Hello and welcome to the Physician Assistant Exam Review Podcast and this is episode 139. We’re going to be covering substance and addiction disorders as well as sleep disorders and human sexuality. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review and I am thrilled to have you here today listening in. These podcasts are just a ton of fun for me. It’s a great way for me to go through the material, pick out the things that I think are most valuable and to outline it for you. I get a ton of great feedback and I love every second of it.

So I do appreciate that. Thank you so much. In this episode, we’re going to be finishing up psych. Yep. Finishing up. We’re going to be done with the entire PANCE blueprint second time through after this, this very episode. After that, I have a couple of interviews lined up for you that I think will be a ton of fun before we start round three of going through the blueprint.

I wasn’t sure the first time I did this what I was going to do when I finished the blueprint. And what’s fun is that you get better at things, right? I get better at going through the material. I get better at what’s necessary. I make things a little bit tighter, a little bit cleaner, stick a little bit better. So I’m looking forward to actually the third time through to see what improvements we can make as we move on. We just recently added in the PANCE questions.

We just recently started changing a little bit of how the notes are. And I’m really liking it a whole lot more and I’m getting a little rejuvenated by it. So I’m excited to do that moving forward. Oh, last week, I mentioned that I was going to be doing a giveaway this week for the 33 Days November cohort. I’m really excited about that cohort, but what I thought would be more fun is if I do that giveaway during PA week. So I’m going to push it back just a little bit so that’ll run the week of October 6th, the giveaway for the scholarship to the November 33 Days to Pass the PANCE cohort. Really excited about that.

We’re actually wrapping up the September cohort, getting towards the end of it. And this class, like I said, has been just a ton of fun. I’m looking forward to the results and seeing how things are going. Got a lot of momentum going into the November cohort. A lot of people reaching out and getting ready for that. But before that, what I decided to do leading into PA week was to host a Master Class on passing the PANCE for everyone. This is going to be a free class where I’m going to go through sessions on how to, a couple of things you can do to boost scores without much more work or any more work.

Just a couple of different ways you can think about things and a couple of different ways to go through the material that can help you improve your scores easily 5%. If you just come, listen in, actively participate and get through the 45 minute class, I’m going to show you how to boost your scores by 5% without any more work at all. You can join that. I’ll register for that at physicianassistantexamreview.com/masterclass. That’ll be October 1st and 2nd. Right before we get into the giveaway and PA week. So that’s just going to be a lot of fun.

I’m looking forward to that too.

All right, so let’s get into our priming questions for today. Remember, we’re going to be covering substance and addictive disorders, sleep disorders, and human sexuality today to round out our psych. So for starters, what medication prevents relapse and alcohol use disorder by blocking the buzz? What medication prevents relapse in alcohol use disorder by blocking the buzz? What sleep disorder is marked by cataplexy and sleep paralysis? What sleep disorder is marked by cataplexy and sleep paralysis? What drug class is first line for erectile dysfunction?

What drug class is first line for erectile dysfunction? What diagnosis describes distress from a mismatch between gender identity and assigned sex? What diagnosis describes distress from a mismatch between gender identity and assigned sex? We’re going to start with substance-related and addictive disorders. These are chronic relapsing brain disorders involving dopamine reward pathways. It includes alcohol, opioids, stimulants, cannabis, hallucinogens, nicotine, and gambling, which is the only behavioral addiction formally recognized by DSM-5. I actually was kind of thinking that you might find sex in this or at this stage, video games, Instagram, something like that, but not recognized by DSM-5 at this stage.

This is marked by craving, tolerance, withdrawal, and continued use despite harm. That’s always the big one. When we talk about psych, it interferes with your daily life. It causes a problem. It makes it so you can’t do the things that would be good for you. We’re going to walk through these kind of one at a time-ish. Clinical presentation for alcohol use disorder would be intoxication.

You’d see slurred speech, incoordination, and impaired judgment. We all have an idea what intoxication looks like. Withdrawal symptoms could be tremors within hours, seizures within 12 to 24 hours, hallucinations, and delirium tremens. Delirium tremens is a severe withdrawal. This usually takes about 48 hours to set up, 48 to 96 hours after the person’s last drink. They’re severely agitated. They’re confused.

They can have hallucinations, fever, hypertension, tachycardia, diaphoresis. This can be a life-threatening if untreated. One of the places you see this, or I’ve seen it, is on rotations as a student when you have a patient who’s been hospitalized, who’s an alcoholic, and now can’t have alcohol. So we have patients in the ICU who they were worried about them developing delirium tremens because they were an alcoholic, right? So you have to be able to deal with that. Lab studies and physical exam findings, blood alcohol concentration for acute intoxication, or the Clinical Institute Withdrawal Assessment for Alcohol revised, which is a score for withdrawal severity. So this guides the use of benzodiazepines for dealing with withdrawal symptoms.

In an acute setting, we can use benzodiazepines, which enhance GABA to calm nervous system and prevent seizures and DTs. And relapse prevention. This is some other meds. I don’t know. I mean, maybe you’ll get asked these. This isn’t something that I personally would spend a lot of time on. But naltrexone is an opioid receptor antagonist.

It blocks reward effects and reduces cravings, avoid in liver failure or opioid users. Acamprosate modulates glutamate, GABA, reduces anxiety and insomnia, best for maintenance abstinence, safe in liver disease, avoid in renal failure. And disulfiram blocks aldehyde dehydrogenase, causes flushing, nausea, palpitations if alcohol is consumed. This requires high motivation. This is something you’re going to take to prevent you from drinking, so you have to think about it ahead of time. A key differentiator is a tremor after stopping alcohol that progresses to seizures is a delirium tremens. Opioid use disorder.

This is obviously chronic use of opioids such as heroin, oxycodone, or morphine with tolerance, dependence, and withdrawal. Clinical presentation intoxication will be pinpoint pupils, right? So that’s a big one. Pinpoint pupils for opioid intoxication, miosis. They can get respiratory depression and feeling of euphoria. The withdrawal is rhinorrhea, tearing, yawning, sweating, anxiety, piloerection, which I just found out is goosebumps from autonomic overactivity. Lab studies and physical exam findings.

You would do a urine drug screen to detect opioids for this. That would be your only lab available. Treatment, naloxone. So this is a short-acting antagonist, reverses respiratory depression, and you can do repeat dosings. For long-term maintenance of opioid addictions, methadone is a full agonist which prevents withdrawal and cravings. It’s suspended daily, but this is obviously done in licensed clinics. I actually have a good friend who has worked and run methadone clinics most of her PA career.

This is effective in severe cases, but can prolong QT intervals. Buprenorphine, I nailed that one, is a partial agonist safer due to ceiling effect on respiratory depression, often combined with naloxone. And this requires a very specific type of prescription. Naltrexone is a long-acting antagonist. So this blocks the euphoria if opioids are used. Must be opioid-free before initiation, though. So this is, again, this is, I kind of think of this like disulfiram.

This is something that the patient knows ahead of time. I’m going to take this. It’s going to make me not feel good if I do wind up with an opioid. Pinpoint pupils is something I just want to touch on. It’s the key here that should really jump off the page at you. Stimulant use disorder. So cocaine or amphetamines.

Abuse of stimulants leading to euphoria, cardiovascular complications, and withdrawal symptoms. Intoxication here is dilated pupils. So mydriasis. Feeling of euphoria, hypertension, arrhythmia, and agitation. So this is something you should be able to picture, right? This is someone who’s, you know, I think incredibly caffeinated, right? So they get that dilated, wide open eyes.

They feel euphoric. They’ve got hypertension. They could have arrhythmias, and they’re agitated. Withdrawal can be fatigue, hypersomnia, and depression. Urine drug screen is how we’re going to test for this. Acute intoxication, what are you going to do for them? Well, supportive care, and benzodiazepines for agitation or seizures.

For withdrawals, nothing really specific here, supportive management, and watch for depression. Again, it’s that dilated pupils are going to make you think here. So to me, it’s the dilated pupils and the pinpoint pupils. Keep an eye on, that wasn’t supposed, that wasn’t really meant to be a pun, but keep an eye on those two things. That’ll help you to discern the difference between these two. Nicotine use disorder. This is obviously dependence on nicotine.

Strong cravings. Dependence shows irritability, anxiety, and craving. Withdrawals of restlessness, increased appetite, difficulty concentrating. You can use replacement therapy like a patch or gum. Bupropion reduces cravings. It’s useful in smokers who also have depression, but contraindicated in those with seizures or eating disorders. Gambling disorder is the last one here, so it’s a persistent, recurrent gambling behavior leading to distress or impairment.

It is the only behavioral addiction formally recognized by the DSM-5. The treatment here is going to be psychotherapy, especially cognitive behavioral therapy and support groups.

Next, we’re going to move into sleep-wake disorders. We’re going to start with insomnia. Insomnia is persistent difficulty falling asleep, staying asleep, or waking up too early. I don’t know anyone who has those issues, must occur at least three nights per week for at least three months despite adequate opportunity to sleep. Clinical presentation, the patient describes lying awake for hours even though they’re tired. They wake up multiple times during the night, and they have daytime fatigue and irritability. And they have a lot of trouble focusing, right?

Because if you’re not sleeping, you have trouble focusing, whether that’s at school or work or whatever. The diagnosis is going to be clinical mostly, but you can get a polysomnography, maybe ordered if unclear, but it’s usually going to be normal. Treatment is cognitive behavioral therapy for insomnia. Challenges are unhelpful sleep thoughts like I’ll never fall asleep. This is a bad thing to tell yourself and we’ll get more into that in a little bit. But those unhelpful sleep thoughts are really a problem. You want to set strict bedtime wake schedule and limit the use of the bed or the bedroom to sleep and sex.

I’m going to talk more about that in a minute. Sleep hygiene, no screens before bed, avoid caffeine late in the day, consistent routines, short-term meds if refractory. So zolpidem is a non-benzodiazepine hypnotic that enhances GABA, helps initiate sleep. Benzodiazepines may be effective, but risk dependence for long-term use, not a great idea. Narcolepsy is our next one. This is a neurologic disorder of sleep regulation caused by loss of hypocretin in the hypothalamus. This leads to abnormal REM transitions and excessive daytime sleepiness.

Clinical presentation. What does this look like? Patient falls asleep suddenly at work or in class despite a full night’s rest. Cataplexy, which is a sudden loss of muscle tone triggered by strong emotions. You get the jaw drop, head nods. Knees can buckle, but the patient is awake. You can get hypnagogic hallucinations.

Again, this is not in my wheelhouse and not terms that I’m familiar with. Vivid dreamlike experience when falling asleep. Sleep paralysis is brief inability to move when waking or falling asleep. And symptoms usually begin in adolescence or young adulthood. Again, polysomnography followed by multiple sleep latency tests. Findings would be short sleep onset, rapid transition into REM sleep. The treatment here, we’re going to have a few medications.

Modafinil or armodafinil. Nailed those two for you. Wake-promoting agents that increase dopamine signaling, keeping patients alert during the day without stimulant highs. So these are ways to keep people up throughout the day so they’re not falling asleep. Sodium oxybate, strong nighttime sedative that consolidates sleep and reduces cataplexy. Dispensed in a restricted program. So you have to be, this isn’t something just anybody prescribes, just kind of like methadone, that kind of thing.

Scheduled naps can help to reduce daytime sleep attacks. I included obstructive sleep apnea here. I don’t love it here. But I thought it might be relevant. I’m always looking for how you’re going to be tested, how you’re going to be asked questions. And to me, this is a possibility, right? How are we going to look at this?

Well, if you have someone who can’t sleep overnight or is struggling during the day to stay awake, you’re going to be comparing things like insomnia and obstructive sleep apnea. So although you might not see the direct connection here, to me, they can be very much asked in a test question, which is what I’m always looking for. So this is recurrent collapse of the upper airway during sleep causing apneas. So they stopped stopping breathing. Hypoxemia and fragmented sleep. I just want to fix something in my notes real quick. And I don’t like there.

Okay, good. So you get that breakup in your sleep. That’s really what the problem is. The clinical presentation here is an obese middle-aged man. Typically, they’re snoring so loud that the spouse can’t sleep. That tends to be how they come in. Maybe the spouse is the reason why the patient’s here.

The spouse may even notice pauses in breathing, followed by gasping. Patient wakes with morning headaches, feels excessively tired during the day, struggles to concentrate at work. This can also lead to hypertension, arrhythmias, and pulmonary hypertension. So it’s really bad for overall health. But I mean, think about it. This is, the patient is overnight, periodically not breathing for a couple of seconds. And becoming hypoxemic overnight and then waking up just a little bit so that they breathe again and then going back to sleep without even knowing that they were awake.

And this is happening hundreds of times overnight, right? So you can see how this can turn into a bad situation. Lab studies and physical exam findings. Again, polysomnography just shows repeated apneic episodes with oxygen desaturations. The STOP-BANG Questionnaire is a screening tool for obstructive sleep apnea. I hear about this all the time at work with the anesthesiologist who use this for dealing with patients. It’s going to rank snoring, tiredness, observed apneas.

The P is for pressure or hypertension. The B is for BMI greater than 35. A is for age greater than 50. N is for neck circumference greater than 40 centimeters. G is for gender. Males tend to have this more often than not. So the more yeses to those things, are you snoring?

Are you tired in the day? Does someone observe you being apneic? Do you have hypertension? Is your BMI over 35? Is your age over 50? And is your neck circumference bigger than 40 centimeters? And are you a male?

Then you have a higher risk of OSA.

Now, I don’t want to go down that road.

Let’s just leave it at that. Treatment, CPAP. So continuous positive airway pressure keeps airways open during sleep, prevents hypoxemia and cardiovascular complications. So this is a device you hook up to your face and it blows air into your nose and mouth during your, depending on how it’s set up, to keep your airway open. Doesn’t look like the most fun thing in the world. Weight loss, avid alcohol and sedatives to reduce, I’m sorry, weight loss, avoid, not avid, avoid alcohol and sedatives to reduce airway collapse. And then surgery if CPAP fails or anatomy is severely obstructed.

So they’re talking about what I came across initially was, you know, partial uvulectomies, different things for surgery. What we’re doing now is pretty cool, actually. It’s the Inspire. I’m hoping I put these in from time to time. It’s an Inspire device, which stimulates the hypoglossal nerve to stick the tongue out on inspiration. So as the patient’s breathing in, a little monitor that’s implanted in their chest, notifies, notices the inspiration and sends a signal to the hypoglossal nerve to stick out to make the tongue protrude to open up the airway so that as they breathe in, it opens that airway for them overnight. It’s a little electrical impulse that they can’t even really feel, but will kick in at night and help to prevent that.

It’s actually a pretty cool surgery, pretty neat system.

Next, we have circadian rhythm disorders. Normal sleepability but misaligned with external environment, so internal clock disruption. This is something like jet lag. So after flying, you know, everybody knows what jet lag is. A patient cannot fall asleep at night and feels groggy during the day because of the time shifts or shift work disorders. A nurse or a factory worker working on a rotating night shift has chronic fatigue and difficulty sleeping at unusual times. Diagnosis is clinical and polysomnography usually normal.

Treatments here are light therapy. Exposure to bright light helps reset circadian clocks, especially the sun. The sun is incredibly powerful at resetting circadian clocks. Obviously, that’s a problem if you are on the night shift, and that’s a constant issue. But if you’re working with something like jet lag, using the sun, incredibly powerful. Melatonin mimics natural hormone signaling at nighttime. So different hormones cycle up and down.

Obviously, you know that to help you fall asleep and help you wake and control those cycles. Melatonin will help with that. And then a gradual adjustment of sleep schedule. It’s easier if we move your sleeping window up or back slowly than if we do it all at once over multiple hours, right? And we’re going to come back around to that in just a second. First, we’re going to cover human sexuality and gender dysphoria.

All right, this is a disorder involving problems with sexual desire, arousal, orgasm, or pain that cause distress or relationship difficulty. I’m sorry, this is sexual dysfunction disorder. Disorders involving problems with sexual desire, arousal, orgasm, or pain that causes distress or relationship difficulty. I’m doing this at night. I usually record these during the early morning or during the day for obvious reasons. I tend to get up super early in the morning, so I tend to crash early in the evening. So that’s happening directly in front of you right now.

Clinical presentation. Erectile disorder. Persistent inability to achieve or maintain an erection during sex. Premature ejaculation would be ejaculation, which occurs within one minute of penetration and is recurrent, leading to frustration and distress. We have female sexual interest slash arousal disorder as a persistent lack of sexual thoughts, interest, or responsiveness. We have genitopelvic pain slash penetration disorder, which is difficulty with vaginal penetration, marked pain, or tightening of pelvic floor muscles with attempts of penetration. Lab studies and physical exam findings.

The key here is to separate psychogenic issues versus physical issues versus organic issues. That’s really going to be the big thing you’re trying to parse out. Organic erectile dysfunction is a gradual, consistent, often linked to diabetes, vascular disease, or medications. Versus psychogenic erectile dysfunction, sudden situational, but with normal nocturnal erections.

Let’s run through the treatments here. Treatment for erectile dysfunction. The mainstay is going to be sildenafil or tadalafil, which are PDE5 inhibitors. They increase nitric oxide in penile tissue, leading to smooth muscle relaxation and improved blood flow. Contraindications here is with nitrates due to risk of life-threatening hypotension. That seems to be where you’re going to run into questions here. Premature ejaculations.

You can use SSRIs like sertraline or paroxetine. This increases serotonin, which delays ejaculation and extends time to orgasm. That was something I didn’t know until going through the notes for this section. Topical anesthetics. You could use like lidocaine cream for decreased sensitivity. And then you can use behavioral therapy. Stop, start techniques, which teach patients to control climax.

For female sexual interest or arousal disorder, psychotherapy and couples therapy to address psychological or relational contributions, right? That’s really a major factor here. You could also get hormonal causes. Something like menopause may cause this, can be treated with estrogen. You also want to look at medications, which may lower libido. So SSRIs may be a problem here. Anti-hypertensives may be a problem here.

Genitopelvic pain and penetration disorder, pelvic floor physical therapy can be very valuable. We actually just had, the last couple of years, I think that’s become a little bit more of a mainstay is pelvic floor physical therapy. I know we have a great group at our hospital who does this and progressive vaginal dilators may be able to reduce pain. Cognitive behavioral therapy for anxiety may also be necessary. Paraphilic disorders. This is recurrent intense sexual urges, fantasies or behaviors involving inappropriate targets or context. The key here, like the rest of our issues with psych, must cause distress, impairment, or risk and harm to self or others.

Clinical presentation. So there’s a couple different we’re going to run through these, really just memorization kind of questions, more like matching. Exhibitionists would be exposing genitals to unsuspecting strangers. Voyeuristic would be watching unsuspecting people who are naked or engaged in sex. Frotteuristic disorder, that one I’m having trouble pronouncing, touching or rubbing against a non-consenting person. This reminds me of the subway in New York, maybe. Sexual masochism disorder, arousal from being humiliated, beaten, or bound.

Sexual sadism disorder, arousal from inflicting suffering on other people. And then pedophilic disorder, sexual attraction to prepubescent children. These are obviously clinically based on history and repetitive behaviors and reported behaviors. Psychotherapy, particularly cognitive behavioral therapy, to address maladaptive behaviors and thoughts. SSRIs may be helpful. And then, let’s leave it at that. Gender dysphoria will be our last one for today.

I think, yep, that’ll be our last one for today. This is distress caused by mismatch between experienced gender and identity assigned at sex, I’m sorry, identity and assigned sex at birth. This must cause significant distress or functional impairment. Again, just hang on to that. That’s going to be for all of these. Clinical presentation. A child insists that they are other gender, prefers clothing and play, typical of that gender distressed by birth assigned roles.

Adolescent or adult reports strong desire to be treated as another gender, discomfort with their own anatomy, distress in daily life. The diagnosis here is also going to be clinical. But again, you have to distinguish between gender nonconformity without distress, which would not be gender dysphoria disorder. Treatment is going to be supportive psychotherapy and counseling, social transitioning, like clothing, name, pronouns, if desired, hormone therapy, gender-affirming surgery for some adults after thorough evaluation. And again, we’ll come back to that distress that is really going to be the major, major problem here.

All right, and that’ll wrap us up for psych for tonight. I do want to let’s touch on our study tip before we hit our priming questions and the answer there. And our study tip for tonight is going to be on sleep, but I figured it really fit in well here. And that negative self-talk at sleep is it can be a major problem. I’m never going to be able to fall asleep. I’m never going to be able to fall asleep. I talk with students about this, especially before they sit down to take their PANCE and they’re worried about the night before or a couple nights before, how they’re going to sleep.

What if they don’t? You get that insomnia. One thing is just to straight up lie to yourself, honestly, is to say, I’m great on no sleep. I have no problem. Finally get too hard to sleep tonight. Things are going to be great. That way you reduce that panic, right?

It’s not true. I get that it’s not true, but I’m okay with that because it works. So rather than tossing and turning and telling yourself what a terrible sleeper you are, how it’s never going to work, how you’re going to be miserable all day tomorrow. That’s the wrong way to go about this. You want to reframe it as if it’s really just not a problem. You also want to do some of the things that we talked about there, some behavioral things to help with sleep, right? So one is you want your room dark, super dark, dark, dark, dark, dark.

Like I took electrical tape and put it over all the little blue lights in my room to make sure that I don’t see anything. You want it to be so dark that when you open your eyes, you can’t tell that they’re open. I’ve got room darkening shades, right? You want all of these things in place. Sound is a big one. I use a white noise on my phone, but you could use, I used to use a white noise machine. Sometimes I just run a fan.

But blocking out sound and getting that just right can be really helpful. Routines are incredibly powerful, right? Your hormones are based off of the routines you have throughout the day, right? Seeing sunlight at certain times of day. Getting out of bright areas at certain times of day, the different colors of the light, all these things play factors into how you sleep. We all know that we don’t control this. You can’t just tell yourself to go to sleep any more than you can just tell yourself to stay awake.

There are systems in place that run this, but you can game those systems and make them better. By having the same routine and going to bed at the same exact time every day and getting up at the same exact time every day, you really help to mitigate some of these problems. Having a routine before you go to sleep that tells your brain it’s time to get ready for bed and start to settle down. Really, really powerful. Watching something stimulating right before bed is going to be a problem. You want to watch something soothing or not at all, or do something that’s a little bit more soothing or calming. I talk a lot about phones and screens before bed, and they’ve done a ton of studies on this.

Yes, you can flip through Instagram in your bed, and you can definitely fall asleep. For a lot of people, it’s not the falling asleep problem. It’s that you’re not getting into REM sleep as quickly. So then you’re not getting worse sleep. And you don’t notice that. That’s not something you can tell. But that’s what’s happening.

Exercise can be really powerful to fight insomnia. Not for everybody, not all the time. But if you go for an eight or 10 mile walk one day, you’re going to have a really good chance of sleeping well that night. One more thing that’s been helping me recently is magnesium. If I take magnesium sometime before bed, I really sleep amazingly well. You have to be a little careful with it because it will cause diarrhea if you have too much. So I find I don’t do it every night for those reasons, but it can be really, really helpful.

All right, let’s jump into our priming questions. What medication prevents relapse in alcohol use disorder by blocking the buzz? That’s naltrexone. What sleep disorder is marked by cataplexy and sleep paralysis? Narcolepsy. What drug class is first line for erectile dysfunction? This is sildenafil and tadalafil.

They’re the PDE5 inhibitors. What diagnosis describes distress from a mismatch between gender identity and assigned sex? That would be gender dysphoria. Then I’ve got two PANCE questions for you. These shouldn’t be too bad. We have a 54-year-old male with a history of hypertension, reports difficulty achieving an erection during sexual activity. He has a normal libido but cannot maintain an erection in any setting.

Which of the following is the best initial treatment? A, testosterone replacement, cognitive behavioral therapy, sildenafil, vacuum erection device, or bupropion. And our answer, of course, is sildenafil. I just said what’s the number one treatment there. And if you remember, that enhances nitric oxide and helps with vasodilation, increasing penile blood flow. This is first line for most men with erectile dysfunction. It wouldn’t be testosterone because he’s got a normal libido, so testosterone deficiency is unlikely.

Cognitive behavioral therapy could help for psychogenic erectile dysfunction, but this doesn’t seem to be psychogenic because it happens in all instances. A vacuum erection device, this is an option if oral medications fail, but it’s not going to be first line. And bupropion is used for depression and smoking cessation, not really erectile dysfunction. A 23-year-old college student presents with episodes of sudden muscle weakness triggered by laughter. He also describes vivid dreamlike images when falling asleep and brief paralysis upon awakening. He reports excessive daytime sleepiness despite adequate nighttime sleep. Physical exam is normal.

Polysomnography followed by multiple sleep latency tests shows short sleep latency with early onset REM sleep. Which of the following is the most appropriate first-line pharmacological treatment? Zolpidem at bedtime, sodium oxybate at bedtime, modafinil in the morning, fluoxetine daily, or clonazepam at bedtime? And our answer is C, modafinil in the morning. So, zolpidem is a non-benzodiazepine hypnotic used for insomnia. It helps you fall asleep, but not stay awake. Sodium oxybate is used in narcolepsy, especially for cataplexy and nighttime sleep consolidation, but not for daytime sleepiness.

So, that’s what we’re looking for here. Fluoxetine is an SSRI, and it will sometimes help with cataplexy, but it’s not for overall narcolepsy management. And clonazepam is a benzodiazepine has been used for REM behavior disorders or restless legs, not narcolepsy. Beautiful. So that takes us out of psychiatry. As you may have noticed over the last couple of weeks, not my favorite topic, not my area of expertise in medicine, but something that we have to cover either way, right? I always said that when I was in PA school, I had to find ways to make these different things interesting to myself because I knew I wouldn’t be covering them, right?

You know there are certain topics you’re not going to be doing when you get out into practice. Some of you are not going to be practicing cardiology. Some of you are not going to be practicing pulmonology. They’re going to be non-issues for you. Some of you are not going to be practicing psych, but you still have to get through it, right? You still have to figure it out. So anyway, huge, really ton of fun getting through this.

So happy to be done with our second time through the entire blueprint. Don’t forget, I’ve got the the October 1st and 2nd, that Master Class coming up, physicianassistantexamreview.com/masterclass to register for that. Really excited about what we’re going to cover there. Again, you’re going to pick up five to ten percent on your next next big exam without any question whatsoever, as long as you attend that and put in to play a couple of things we talk about. That’s going to be a ton of fun. Anyway, that’ll end this for tonight. Take care.

Good luck in your exams this week, and I will look forward talking to you again next week with a… What we’ll do is we’ll put together a couple of interviews before we start the next round. I think that’ll be a fun way to do things over the next couple of weeks. Thank you.