 12:05
  something
• 12:05
  that
• 12:05
  psychotherapy
• 12:06
  can
• 12:06
  handle?
• 12:07
  Psychotherapy
• 12:07
  has
• 12:07
  a
• 12:07
  good
• 12:08
  effect
• 12:08
  size,
• 12:09
  right.
• 12:09
  It's
• 12:10
  perfectly
• 12:10
  appropriate
• 12:11
  to
• 12:11
  treat
• 12:12
  depression
• 12:13
  or
• 12:13
  grief.
• 12:13
  You
• 12:14
  know,
• 12:14
  she
• 12:14
  lost
• 12:14
  her
• 12:14
  husband
• 12:15
  three
• 12:15
  months
• 12:15
  ago.
• 12:15
  Maybe
• 12:16
  you,
• 12:16
  maybe
• 12:16
  you
• 12:17
  orient
• 12:18
  her
• 12:18
  to
• 12:18
  like
• 12:18
  grief
• 12:18
  counseling
• 12:19
  or
• 12:19
  a
• 12:19
  group.
• 12:20
  Group
• 12:20
  therapy.
• 12:20
  Grief
• 12:21
  group
• 12:21
  or
• 12:22
  a
• 12:22
  therapist
• 12:22
  who
• 12:23
  specializes
• 12:23
  in
• 12:24
  grief.
• 12:24
  Right?
• 12:25
  I
• 12:26
  mean
• 12:26
  her
• 12:26
  PHQ9
• 12:27
  score
• 12:27
  is
• 12:27
  high,
• 12:28
  you
• 12:29
  know,
• 12:29
  so
• 12:29
  you.
• 12:29
  But
• 12:30
  there's
• 12:30
  other
• 12:30
  ways
• 12:30
  to
• 12:31
  skin
• 12:31
  the
• 12:31
  cat,
• 12:31
  right?
• 12:31
  We
• 12:32
  don't
• 12:32
  necessarily
• 12:32
  have
• 12:33
  to
• 12:33
  go
• 12:33
  to
• 12:33
  ssri.
• 12:34
  There's
• 12:34
  non
• 12:35
  serotonergic
• 12:36
  paths
• 12:37
  to,
• 12:39
  to
• 12:39
  treat
• 12:39
  her
• 12:39
  depression,
• 12:40
  which
• 12:40
  I
• 12:40
  think
• 12:40
  are
• 12:41
  very
• 12:41
  important.
• 12:42
  Okay.
• 12:43
  You
• 12:43
  want
• 12:44
  to
• 12:44
  run
• 12:44
  labs,
• 12:44
  obviously
• 12:45
  make
• 12:45
  sure
• 12:45
  that
• 12:46
  the
• 12:46
  depression
• 12:47
  isn't
• 12:47
  being
• 12:47
  manifested
• 12:48
  in
• 12:48
  other
• 12:48
  ways.
• 12:49
  How's
• 12:49
  her
• 12:49
  thyroid?
• 12:50
  How's
• 12:50
  her
• 12:50
  vitamin
• 12:50
  d?
• 12:50
  How's
• 12:51
  her
• 12:51
  B12
• 12:51
  and
• 12:51
  folate,
• 12:52
  et
• 12:52
  cetera,
• 12:53
  et
• 12:53
  cetera,
• 12:53
  et
• 12:53
  cetera.
• 12:54
  Hopefully
• 12:54
  those
• 12:54
  are
• 12:54
  the
• 12:54
  things
• 12:55
  driving
• 12:55
  her
• 12:55
  depression
• 12:56
  because
• 12:57
  you're
• 12:57
  kind
• 12:57
  of
• 12:57
  getting
• 12:58
  a
• 12:58
  slim
• 12:58
  pickings
• 12:59
  when
• 12:59
  you
• 12:59
  don't
• 12:59
  have
• 12:59
  SSRIs
• 13:00
  or
• 13:00
  Wellbutrin
• 13:01
  to
• 13:01
  prescribe.
• 13:02
  So
• 13:02
  I
• 13:02
  hope
• 13:02
  you
• 13:02
  appreciated
• 13:03
  this
• 13:03
  little
• 13:03
  case
• 13:03
  study
• 13:04
  today
• 13:05
  and
• 13:05
  definitely
• 13:06
  share
• 13:06
  it
• 13:06
  and
• 13:06
  enjoy
• 13:07
  it.
• 13:07
  These
• 13:08
  are
• 13:08
  the
• 13:08
  kind
• 13:08
  of
• 13:08
  ones
• 13:08
  that
• 13:08
  keep
• 13:09
  us
• 13:09
  on
• 13:09
  our
• 13:09
  toes
• 13:09
  and
• 13:10
  make
• 13:10
  us
• 13:10
  better
• 13:11
  at
• 13:11
  what
• 13:11
  we
• 13:11
  do.
• 13:11
  And
• 13:11
  remember,
• 13:12
  my
• 13:12
  friends,
• 13:13
  if
• 13:13
  you
• 13:14
  really
• 13:14
  want
• 13:14
  to
• 13:14
  stand
• 13:15
  out
• 13:15
  as
• 13:15
  a
• 13:15
  clinician
• 13:16
  and
• 13:16
  feel
• 13:16
  confident
• 13:17
  on
• 13:17
  details
• 13:18
  without
• 13:18
  getting
• 13:18
  stuck
• 13:19
  in
• 13:19
  front
• 13:19
  of
• 13:19
  your
• 13:19
  patient,
• 13:20
  check
• 13:20
  out
• 13:20
  our
• 13:20
  Patreon
• 13:21
  membership
• 13:21
  in
• 13:22
  the
• 13:22
  show
• 13:22
  notes.
• 13:23
  That's
• 13:23
  where
• 13:23
  we
• 13:24
  do
• 13:24
  deep
• 13:24
  case
• 13:25
  breakdowns,
• 13:26
  medication,
• 13:26
  deep
• 13:26
  dives,
• 13:27
  and
• 13:27
  gritty
• 13:28
  weekly
• 13:29
  street
• 13:29
  pearls,
• 13:29
  all
• 13:30
  organized
• 13:30
  so
• 13:30
  you
• 13:30
  can
• 13:31
  actually
• 13:31
  see
• 13:31
  them
• 13:31
  and
• 13:31
  use
• 13:32
  them.
• 13:32
  It's
• 13:32
  next
• 13:33
  next
• 13:33
  level
• 13:33
  stuff.
• 13:34
  It's
• 13:34
  it's
• 13:34
  about
• 13:35
  being
• 13:35
  confident
• 13:35
  in
• 13:36
  front
• 13:36
  of
• 13:36
  who
• 13:36
  you're
• 13:37
  in
• 13:37
  front
• 13:37
  of
• 13:37
  your
• 13:37
  patients.
• 13:38
  So
• 13:38
  you
• 13:38
  develop
• 13:39
  a
• 13:39
  mastery
• 13:39
  and
• 13:39
  an
• 13:40
  edge
• 13:40
  in
• 13:40
  the
• 13:40
  field.
• 13:41
  And
• 13:41
  that's
• 13:41
  what
• 13:41
  Patreon
• 13:42
  is
• 13:42
  for.
• 13:43
  All
• 13:43
  right,
• 13:43
  my
• 13:43
  friends,
• 13:44
  without
• 13:44
  further
• 13:44
  ado,
• 13:45
  have
• 13:45
  a
• 13:45
  great
• 13:46
  Sunday.
• 13:46
  See
• 13:46
  you
• 13:47
  next
• 13:47
  time
• 13:47
  on
• 13:47
  Pearls
• 13:48
  and
• 13:48
  Prep.