DIP Episode 189 - USMLE Step 2CK Rapid Review Series 26

Okay, welcome. My name is Divine and my resident. This is episode 189 of the Divine Intervention Podcasts. In this podcast I'm going to be continuing the rapid review series for the USM and the Stab 2 CK exam. This is series 26. And this one is gonna involve like some mixture of OBGYN and you know many different things like OBGYN, some internal medicine, some surgery so but this is actually a super high-level podcast. For those of you that are gonna be taking the exam so this is a podcast really want to pay attention to. So let's just jump right into it. So and today I'm gonna try to compare and contrast things that tend to be confusing for many people on MBME exams right. So the first thing I want to compare and contrast is like Foconodola hyperplegia versus hepatic adenoma right. So what are the big differences between those two things? Well, the thing is you want to know that hepatic adenomas they will typically set up the stage in a woman that you know takes OCP's or some kind of estrogen containing product on exams. That's one. Another thing you'll find with hepatic adenoma right is that it does not very high it does not contain a central scar. Sometimes you may see the central scar referred to as a stellate scar on MBME exams. So if you if you don't see a central scar you don't see a stellate scar that's more likely to be a hepatic adenoma okay.

And then another thing is that the hepatic adenoma right if you do like a CT scan during the arterial phase you have something known as St. Tripodol enhancement okay. St. Tripodol enhancement on the arterial phase of a CT scan is indicative on an MBME exam of a person potentially having a hepatic adenoma. And then one unusual thing that when people mission the newer USMD exams that they be a little bizarre is they may tell you about a high-dose scan in the context of a hepatic adenoma. It's actually important to remember that hepatic adenomas do not contain like ball duct epithelium right. So because they don't contain like ball duct epithelium so basically you don't have you essentially don't have a biliary tree within a hepatic adenoma. So the thing is it would actually not give you any positive either results okay. It would not enhance on a high-dose scan. That's a very very high yield to know. It's a very unique difference from a focal nodulahyproplysion. So how does how is focal nodulahyproplysion set up? The big set up you want to think about is again we can tell you that it has like a central scar or a stellate scar. The almost almost always put that on exam. That's one high yield thing to know. Second high yield thing to know is that FNH on when you do those CT scans it has like a centrifugal right. A centrifugal pattern of enhancement right.

So you kind of have like enhancement around the periphery versus a centripetal where you're like going like enhancing from the outside and going towards the center okay. So a centrifugal pattern of enhancement on the arterial phase is pathonomonic of FNH on exams. I remember F in centrifugal for the F in focal nodulahyproplysion right. That's under high yield thing to know. Then FNH is actually important to remember that it contains like biliary duct epithetium. So it's actually positive on a high-dose scan. That's a unique difference from a hepatic adenoma. Now the next thing I want to compare and contrast is the different kinds of hernias right. Especially in relation to like the diaphragm right. So the thing is remember that we have like the sliding hydrohernias right. Those can increase a person's risk of like like gird right. But in a sliding hydrohernias it's critical to remember and exams that the GE junction is part of what her needs into the esophagus right. Compare and contrast that with a part of the geochirnear where the GE junction actually stays in its normal place. It's the fondest of the stomach that her needs into the into the like through the diaphragm right. And it's very important to remember that parts of a geochirnear as you don't observe those you actually go ahead and send those people to surgery okay.

Don't you go ahead and send those people to surgery because parts of a geochirnear have a very high risk of incarceration and subsequent strangulation right. Remember there are two kinds of hernias that you don't really observe like you do for many of the others and that's one, a part of a geochirnear and then two of femoral hernia right. Remember a femoral hernia being a female on MBME exams and it's going to be under the inguidown ligament and medial to the femoral vessels okay. Very high yield to know that. So that's how you compare and contrast the parts of a geochirnear with a sliding hydroherniar. Now the next concept I want to talk about is a construct that shows up quite a bit on MBM Es but people seem to get wrong. One thing I want you to keep in mind is if you have chronic inflammation in an organ right like a hollow organ you can actually form structures within that organ that can cause obstructive like symptoms. So let's sort of go from head to toe in the body to talk about like key areas with this concept tends to pop up. One is if a person has a history of chronic gird that can cause structures in their softagos right and they can have signs and symptoms of dysphysia okay. They can have signs and symptoms of dysphysia because again all those structures from the chronic inflammation of gird right can cause those structures and they'll have like a solid food dysphysia on MBME exams. Next one if you go a little lower in the GI tract is Crohn's disease right.

So again Crohn's right again is typically accomplished by a ton of inflammation so all that inflammation can certainly cause problems with cause like obstructive style symptoms okay. So if you see a person that has a history of Crohn's and maybe he's not on medication or they recently tapered their medication or whatever and then you're like man this person has like signs and symptoms of a small bowel obstruction. Think about Crohn's disease causing structures in the small bowel that's then causing a small bowel obstructive style symptoms and then the last one I want to get to is if they give you a question about a person you know this person has like very risky sexual behaviors and then you know this person has had many episodes of PID and this person is having like you know like imminuria problems or problems with coming pregnant. Think about potential structures occurring in that person's uterus okay that's essentially Ashmen syndrome okay Ashmen syndrome.

If a person has had like a lot of DN Cs for like you know like recurring abortions or whatever right that's Ashmen syndrome right that's essentially like a structural disorder of the uterus right and typically the way you make the diagnosis of structures of the uterus is that you do like you can do something like you can do something known as saline infusion sono hysterography it's almost like an ultrasound where you inject water into the cavity of the uterus as contrast that's one thing you can do or you can also do like hysteroscopy right and inject contrast and just take like x-ray images and then the way you trade Ashmen syndrome obviously right is to hysteroscopically like those adhesions right and then you give them estrogen to build up that endometrium and their problems kind of go away so those are the structural disorders I want you to keep in mind for purposes of the US immunies now what if they give you a question about a person you know that has like a skin condition on extensor surfaces and they tell you that it has like silvery scale what are you thinking about well I would really hope you're thinking about psoriasis on mbim exams the main thing I want to focus on with psoriasis is the treatment because this is something that people on like your friends at the mbimidiew they would like you to confuse this with the treatment of acne right psoriasis is treated in a somewhat different fashion from acne so let's talk about some quick things here your first line treatment strategy for psoriasis is to use a topical agent right so what would this topical agents be right topical agents you can use things like topical steroids right remember you actually do not use topical steroids for acne right so you can use topical steroids for so first line you can use topical agents for psoriasis what does first line what do these topical agents include you can use anything

from like topical cortical steroids like libethasol or you can use like topical co-tar right or you can use like a topical vitamin D analog a classic one you may see on an exam is something known as calcipo trying remember right vitamin D like there's vitamin D analogs that are not like calcium dial calcium trial so memorizing the term calcipo trying right should not be that big of a stretch right so that's first line topical agents now your second line agents for psoriasis right in addition to the topical agents you then add on it I almost think of it as almost like step-up therapy like you do for asthma right so if topical agents are not coding for a person you retain those topical agents but you then add a systemic agent right you add a systemic agent like metaltrex seed or cyclosporine very high you to know that those are your second line add on agents for a person that has psoriasis now your third line agents you can use biologics right like you infleximab adalimumab etanersept so your TNF alpha inhibitors alternatively you can actually use a phototherapy right you can use like UVB phototherapy not UVA UVB phototherapy or you can use something known as pova right pova puv just remember the term pova although remember that subjecting yourself to provide increases the presence risk of a suicide carcinoma of the skin okay so that's third line for the treatment of psoriasis compare and contrast this with acne we're the first line treatment for acne is again you can use a topical agent you can use like a topical retinoid or topical salicylic acid or topical benzoil peroxide right if that's not coordinate you can then jump to like a topical antibiotic right like topical like clean the mice know something if that's not working you go to an oral antibiotic right again like oral clean the mice in or oral doxycycline you'll probably be oral doxycycline that'll be the right

answer when you examine and then if that's not coordinate you need to make sure do a pregnancy test make sure the person is not pregnant check their LF Ts make sure they live as work well right and then you go ahead and start them on iso trait knowing remember if you're an iso trait knowing you need to be on two forms of birth control because iso trait knowing is certainly a teradogin and then one last thing I'll go ahead and see with psoriasis is again they can give you a big dessert question and say in a patient with psoriasis which is the most likely mental health complication of this disorder it's actually depression right major depressive disorder is very common in patients that have a long history of psoriasis right which kind of makes sense right I mean like for patients this skin condition that's kind of like chronic kind of hard to treat right it makes sense that they won't feel good all the time right so that's one weird thing you want to keep at the back of your mind for exams now let's talk about the three different kinds of shock but I want to talk about them in the context of cardiac output like effects on cardiac output effects on systemic vascular resistance and effects on pulmonary capillary wedge pressure right so if a person has like an M.I.

right what kind of shock will they have well obviously they'll have a cardiogenic style shock right so for the president's cardiogenic shock well the heart is not working very well anymore if your heart is not working very well anymore what should be true of the cardiac output it should be decreased right okay and if the cardiac output is decreased what should happen to the pulmonary capillary wedge pressure it should be increased right because remember PCWP is a proxy right for left-heteropresure so this person will have elevated left-heteropresures which will be manifested as elevated pulmonary capillary wedge pressures on M.B.M.

exams right and if this person with cardiogenic shock happens to have pulmonary dima right you would expect that the PCWP should be greater than 18 right because this is a cardiogenic source of pulmonary dima compared to the ARDS where people have a non-cardiogenic pulmonary dima okay very high you'll to know that for tests and then finally right I mean obviously the president's cardiac output is in the toilet then they are not profusing the organs very well the blood pressure should be very low so the way the body tries to adjust is to try to clamp down on the blood vessels so they will have elevated systemic vascular resistance again very high you to know that right and cardiogenic shock obviously already want to give that person a positive I know trope like the joxin or you want to give something like dubia the mean right or me or in order to help with a cardiogenic shock now if a person has septic shock right the primary event in septic shock is that this person has the release of inflammatory mediators right so those people will have like systemic visual dilation right they'll have systemic visual dilation so if you have systemic visual dilation what should that do to your after-loop that should crush the after-loop if your after-loop goes down what happens to your cardiac output your cardiac output will go up okay so cardiac output is elevated in a person that has septic shock and if your cardiac output is up what should be true of the pulmonary capillary wedge pressure in septic shock well it should be low right because again if your heart is working well then that means you will not have retention of stuff in the left teacher so the PCWP is low in a person that has septic shock right and the systemic vascular resistance it should make sense that it should be low as well because as I already said right septic shock you have a release of like histamine and brady

kining and all those inflammatory mediators those things cause visual dilation okay those things cause visual dilation right so ultimately the president will have a decrease in systemic vascular resistance and remember that one common pulmonary complication of sepsis is ARDS basically for president has like a systemic inflammatory disorder and they ask you what is the most likely complication of blah blah blah blah you want to think about ARDS on that those circumstances and then the last kind of shock I want to talk about right what if a president has like a massive massive massive GI bleed right what kind of shock will those people have well I will hope you're telling me that they have hyperbolemic shock okay the characteristic of hyperbolemic shock is that they have decreased blood volume right so they are preload goals down right so if a president has decreased preload what happens to their endastonic volume it should go down right and if the EDV EDV goes down then what ultimately happens with their cardiac output it should go down as well right so cardiac output is low in a person that has hyperbolemic shock and if the cardiac output is but notice the cardiac output is not low because the heart does not work the cardiac output is low because the heart is not getting enough blood the heart is not getting enough preload okay so the cardiac output is low in hyperbolemic shock but the PCWP is also low in hyperbolemic shock because there's just literally no blood in the heart right the reason I'm emphasizing these differences is that if a president has cardiac shock the cardiac output is low but because their heart does not work their PCWP is high compared contrast this with hyperbolemic shock where the president's cardiac output is low but the PCWP is low because it's not a cardiac problem that's causing the cardiac output to be low very high you to understand that a

nd obviously for a person has hyperbolemic shock and again the blood pressure is very low they're not producing their organs right in the thing that's gonna happen is that the systemic muscular resistance is gonna increase to try to prop up blood pressures and obviously for a president's hyperbolemic shock you start with giving the president fluids first not blood fluids right crystal oil first and then if that's not calling it you can then go ahead and add in blood and then for septic shock as I mentioned you can try with norepinephrine or norepinephrine is the pressure of choice for septic shock if that's not calling it you can then go ahead and add visual pressure but again remember before you start norepinephrine for septic shock you must have given the president antibiotics and you must have given them fluids and they must not have responded to those fluids before you can then jump to initiating pressures again please please please make sure this is something you absolutely understand so again the hallmark of cardiogenic shock is the president's heart does not work okay the hallmark of septic shock is the person has systemic visualization and then the hallmark of hyperbolemic shock is that the person has low preload okay now let's talk about some risk factors for common malignancies I mean I've kind of talked about this in prior podcast but again every sort of repetition always helps for sure so what is the most important or you can see the biggest risk factor for breast cancer that's age right that's age right and remember right in breast cancer people can have like problems with like double-stranded DNA brick repair right like in the as in like the brachamutations or if a president has like linch syndrome right that's more a problem with like mismatch repair so don't mix those up mismatch repair problems that's linch syndrome aka HPCC right like hereditary non

polyposis coloreto cancer versus double-stranded brick repair that's more with with the brachamutations that on the like breast cancer now what is the biggest risk factor for scrimal cell carcinoma of like the penis or cervical cancer or scrimal cell carcinoma of the vulva or whatever what is the biggest risk factor when I will hope you're telling me about HPV right HPV is the risk biggest risk factor for most of the scrimal cell carcinomas that we find in like the large and it'll attract okay now what is the biggest risk factor for endometrial cancer well I hope you're telling me on a post estrogen remember there's a big difference between on a post estrogen and a post estrogen on a post estrogen is straight estrogen a post estrogen is estrogen that is conjugated with progestin right if you have estrogen conjugated with progestin that does not increase a presence risk of endometrial cancer but if you have just straight on a post estrogen from either like PCOS we're taking like common replacement therapy that does not increase the group of just in that can certainly raise a presence risk of endometrial cancer right and it's actually important to remember that if a person has a history of breast cancer they should not be taking any kind of OCP right because OCP remember many breast cancers are ERP are positive right so those things can spurs because I mean literally OC Ps contain estrogen and progestin right so those can activate those breast cancers and cause them to proliferate somewhat right so you don't want that now what is the biggest risk factor for long cancer that's easier that's smoking okay now what's the biggest risk factor for ovarian cancer well that's like age right ovarian cancer is much more common in order women and also having a family history of ovarian cancer is definitely a big risk factor for ovarian cancer now what is the biggest risk factor for

a popular thyroid cancer that's actually exposure of radiation right to the head and neck right like prior to the history of like head and neck radiation exposure probably a person that had like like some kind of like lymphoma in childhood that you should out radiation therapy or breast cancer in childhood not in childhood but you know some kind of breast cancer and then they got like radiation therapy and then they got into trouble in the future with a popular thyroid cancer remember a popular thyroid cancer has those anti often any I nuclei and it also has like the Samoma but it's right kind of like you have with like mesotheliuma and meninjoma and cirrhosis that no customer of the ovaries now what is the biggest risk factor for brachyxlinforma well that's ebv right that's ebv remember brachyxlinforma has the 814 translocation remember that your CML has the 922 translocation remember your acute pro myocytic leukemia right your AML has the 1517 translocation and then don't forget that your E-winkcer coma has the 1122 translocation where you create that EWSFLI fusion protein now what is the biggest risk factor for renosal carcinoma well I hope you're thinking about smoking right if you say a person on bilateral renosal carcinomas I would hope you think about a V-chal when he pull in that with that now what is the biggest risk factor for bladder cancer that is also smoking as well right and they're finally what's the biggest risk factor for pancreatic cancer that'll be smoking as well right so again hopefully at least with this quick run through with these different malignancies you know your different risk factors now the next thing I think I want to compare and contrast for us is the difference between growing pains and osteoidosteoma this is something that seems to confuse people quite a bit on mbim exempt okay so growing pains the key thing you want to remember is

that growing pains tend to be bilateral right be tend to be bilateral like this child will have problems in both lower extremities right so they tend to be bilateral the pain is usually worse at night and it's usually worsened by a person having a ton of physical activity during the day okay so bilateral worse at night worsened by a ton of physical activity during the day especially in the present that's undergoing like a big root spurt think about growing pains right it's a pain that arises because you're growing right now compared contrast to osteoidosteoma osteoidosteoma is unilateral they won't have bilateral symptoms they'll be unilateral okay and the problem with osteoidosteoma is that they'll have been at night kind of like growing pains but they'll put the term that it's relieved relieved with NSAID because the thing is apparently prostate glandins like an increase in prostate glandins pleaser role in the pathophysiology behind the pain that's experiencing people that have osteoidosteoma okay so if you give an NSAID NSAI Ds are cox inhibitors so that would downgrade the levels of prostate glandins and that will help with that disorder and the thing is people that have osteoidosteoma they tend they may have like a body prominence on physical exam on imaging on the mbim so again grain pains bilateral pain wors at night worsened by a ton of physical activity during the day osteoidosteoma unilateral pain at night relieved with NSAI Ds and they may have a bony prominence on physical exam on imaging now the next thing I want to talk about because again this is just something that does not again it's a common thing so you think that people you know have this downpour by now but unfortunately people don't have this top down part just yet so let me kind of talk about it and compare and contrast them right so there are three biliary pathologies you do not want to confuse

on your mbim exams colisistitis ascending colonitis and colidocolithitis so how do let me give you these things as like a set of three equations for colisistitis think about it on an exam as fever and right over corduan pain only so fever plus right over corduan pain is colisistitis fever plus right over corduan pain plus jondis is ascending colonitis I mean that's the classically described shackles triad right like fever right over corduan pain jondis if you add altered mental status and hypertension to that you know you're dealing with renault's pentad now colidocolithitis is on the other hand is a pressing having right over corduan pain that may be mild plus jondis they do not have fevers on mbim exams again it's very important to know so fever plus right over corduan pain colisistitis fever plus right over corduan pain plus jondis ascending colonitis right over corduan pain that's usually mild plus jondis is colidocolithitis so you may see divine why do people that have colisistitis not have jondis well think about it if a person has colisistitis the obstruction is at the level of the cystic duct right you are not specifically obstructing any part of the person's biliratory right so because you're not blocking any part of the biliratory the person is highly unlikely to have jondis okay but in colidocolithitis is an ascending colonitis the obstruction is at the level of the common bowel doctor right so obviously those people are gonna have jondis now remember that for colisistitis right your first step in that noces is a right over corduan ultrasound right if the right over corduan ultrasound is a quiver call it doesn't show you what you want then you go ahead and go down a high the scan and include the colisistectin for colidocolithitis is your first step in that noces you can do a right over corduan ultrasound if that's a quiver call or not show you what you want

you can do an ERCP or an MRCP either or is just fine but for ascending colonitis you jump straight to the ERCP you don't do a right over corduan ultrasound for ascending colonitis and obviously you're gonna give those people antibiotics and remember people that have ascending colonitis right you do not do a colisistectomy during the acute phase you do it you know like a while after the episode of colonitis has resolved again very important to know that for exams now the next things I want to compare and contrast I guess maybe talk about in terms of a gradation at these biliary tracts disorders that pop up in pregnancy right so I think I want to differentiate between intra-hypatic colisistitis versus acute fatty liver of pregnancy versus help syndrome helps syndrome is probably easiest for most people to recognize on exams right they'll have like a molasses right so they'll have like an indirect type of bilirubinemia right they will she's to sites on a blood smear right so help syndrome um he molasses elevated liver enzymes so the liver enzymes will be elevated right and then you have a thrombosidopenia low placements right contrast that with um intra-hypatic colisistitis intra-hypatic colisistitis right those people will have more of an obstructive jaundice style picture classically on MDMA exams those people have a ton of excoration like a ton of itching right and you'll have like a direct hyperbibiliarobinemia okay direct or you can say conjugated hyperbiliarobinemia and in addition to that they'll have like an elevation in their alkaline phosphatids their AST and ALT will not be significantly elevated if it's elevated at all right contrast that with acute fatty liver of pregnancy where these people will have like markedly elevated AST ALT they'll have like many signs of like bad bad bad is almost like a person being an a serotic like bad bad bad anxiety level dise

ase like they'll have like hypoglycemia they'll have like elevation in their ptptt their AST ALT will be like through the roof it will be like super high right and the person just will not be doing well like and it will be something that happens acutely that's why it's called acute fatty liver of pregnancy okay and again remember you're all that like I guess hypertensive relief data disorders of pregnancy like like just like just like just additional hypertension shows up after like 20 weeks right so if it's before 20 weeks on an in-bim exam it's not just additional hypertension right and remember is defined as blood pressure is being greater than 140 over 90 right and then if a person has that hypertension and then they have proteinuria and that proteinuria the definition is having more than 300 milligrams of protein in the urine in a 24-hour period if you see that then that's pre-eclampsia so hypertension plus proteinuria right it's pre-eclampsia and then a clumsy is when they have all those things okay but they now have seizures and obviously it treats those seizures with magnesium and if a person has that hypertensive disorder in pregnancy remember that the drugs that are available to you are drugs like hydrozene alpha methyl dopadol labeta law and my phydi-pine remember there's an harmonic for that that hypertensive moms love my phydi-pine right so you can use hydrozene so high hypertensive and then moms M alpha methyl dopadol and then L labeta law and then N my phydi-pine okay my phydi-pine and if they want to kind of like measure your head and say oh do you know the difference between like regular preeclampsia and preeclampsia with severe features well preeclampsia with severe features those people have like signs and symptoms of like altered mental status you have like low pleaklets so you have a thrombocytopenia or if you see a person that has preeclampsia an

d their blood pressure systolic is more than 160 or their blood pressure that systolic is more than 110 that qualifies for preeclampsia with severe features okay and again if a person is having like preeclampsia severe features you want to start thinking about delivering some way shape of four if the person is less than 34 weeks you know go ahead and give them like beta-metha zone two doses in a 24 period right and then proceed towards the delivery but if they are more than 34 weeks just go ahead and deliver the baby okay if they are more than 34 weeks just go ahead and deliver the baby now the other thing I think I want to differentiate between is the difference between something called an ectopic pregnancy and something called a blighted oval that's again another problem that people seem to kind of get hung up with on mmexams an ectopic pregnancy by definition is not in the uterus I'll say that again an ectopic pregnancy by definition is not in the uterus it did not implant in the uterus that's why it's called an ectopic pregnancy in the first place again remember the word ectopic ectopic means something is coming from or is situated where it's not supposed to be right so like can I like ectopic acct right oh it's like oh easy change comes from the anterior pretoid where we're getting it from the small cell lung cancer that's in the lungs right that's ectopic acct so an ectopic pregnancy is in a different spot from where it should normally be now a blighted ovum by definition is an ovum that actually implants in the uterus very high yield a blighted ovum implant in the uterus so you will have a gestational sac but for whatever reason an embryo does not develop inside that gestational sac if you see that that's a blighted ovum okay blighted is B L I G H T E B a blighted ovum it actually does implant so it's an egg that you know gets fertilized in implant in the uteru

s right but for whatever reason no embryonic tissue develops from that okay sometimes they call it like an unembryonic pregnancy on an mbim exams on an m not on an mbim exams that's terrible English on an mbim exam because that's one right to kind of mess with your head on test so again gestational sac no be insided implanted in the uterus blighted ovum a topic pregnancy by definition is not in the uterus now the next thing I want to talk about is a hyper-message gravity dynarm right so hyper-message gravity dynarm very high yield disorder to know remember right it's will be a woman usually first trimester you know just throwing up a ton can keep anything down obviously for those people you go ahead and admit them to the hospital you put them on like you know give them IV hydration IV anti-medics like on dancer tron right and then you want to supplement the vitamin B one so like thiamine and vitamin B six right the vitamin B six is more like chronic supplementation tell them like oh take like B six plus doxelamine and then it's more small meals but in the acute phase when they come into the hospital go ahead and give those people IV thiamine okay that's another indication for IV thiamine treatment on an mbim exams besides a wienicic or socophur syndrome right and remember that people that have hyper-message gravity dynarm declassically have like ketosis right they may have like ketones elevated in their blood or in the urine or an mbim test now the next thing I want to talk about is like cervical incompetence again this is a concept that people seem to be struggling with a lot on mbim exams right the thing is if they ask about like risk factors right like in my OB-GYN video I clearly talk about like you know a history of like a lip procedure or like a cervical colonization procedure so lip procedure LWEP right like a lip procedure a cervical colonization procedure rig

ht but there are some other things that on an mbim especially like the newer exams like the newer you're a semily step to seek exam it kind of seems to make you want you to remember right so things like if a prison has like a connectivity shooter like a less thanal syndrome that is a risk factor for cervical incompetence if a prison has also been exposed to like a diet they'll still best draw okay that believe it or not that's also a risk factor for for cervical incompetence because the thing is I mean again if you're it doesn't if you read if you look on Reddit or Nesd or whatever people's common complaints with the current USMD exams is that oh you read the question as you read the question and like yeah I think I know what they're talking about and then you look at the answers you're like man I don't see anything that released to anything I know right or they give you a common pathology you're aware of but it presented to you in an uncommon fashion right it uh that's why if you notice I've been going a little bit off the reservation in my more recent podcast to kind of try to combat those needs and again for people that are going to be taking the exam soon you absolutely need to listen to episode 100 and EV4 okay on the website before you take like I mean it's a given that you should listen to episode 37 and 97 but episode 184 is I almost think of it as like the third part of the risk factors trilogy in episode one EV4 I talk about like oh like what is the most common complication what is the most likely outcome of this disorder or like some weird screening guidelines so like oh what additional finding would you expect on further workup of the patient right or what's the most likely psychiatric complication of this right like those weird kind of like risk factors stuff like complications like biggest prognostic factor and things like that that I did not cover in 37

and 97 I covered them very thoroughly in episode 100 and EV4 that is a floridly high-yield podcast to listen to for the new USM list step 2 ck exam so server-go-ling competence right again like you know your lip colonization procedures but having a connective tissue disorder like your list downloads syndrome increases your risk being exposed to diethyl steel best role increases your risk having a history of like preterm delivery also increases your risk for cervical incompetence right and the classic way we present is you present as up this one will not have contractions right but they'll tell you that all that they are seeing like the the fetus like in the vagina or whatever right like in the second trimester it's a painless second trimester pregnancy loss and really how do you treat cervical incompetence you can do something like a circle edge right you can do like a cervical circle edge and then if a person has a history of cervical incompetence for future pregnancies one thing you can actually do is you can try to supplement with like vaginal progestin to kind of bifop the lining of the cervix that will somewhat decrease the presence risk of cervical incompetence okay now one of the weird bizarre concept i think i want to talk about is people always seem to wonder and actually it's not something you should just wonder about it's something you should actually care about it's really if you're like you know like a reproductive age female like a young female like a teenager basically or you know like you're in the early 20s 30s whatever or you're taking any of the USM right that's probably your bigger concern with this well there is this concept known as cervical ectopi so let me go ahead and talk about it so it's called cervical ectopi sometimes on in the me an example it's called it like a cervical ectropion so ec tropi i o n right so cervical ectopi so let's talk

about this thing so the thing is there are two major parts of the cervix there is the endoservix and there is the ectoservix the endoservix is lined by column epithelium i'll say that again the endoservix is lined by columna epithelium on the flip side the ectoservix is lined by stratified squamous epithelium and if i'm not mistaken i'm pretty sure it is stratified squamous keratinized epithelium right so think about it between those two kinds of epithelium which one is most sturdy which one provides better protection if you may well i hope you're telling me that it's the stratified squamous keratinized epithelium that should provide better protection i mean that's literally the kind of epithelium that you find on your skin right so the thing is the epithelium that we find in the ectoservix is very resistant to infection but the columna epithelium that we see in the endoservix is actually not very resistant to infection like at all right so the thing is obviously if you're a female i mean like it should then make physiologic sense maybe before i see my next point let me see this way it should then make physiologic sense as to why the endoservix i mean it's called endos it's on the inside it should then make physiologic sense why the endoservix is more on the inside versus the ectoservix that is more on the outside okay that's one high level thing to know so think about it if you're a female and you're like man i don't want to be getting all these ST Is and all this stuff well you would not want your endoservix to see the outside world in any way shape or form right so the thing is if whatever reason you are in a state as a female where big chunks of your endoservix are kind of hanging out to the outside world right you're kind of like staining the place where you would expect your ectoservix to be then that person will have a very high risk of ST Is right so the reason

i'm explaining this stuff is that that's actually the mechanism behind young females being most because think about it right who do you typically see on MBM exams classically get ST Is it's almost always in a young female right i mean you have to all people do risky things yes they do right but let's just say all people don't do risky things on MBM exams right so the thing is because young people in general they like okay let me put it this way as you get older your endoservix begins to go more and more inwards so as you are young like when a woman is young or if a woman uses like a ton of OC Ps that actually increases her risk of having that endoservix hung out closer to the outside world than it should be right and that was searching her risk risk of a lot of like service ideas and all these ST Is so again i hope that's a concept that makes sense ectopere it again something being a topic means its way should not be okay so your endoservix should be inside but if you see more and more of it on the outside because you're just a young female or because you take a ton of OC Ps right then that will make you most susceptible to infections off your genital tract now one other thing that again has seemed to pop up quite a bit on the current USML that give people a lot of trouble is this whole concept of immune fusion right the whole concept of immune fusion so let's talk about it right let's talk about this so the thing is immune fusion has three indications on the USML exams one is if a woman has like you know like variable these like a ton of variable decals right that tells you that you're likely dealing with cold compression you can use an immune fusion for that because think about it why would you get cold compression well if you have a ton of oligohydraminums right the baby's body is more likely banging on the on the on the umbilical cord right so the thing is if you were

to put like some fluid into the amniotic sac right that would almost like put the baby in a bubble so that it doesn't keep banging into the into the into the umbilical cord okay so um immune fusion is indicated for variable decals again cold compression right or if a person has like very severe oligohydraminums that's like the second indication like very severe oligohydraminums and then they ask me the question which of the following measures should be taken to decrease this woman's risk of cold compression as a complication of pregnancy right think about immune fusion under those circumstances and then the third indication it's more of a soft indication but it's an indication you certainly want to know for purposes of the USMLA exams is having like a meconium right like uh like to decrease the risk of meconium aspiration syndrome and this is classically something you'll find in a woman that is like post-term or close to post-term on MDMA exams right so like a woman that's you know still pregnant and she's like 40 weeks 41 weeks 42 weeks on an MDMA exam right so the thing here is think about it what is meconium let's maybe start there what is meconium well meconium is your first poop as a kid and the thing is you're supposed to poop within the first 48 hours of life right so the thing is if a baby kind of expenses like oh you know what let's say the baby's telling all these little buddies in baby world that you know what I'm gonna get out of my mom's a uterus by like you know like 38 39 weeks and I can go and you know poop and leave a free life in the world well if the baby is not like hanging out like man it's like 40 weeks 41 weeks 42 weeks is like you know what I can hold this anymore and then it kind of pops on himself right basically popping on it's like popping into the amniotic fluid well the thing is that usually doesn't cause many problems but it can be bad

because in the process of delivery if the baby inheres that meconium right that can cause meconium aspiration syndrome it can cause like persistent pulmonary hypertension it can cause like problems right so if you want to try to avoid that you can actually do an amniu infusion right that amniu infusion at least the way I think about it is it will almost like solubilize the meconium so that that would decrease the presence the child's risk of aspirating it like if you look at certain guidelines actually doing this amniu infusion for to prevent MAS is actually not really indicated right but it's just one of those recommendations that I feel like the MBM is test classically so it's something you want to keep in mind so you can actually in MBM world lower a child's risk of meconium aspiration syndrome by doing an amniu infusion by doing an amniu infusion now the last thing I think I'll talk about sorry I know this is this supposed to be a rapid review podcast but the thing is I just want to get through certain things because I want to get them out I don't want to delay delay because this this could be something that is vital for persons exam so I want to get it out right now so the last thing I will talk about is this unique bug okay it's a bug that doesn't get a lot of fun fear in review resources but it's a very very high-yout bug to know for the USMLA exams right and it's this bug known as ure plasma ure lidicom I'll say it again you're a plasma ure AAP LASMA ure lidicom ure A LYTICUM right so ure plasma ure lidicom okay so the thing is if they give you a question about like a sexually active young female that you know has uti's think about ure plasma ure lidicom as a potential cause although right you want to think about equally as the most common cause and then you want to think about steps of a prophyrycos as a second most common cause but if you don't see e coli as

an answer choice or you don't see steps of a prophyrycos as an answer choice I would want you to go with ure plasma ure lidicom that's one second thing you want to keep in mind with ure plasma ure lidicom and this is actually like something that's like ridiculously high yield to know for the USMLA is the fact that ure plasma ure lidicom can actually be a cause of corromionitis on mbim exams right so if if you see corromionitis in a woman that's like delivering a child think about ure plasma ure lidicom as a potential etiology right and the thing is the reason why it's very important to know this is that there's actually been a lot of studies that have come out that have shown that actually if a woman has corromionitis from ure plasma it actually increases the risk of the newborn needing like prolonged intubation and mechanical ventilation right it basically replacement causes a lot of amniotic fluid problems and I mean it also resistors from any other things like preterm labor, preterm delivery right and one clue that you may see in a question especially in a person that has a UTI from ure plasma ure lidicom is that the urine pH will be high because remember ure plasma is actually a ure is I mean it's kind of easy to remember this right it's a ure is positive bug right and one thing to keep in mind is that um you're a plasma ure lidicom right with all these like complications that can arise where the newborn ends up needing like prolonged intubation mechanical ventilation it can actually raise the child risk of like like bronchopominary dysplasia right it can raise the child's risk of like neonidol pneumonia and again it's transmitted obvious theory from mom from mom to baby and the thing is like ure plasma can even cost things like pid, costings like miscarriages right so and you may say okay define how do we treat this stuff or which are the word doxic cycling or y

ou can also use like isitromycin right so you can treat it with doxic cycling or isitromycin the thing is you cannot use a cell wall inhibitor because the thing is ure plasma does not have a cell wall right it's kind of like micro plasma it doesn't have a cell wall so a penicillin based agent is not gonna do squat for you right so again you may see the volume of the urine so more time to your plasma your plasma is a very very high yield bug to know for the purposes of the ure semil exams and one last thing I'll say is if a woman has coriomyonitis that is not an indication for C-section I see people make this mistake all the time on the mbim exams coriomyonitis if a woman has coriomyonitis you don't want to let the baby kind of like sit and chill there no you want to go ahead and deliver the baby right but that does not mean that you need to do a C-section right you know just proceed towards the delivery like if mom is not having enough contractions give her oxytocin or give her a prostaglandin right you want to deliver the baby soon well you don't have to do a C-section for coriomyonitis okay that's a very common mistake that people make on the ure semil exams and then the final thing I will say I promise is that you want to be able to recognize i'm not like fluid embolism right so I'm not like fluid embolism on mbim exam for I will present as like as a you know woman that you know around the process of the delivery she becomes unresponsive or she has like a low platelet like a thrombocytopenia her fibrene split products will be elevated right she may have like an invasion like ptt and pt stuff like that right so those are kind of like big things you want to be able to recognize and as I do at the end of every podcast I do offer like both large group and one on one tutoring for step one step two ck step two cs and step three preclinical med school exams 30-ish off exa

ms if you're a medicine resident if you're preparing for the a b i m board exam the medicine training exam or your college student I need to learn for like gen chem or chem physics biochem histology physiology offered to learn for all those things and then if you need like application advice in right for like you know like ira's applications if you're planning to residency or i'm cast applications if you're planning to med school I'm I don't for like one on one like advising with like you know like recliders personal statements editing applications mug interviews I don't offer all those things I mean I've worked with tons of people and I actually have admissions committee experience I was actually an admissions committee member at the top two med school for a year so I've reviewed thousands of high quality applications right so um uh so just something to keep in mind so if you need any of these things just either reach out to me through the website right um or you can send me an email at divine intervention podcasts with an s av in at gmail.com and then as I said in a much earlier podcast these podcasts are now available on on uh Spotify Apple podcasts Google Play stuff like that right so whatever podcast app that floats your boat you can actually get these podcasts there so have a wonderful rest of your day please listen to those podcasts before you take your US Emily step 2ck exam it's a very high-yield one and I mean I'm gonna bring out some more higher podcasts down the line so have a wonderful rest of your day God bless you thank you

A centrifugal pattern of enhancement on the arterial phase.

Hepatic adenoma.

Cardiogenic shock has high PCWP because the heart cannot pump blood forward; Hypovolemic shock has low PCWP due to low preload.

1) Variable decelerations (to prevent cord compression), 2) Severe oligohydramnios, and 3) To decrease the risk of meconium aspiration syndrome.

The urine pH will be high because Ureaplasma is a urease-positive bug.

Topical corticosteroids, topical coal tar, or topical vitamin D analogs (e.g., calcipotriol).

Parastomal hernia (or general diaphragmatic hernias, as discussed in relation to the hiatus).

Growing pains are bilateral, worse at night, and worsened by physical activity. Osteoid osteoma is unilateral, worse at night, and relieved with NSAI Ds (due to prostaglandin inhibition).

Hypertension (BP > 140/90) PLUS proteinuria (>300 mg in 24 hours).

Oral Contraceptive Pills (OC Ps), because they contain estrogen and progestin, which can stimulate proliferation.

Neonatal pneumonia or prolonged intubation/mechanical ventilation (due to inflammatory complications).

Parastomal hernia (or general diaphragmatic hernias, as discussed in relation to the hiatus).

Growing pains are bilateral, worse at night, and worsened by physical activity. Osteoid osteoma is unilateral, worse at night, and relieved with NSAI Ds (due to prostaglandin inhibition).

Hypertension (BP > 140/90) PLUS proteinuria (>300 mg in 24 hours).

Oral Contraceptive Pills (OC Ps), because they contain estrogen and progestin, which can stimulate proliferation.

Neonatal pneumonia or prolonged intubation/mechanical ventilation (due to inflammatory complications).