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

Source / episode info

• Episode: 189
• Title: Divine Intervention Episode 189 – USMLE Step 2 CK Rapid Review Series 26.
• Published: 2019-12-05
• Source: Episode page

One-liner

This episode provides a rapid review comparing hepatic adenoma vs focal nodular hyperplasia (FNH), differentiating types of hernias, reviewing structural complications from chronic inflammation in various organs, detailing the stepwise management and pharmacology for psoriasis and acne, analyzing the hemodynamic profiles of three major shock states, and covering critical OBGYN topics including preeclampsia, ectopic pregnancy, and UTI pathogens.

High-yield summary

• FNH vs HA: FNH classically has a central/stellate scar and shows a centrifugal enhancement pattern on arterial CT; it also contains biliary duct epithelium (positive on high-dose scan). HA is associated with OCP use, lacks a central scar, and shows star-tripod enhancement.
• Shock Hemodynamics: Cardiogenic shock presents with low CO, high PCWP, and high SVR. Septic shock presents with high CO, low PCWP, and low SVR. Hypovolemic shock presents with low CO, low PCWP, and high SVR (due to compensatory vasoconstriction).
• Preeclampsia Management: Diagnosis requires hypertension (>140/90 mm Hg) plus proteinuria (>300 mg/24h). Severe features require immediate consideration of Magnesium Sulfate for seizure prophylaxis. Delivery is the definitive treatment.
• Biliary Pathologies: Cholecystitis = Fever + RUQ pain (no jaundice). Ascending Colitis = Shick's Triad (Fever + RUQ pain + Jaundice). Cholangitis = Pain + Jaundice (often mild/intermittent).
• UTI Etiology: When considering UTI in a young, sexually active female, Ureaplasma urealyticum must be considered alongside E. coli, especially if the urine pH is high or if pyelonephritis complications are suspected.

Learning objectives

• Differentiate between hepatic adenoma and focal nodular hyperplasia using imaging findings and clinical risk factors.
• Apply the principles of shock state hemodynamics (CO, PCWP, SVR) to differentiate cardiogenic, septic, and hypovolemic shock.
• Recognize the diagnostic criteria for preeclampsia with severe features and initiate appropriate emergency management.
• Compare and contrast the pathophysiology and treatment regimens for psoriasis versus acne vulgaris.
• Identify key risk factors and associated pathogens for common malignancies (e.g., HPV for cervical cancer; Ureaplasma for UTI).

Board exam buzzwords

Rapid review table

Board-speak -> diagnosis

Differential diagnosis / distinguishing features

Chronic GI Strictures

Biliary Pathologies

Management pearls

• Preeclampsia: If severe features are present, administer Magnesium Sulfate (\text{MgSO}_4) for seizure prophylaxis immediately. Delivery is the definitive cure.
• Ectopic Pregnancy: Suspect in any positive \beta-hCG with a uterus ultrasound showing no intrauterine gestational sac; requires quantitative \beta-hCG and possible serial transvaginal ultrasounds.
• Hyperemesis Gravidarum (HG): Initial management involves IV hydration, antiemetics (e.g., Ondansetron), and Vitamin supplementation (especially Thiamine). If severe/ketotic, consider parenteral nutrition or admission.
• Cervical Incompetence: Risk factors include prior cervical LEEP procedure, connective tissue disorders (e.g., Ehlers-Danlos Syndrome), and history of preterm delivery. Management includes cerclage or vaginal progesterone supplementation.

Don't miss

Integration & clinical reasoning

• Endocrine/OBGYN Integration: The use of OC Ps increases the risk of both HA formation and endometrial cancer (due to unopposed estrogen), highlighting the importance of understanding hormonal effects on multiple organs.
• Infectious Disease/Obstetrics Integration: Ureaplasma urealyticum infection can lead to pyelonephritis, which in turn is associated with increased risk of preterm labor, prolonged intubation, and even bronchopulmonary dysplasia (BPD) in the neonate.
• Surgical/GI Integration: Recognizing that chronic inflammation (Crohn's or diverticulitis) can cause strictures leading to mechanical obstruction requires a thorough history and imaging workup beyond simple acute symptoms.

OMM / COMLEX integration

• Standard emergency management takes priority: In any unstable patient presenting with shock (e.g., septic, hypovolemic), immediate resuscitation (fluids/pressors) and stabilization of vital signs take precedence over OMT principles.
• For chronic conditions like Crohn's or structural issues like Asherman's syndrome, the focus remains on surgical/medical management rather than physical manipulation techniques.

Concept connections / cross-references

• For detailed review of hormonal effects on cancer risk, see [Episode 37].
• For comprehensive coverage of OBGYN risk factors and complications (e.g., cervical incompetence), review [Episode 100] and [Episode 184].
• For general principles of critical care shock states, refer to [Episode 97].

High-yield association table

Key terms glossary

Study optimization

Question pattern recognition

• Liver Mass Pattern: If a liver mass is associated with OCP use AND shows star-tripod enhancement, think Hepatic Adenoma (HA). If it has a central scar and centrifugal enhancement, think FNH.
• Critical Care Shock Pattern: When presented with low blood pressure, always calculate the expected PCWP/SVR based on whether the primary failure is cardiac pump failure (Cardiogenic) or massive vasodilation (Septic).
• OBGYN Diagnosis Pattern: If a patient presents in the third trimester with HTN and proteinuria, immediately check for severe features (AMS, thrombocytopenia, BP > 160/110) to determine if MgSO4 is needed.

Test yourself

Common mistakes to avoid

Common traps