DIP Episode 156 - USMLE Step 2CK Rapid Review Series 16 (OBGYN)

Okay, welcome. My name is Divine, I'm a resident. This is episode 156 of the Divine Intervention Podcast and in this podcast I'll be continuing as to see here a bit review series. This will be series 16 I guess and this is going to be focused on OBE Guy. So let's get right into it. So what if you get a question about to Mass in a lady that is like a breast mass in a lady that is 52 years old. What is your next best step in management? Like a mass you know, pop up on physical exam. I hope that your next step in management is to go ahead and post your mammogram, right? I mean the primary worry here is that this person likely may have like breast cancer, right? Breast cancer, right? If you see a verse here, breast mass, right? The first thing you want to do is you want to go ahead and get a mammogram. If a woman is more than 30 years old on the MBM Es, if the woman is less than 30, right? You want to go ahead and perform an ultrasound, right? Those are all important things to remember and remember that breast cancer, right? It's, I mean it's probably one of the most common gynecologic cancers in females. Not the most common, but it's one of the most common, at least for sure. It is the second most common cause of cancer-related deaths and women, right? Long cancer is still number one. And I mean you want to know how your things, right? Like the fact that breast cancer tends to occur like in your proud occortion of the breast. And the thing is your friends are the MBME, right?

They love to test breast cancer in the context of risk factors to see if you can identify which one is a positive risk factor, which one is a negative risk factor, right? So, for example, if a person has like a personal history of breast cancer or like a family history of breast cancer, especially like in a first degree relative, right? That will increase risk, right? For a person has like a 1, 2 mutation, right? That increases risk of like early onset of breast cancer. If a person has like anything that makes them have more life-total life-time estrogen exposure, right? So like early menarchy, right? Or like late menopause, or even like, you know, having your first pregnancy like pretty lady life. So let's say like around the age of like 35 or 36, those things only increase risk of breast cancer, right? And you're definitely want to make sure that you remember that breast cancer, right? Love to metastasize, right? Especially with like the bone meds, that's something you want to know. Bone meds, right? Remember it could be lyric or it could be blastic, although in my experience, it could actually go either way. It's about 50-50 on MBME exams. And obviously if a person has hypercalcemia, right? From like bone meds and they come in with symptoms. The first step in management will ideally be to go ahead and give those people a IV fluids, right? Won't go ahead and give them IV fluids.

And they remember overall, hypercalcemia of malignancy is treated with with with bisfossolids, right? With bisfossolids. And remember that breast cancer also loves to metastasize to the to the brain, right? Cause these brain meds. And again, it won't be a single lesion, right? Brain meds tend to be multiple lesions on MBME exams. And remember, right? breast cancer, right? Like if you see like the powder ranger appearance on the breast, you're hopefully thinking about inflammatory breast cancer. I'm just going to try to, you know, talk through most of the higher, higher the breast pathologies, right? But when you see like, you know, the powder ranger appearance of the breast, I would hope you're thinking about like inflammatory breast cancer on those circumstances. Basically, right? The cancer, usually it's invasive doctor or synoma has involved the dermal lymphatics, right? So you get that powder ranger appearance on the breast. The classic presentation on inflammatory breast cancer, really on MBME exams is, is a, they'll talk about a person that seems like they have mastitis, but you know, you're giving this patient a antibiotics. Those enzymes have touched the mastitis at all, especially in a woman that's more than 50 years old. When you see those predispositions, you really want to think about inflammatory breast cancer. And the thing is, they also like you to know, in MBME is the kinds of contraception, right?

That is acceptable in people that have a history of breast cancer, right? So obviously, any contraceptive option that has estrogen or progestin is actually not acceptable, right? So because many people say, oh, if a person has a history of endometrial cancer, you know, you can give them like, you know, the myrena progestin, contina UD. Yes, that is true. But if a person has a history of breast cancer, right? You cannot give them any estrogen or progestin containing option, right? Because remember, they're certain breast cancers that are ERPR positive, right? So for the most part, you cannot, you cannot do those things, right? So your only options really on on the MBME, I'll say you should probably consider giving like the copper IUD, the copper IUD is probably like you'll go to choice in terms of contraceptive options in patients that have, um, in patients that have a history of breast cancer, right? Either they have a history of breast cancer or they currently have breast cancer. And then remember, right? Most times when breast cancer metastasizes, right? It usually likes to go to the to the axillary notes, right? So that's that's high yield to that's kind of high yield to know. Then remember, if a person has like, you know, an exemplatory rush on the breast, what are they going after on the exam? That would be Pages disease of the nipple, right?

Basically, the thing is when a person has like Pages disease of the nipple, the next step in management will still be to get like a mammogram with like cornedal biopsy, right? Because the thing is most times many people that have a Pages disease of the nipple, they tend to have like an underliner DCIS, like an underline like doctor or snowman or doing some rare cases you can also notice that they will have like in VC, a doctor carcinoma. So those are all high yield things you want to know, you want to know for your exam. Now, if for example, right, like sometimes your friends at the end of the end of the day believe it or not have actually been known to do this thing where they describe my demographic characteristics of certain of like a breast mass and then ask which of the following is the most worrisome, right? From a from a perspective as to like, oh, being and like being the most worrisome for like a malignant process as against like a benign breast process. Whenever you see stuff like that, I would strongly strongly encourage you to consider picking the answer that talks about the lesion being speculated on imaging. If you ever see like, you know, something that has like micro-cultification, like irregular borders and it's speculated, you really want to think about something that's really bad, but really being speculated just in general, whenever you see a speculated mass in any part of the body, it's usually not a good sign, right?

So being speculated, you want to specifically remember that for purposes of your exam. And the thing is in terms of breast cancer screening, right? You should know that the American Cancer Society says started 40 and do it every year. USPSTF is the more conservative, I guess not really conservative. Let's call it the more L-chipal measure of things, we started 50 and we queue two years, right? But the thing is just in general in my experience, the NBME subscribes to people studying at 40 and going to one year. It just seems to be like the thing I have seen tested most commonly on exams. So take that for, take that for what you will. And then, although the newer exams, the newer Step 2 CK exams are beginning to go that 50 years or queue three years, or you can discuss with the patient and then based on what their preferences are, that kind of determines what you do. So those are just all things you want to keep at the back of your mind. And then, there are certain people on NBM Es where your next step in management for them is actually to go ahead and do something called like an AMO like breast MR in addition to an addition to the mammogram. So there are people where you can have certain breast pathologies and actually getting an MRR is not a bad idea, right? So if a person has like a BRCA mutation, right? Or you're like the person is like, you know, they have like a first degree relative that has had like a BRCA mutation.

Those people are actually eligible for getting like AMO breast MR is in addition to their breast to the mammograms that they get on a regular basis. And the thing is, what if they give you a question about a person, you know, let's say this little lady, she was recently the victim of like, she was recently assaulted and her breast was rounded into the wall and then they tell you that, oh, a week later, she, you know, she has like this hard breast mass and let's say she's like post-menopausal blah blah blah, they try and like, you know, scare you around well on the NBME exams. What do you think is likely going on? Right, this person likely has like a fat macrosis, right? But the thing is, they will try to trick you on your exam to make you think, you know, it's been, it is going to be, it's likely fat macrosis, it's likely be nine, right? But they will try to trick you on your exam that, oh, what is your next step in management? They will say, you know, leave it alone, reassess in X number or weeks, bloody, bloody, bloody, bloody. The thing is, your next step in management, even if you're like, yeah, for sure, you know, post-menopausal female for sure, this is fat macrosis. Do you know your next step in management for NBM Es is, is actually to go ahead and do our mammogram, right? You need to do a mammogram with biopsy. Because the thing is, there are certain things that look like fat macrosis on NBM Es, what they have like a quid-existing breast cancer, right?

So don't go ahead and say, oh, okay, fine, it's, it's this, it's, it's been nine, it's fat macrosis. So I'm not going to do a mammogram it or get a biopsy. Yeah, promise you, we get in that, we get in that question, so just something to keep, something to give at the back of your mind. And the thing is, right, for a person who has a positive mammogram, right? Obviously, your next step in management will be to go ahead and get a, get a corned ol biopsy. If you see like a weird mass on ultrasound, right? So let's say you see this mass on ultrasound, you obviously want to do a finding in the aspiration, right? If you get like serious fluid, you know, send it off for cytology. If you get bloody fluid, right? Then you probably want to go ahead and proceed to get in a mammogram on that those are circumstances. But really, for the most part, they don't go that for an NBME exams. It's like, if you, you know, see a mass on ultrasound, you're aspirated, you send it for cytology. If you get like bloody fluid, in fact, let me make this even easier for you. On ultrasound, if you notice that a person has bloody fluid, or you see a solid mass on ultrasound, quite and do a finding in the aspiration biopsy, okay? And send it off to be looked at biopathologist, to help your diagnosis. And then, remember earlier when I said that, you know, breast cancers, when a person has a history of breast cancer, you try to avoid giving them any contraceptive option that has like estrogen and purgestin.

The reason is, right, breast cancers, there's certain, there's certain breast cancers that, that are ERPR positive, right? So that's why you, you know, you wouldn't want to risk it in those patients. And the thing is, in terms of in terms of treatment, right? So if a person has like an ERPR positive breast cancer, you'll just want to go ahead and give those people a drug that, you know, that inhibits the activity of that ERPR breast cancer, right? So you can give like, you can give like a tamoxifen, right? Tamoxifen, remember, it's a, it's a serum, remember, it's an estrogen receptor on antagonist in the breast. But it's an agonistin bone, so it decrease risk, it decreases risk of osteoporosis. It's also an agonistin, the uterus, so it increases risk of endometrial cancer, right? So if you're trying to do like breast cancer, chemotherapy, relaxes, woman that's less than 50 years old, your next step when MDM is used to give, is to give a tamoxifen. But the lady is more than 50 years old on MDM exams. I want to do breast cancer chemotherapy. Your next step is actually to please the person on an aromatase inhibitor, okay? Tamoxifen is not appropriate in a woman that is greater than 50 years old, that is postmenopausal. So postmenopausal film meal, breast cancer chemotherapy, like the estrogen, progestin or receptor crap, your next step is an aromatase inhibitor, like an astrosol, right?

An astrosol, electrosol, extremistine, remember, aromatase ends and converts testosterone to estrogen, right? So the thing is, by inhibiting aromatase, you decrease the production of estrogen, right? And that can decrease the woman's risk for breast cancer, right? Or stop the growth and the progression of the malignancy. And the thing is, remember, an astrosol obviously will increase your risk of osteoporosis because you're directly taking away estrogen. If the woman is this, you know, more than 50, but not yet like in menopause, giving her an aromatase inhibitor will certainly throw her into menopause. There is not like the increase, there is actually not an increased risk of a venostromboembolic disease on MDM exams, you know, present taking an aromatase inhibitor. Compare this with a person that, you know, is taking a tamoxifen, tamoxifen naturally increases the presence of venostromboembolic risk. So that's something you want to keep, you want to keep at the back of your mind. And then, remember, another thing you want to do with, you know, breast cancer is, you know, to check that her two receptor status have been like her two positive is actually like bad, right? It tends to, yeah, that cancer, you know, is credible, right? Your response to treatment, but the other thing you want to think about is that it actually applies a worse, worse prognosis when a person has a cancer that is her two positive.

Another thing that also confers a poor prognosis is when the cancer is a triple negative, triple negative breast cancer is not a good sign, right? That also implies a worse prognosis. So if a person has a cancer that is her two positive, like her two new, sometimes they call it a B2, then you want to think about treating that breast cancer with a trastuzumab, right? Trastuzumab, trastuzumab is a monoclonal antibody against that her two new receptor, like the human epidermal or growth factor receptor two. Remember, though, in the ass, like, oh, prior to, in a prior to initiating trastuzumab therapy, what is the next best step in management? For those patients, you want to go ahead and get like a, like an echocardiogram, right? Because you want to estimate the ejection fraction. Because remember that trastuzumab has the ability to cause a reversible, it's not irreversible, it's reversible, a reversible dilated cardiomyopathy, right? So you want to go ahead and, you know, get a baseline like ejection fraction before you start the patient on the drop. And obviously, if you start the patient on trastuzumab and the patient starts having like a new S3 heart sound or a thocnia, a prognosis, a monoclonal dyspnea, a d-mind, the lungs bloody bloody blood, right? Then your next step, obviously, a little bit of go ahead and stop the drug.

Basically, if a person is getting like bad side effects from a drug, usually the right thing to do, like 90% of the time on MBB exams is to go ahead and stop, go ahead and stop the drug, right? Go ahead and stop the drug. And then some other big things here, these are more things that, you know, they're just things where you even know you don't know it, if you suspect that a person has like metastatic disease with breast cancer, especially like, like widely metastatic, like bone disease, then your next step in management on the MDM really is to go ahead and get a bone scan. A bone scan is really good for detecting, it's super sensitive, for detecting bone met in most malignancies, especially like malignancies that have a plastic predispositions, like breast cancer. It's very sensitive, but it's not very specific, very sensitive, but it's not, unfortunately, it's not very specific. And then one thing that they also want to, to your friends at the MDM, want you to know is that when a person has a breath, you know, like, like, let's say like, I don't know, like an invasive doctor or someone, whatever, that's kind of like localized, really doing a lumpectomy with radiation, not just lumpectomy or not, right? Doing a lumpectomy with radiation, right? That's what's called like, breast cancer of therapy is equivalent to getting a mastectomy, like the survival and all that is, it's pretty much the same.

Although, if I'm not mistaken, I've actually read literature that shows that getting a lumpectomy plus radiation, you know, there is like a higher risk of recurrent, like, locally recurrent. So like, recurrent at the same site as the exception, like, locally recurrent breast cancer. So that's something you want to keep, keep at the back of your mind for, for exams. And then, if for example, like, again, the occasional of to do this on tests, if for example, a person has, how do I put this? So if for example, a person has, you know, like breast cancer, and let's say, you know, they've had like, lumpectomy plus radiation therapy before, for like previous breast cancer, and they have like a recurrence, right? And that recurrence is like, you know, like in the same breast or whatever, then you really cannot do lumpectomy and radiation like again, right? It's not a smart idea, right? Because remember, once you get a radiation to the breast, that causes a lot of like, fibrosis and fibrosit tissue. When that happens, right? You kind of like in dire streets at that point, you really cannot like, in general, you don't like, you know, like, read the breast again. Some people do it, but on NBM is in general, if a person has had lumpectomy and radiation therapy to a given breast, then you want to consider, um, just doing a mastectomy, right? Down the line, right? Uh, you generally don't want to do lumpectomy and radiation again, right?

And then one other thing you also want to keep at the back of your mind is, what if they give you a question about a patient, you know, if you have radiation therapy for breast cancer, and then they tell you that, the adults, they've now started having, um, you know, like this, like rapidly growing neck mass, and you can feel like some cervical and lymphatic anapathy and all that. Hopefully you think that those people now have a papillary thyroid cancer. Remember, the biggest risk factor for thyroid cancer, right? He's a priori, he's trouble, uh, radiation to like the head and neck area, right? So that's, that's one way they can integrate that with, uh, with a thyroid cancer. So that's just something you want to keep at the back of your mind. Now, if for example, they give you a question about a patient, um, that, um, you know, has like, uh, let's say the, the, the, the, the perform a biography and you notice that they have this breast mass, right? Um, you don't want to do like, you, I mean, obviously, you want to do like a cornydobyrepsi, but one other thing you also want to keep in mind, are you want to do on an endgame? It's to do like, uh, this thing called, um, a sentinel lymph node biopsy, right? You want to go ahead and do a sentinel lymph node biopsy instead of doing like an axillary lymph node dissection, right? Because an axillary lymph node dissection is associated with like higher risk of like, uh, like a lymphedema, right?

So it has, you know, morbidity and mortality in that, uh, in that regard. So you want to try to avoid that on endgame exams, but if a person has a positive sentinel lymph node biopsy, then your next step in management is actually to go ahead and perform an axillary lymph node dissection. But again, they have a very high risk of getting an lymphedema. And then let's assume they give you a question about a patient, you know, that has had lymphedema for like a really long time from like an axillary lymph node dissection. And in detail, you that over like a two, three month period, you know, this person just things just seem to change and change very rapidly in the wrong direction like losing a ton of weight, um, um, having like a rapidly and large like a soft tissue mass in the arm, blah, blah, blah. One of those circumstances you really want to think about like a lymphedema, sarcoma, okay, one thing about a lymphedema, sarcoma, um, it's very, it's very fatal. They're very few treatments for it, but yeah, it's one thing unfortunately that kind of raised in the setting of a certain breast cancers. So I think I'm going to go ahead and pause here. I think I've said like pretty much every like high-yield thing that leads into a breast cancer that you're likely to see on an exam. Um, and as I draw the end of every podcast, I don't know if I want to learn from many exams. Step one, two CK, two C.S.

Step three, if you're a medicine resident, the internal medicine entry in an exam, the medicine boards, I don't for tutoring for those. And then I do like this, uh, you know, booster course, like something you do like your last week before before your USML exams. Um, it's 10 hours for step two, CK or step three, or it's 20 hours for step one. So booster course, you'll just be like, you know, you know, very short time for you reveal a ton of high-yield material for your, for the, uh, those respective exams. And then if you're a med student that needs, uh, you know, like there's just like all of the student tutoring that I do. Um, so if you're like a newly minted first year, second year, third year, I'll tutor you for like your pre-clinical class exams or like your shelf exams. And then at the same time, I tutor you for the board exam that you have coming up, uh, all the people have done this with it being like super successful because they are typically like already prepared for the exams, even before the heated dedicated periods. Um, and then if you have like a college buddy that needs to be doing it like Gen CAM, O-CAM physics, bio-chem, histology, physiology, opportunity for all those things. Um, and then if you're a college student applying to med school, so like an AMCASAP or a med student applying to a residency, so an ERASAP, I do again offer like one on one like coaching for those things.

So like personal statements, rec letters, mock interviews, editing applications, stuff like that. So if you need any of those things, feel free to reach out to me. You can either reach out to me through the website or you send me an email at, uh, divine intervention podcasts with an SAD at gmail.com. So have a wonderful rest of your day. I'll see you in the next podcast. God bless you. Thank you.

Copper IUD, as it contains neither estrogen nor progestin.

A "porphyr ranger" appearance on the breast, especially in a post-menopausal woman presenting with symptoms mimicking mastitis.

Tamoxifen increases the risk of venous thromboembolic disease (VTE), whereas A Is do not carry this specific risk.

It is highly worrisome and suggests a high likelihood of an aggressive or malignant process.

Sentinel Lymph Node Biopsy (SLNB).

Radiation exposure to the head and neck area.

Mammogram.

Aromatase Inhibitor (AI). It inhibits the conversion of testosterone to estrogen.

Solid mass or bloody fluid/material.

Early menarche and late menopause (or first pregnancy after age 35-36).

Lymphedema; subsequent axillary lymph node dissection (ADND) may be required.

ER2+ positive cancer.

Mammogram.

Aromatase Inhibitor (AI). It inhibits the conversion of testosterone to estrogen.

Solid mass or bloody fluid/material.

Early menarche and late menopause (or first pregnancy after age 35-36).

Lymphedema; subsequent axillary lymph node dissection (ADND) may be required.

ER2+ positive cancer.