DIP Episode 225 - USMLE Step 2CK Rapid Review Series 35

Okay, welcome. My name is Divine, I'm a resident. This is episode 225 of the Divine Intervention Podcast. And in today's episode I will be continuing the Rapid Review series that we have for the US semilistep 2 CK exam. This is series 35, right? And I know these series is kind of long, right? But essentially, let me tell you the thing. The thing is, this is what I typically recommend to people is just listen to a couple of these podcasts. They are usually pretty short. Just listen to a couple of them all three are dedicated period, you know, like two or three a day. That's really the smart, prudent thing to do. Start from the ones that are the highest numbered, right? And then just walk your way back to episode one. That's a mean series one. That's really the smart, prudent thing to do. Okay, they essentially give you like some added information that you may not necessarily see like in the dedicated shelf videos, right? Okay, although they get a show videos again, are very, very comprehensive, right? Very, very comprehensive. Okay, so let's just jump right into it. Now, what do they give you a question about a patient and this patient a few days ago, you know, had like an operating pressure infection. And then now this patient is having like trouble breathing, has crackles on a quotation, bilateral crackles on a quotation of the lungs has an a new S three heart sound and has like a new like holosis stomach murmur head vest that the apex going to the axilla.

If you see that, what are you thinking about? I would really, really hope that you're thinking about why you create this, right? Why you create this? Remember this, they can make it this an adult question and an MBME. But believe it or not, your friends at the MBME can also make it a pediatric question, right? So my credit is, this doesn't really respect anyone, right? You can happen to pretty much anyone. So if you see a person that has like an upper respiratory thing going on and then like days later or weeks later, they have like heart failure symptoms like pulmonary edema, pulmonary capillary wedge pressure breathing and 18, uh, new S three heart sound because usually myocarditis leads to like a diluted cardiomyopathy, right? So like a new S three heart sound and then they tell you that, oh, this person has like a new murmur of mitro regurg, because again, the heart gets diluted. So you pull the the mitro valve leaflets apart so you can have like mitro regurg. If you see that, think about myocarditis, right? Think about myocarditis, about 50% of those people end up needing heart transplant. We did not couple of years, right? So it's a pretty bad thing to have. And the most common cause right is coxac-e-b, not coxac-e-a, coxac-e-a causes hand-foot-mouth disease, coxac-e-b is the thing that causes myocarditis, right?

And then another other things I guess you can think about that may cause myocarditis that can give rise to a diluted cardiomyopathy on an ambient, don't forget like your anthrocycline, so like doxodonorobicin, right? Remember those cause an irreversible diluted cardiomyopathy? That's usually like a breast cancer question. And then the hotel that the person is having like again, like heart failure symptoms, new S three heart sound. Think about your doxodonorobicin, right? You would have prevented that by giving the ion chelidonone as a dexrosoxin, right? Because remember, doxodonorobicin, they love to bind iron and that iron through the fainting reaction can cause like free radical damage of the heart, right? So you can cause an irreversible diluted cardiomyopathy. Contrast that with this drug that's used for breast cancer, right? So the hotel that your person has breast cancer and it's positive for like her two new, right? Like the her two or B two, like receptor, whatever, right? If you see that you want to give those people trust, doxiumap, right? Trust, doxiumap. Remember trust, doxiumap is a monoclonal antibody against like the her two receptor and it causes a reversible diluted cardiomyopathy. And one thing your friends at the MBME can do is they can say, oh, in addition to trust, doxiumap therapy or prior to initiating trust, doxiumap therapy, what is the next best step in management? You want to make sure you get like a baseline echocardiogram for those people, right?

Because again, you want to figure out their EF, how it is, right? If your EF starts tanking or you go ahead and stop the drug, right? So that's a high yield thing to keep in mind. And again, remember, trust, doxiumap causes a reversible diluted cardiomyopathy. Your antarocycline is like doxodonorobicin, cause an irreversible diluted cardiomyopathy, okay? That's very high yield to keep in mind. Now, what if they give you a question about, and also don't forget clasping, right? You know, for like schizophrenia, causes amyocarditis, which can again cause a diluted cardiomyopathy, you know, so kind of big things to keep in mind for tests. Now, what if they give you a question about like they can give you make this like a quality control question on an MBME, right? Because again, remember like from this summer and I'm going to start making more podcasts that kind of go with this too. Essentially, but from this summer, I think like in me or something like that is like a specific date to put your friends at the MBME's, they've said that they'll start writing a lot of like social science questions, right? So we'll start going over some social science concepts like in these podcasts. But basically, if for example a patient gets like a diagnostic study, right? Like some kind of imaging, right? And you know, something, you know, that is major is found on the imaging, like cancer is found or this or that. What is always your next step in management?

Or if they give you like a quality improvement question like because they all what is the thing you what can you do to kind of like reduce the risk of like missing out on an important diagnosis, blah, blah. The thing is essentially the standard of care is when a radiologist finds something weird on imaging, they're supposed to call the referring provider, right? So they almost have like like if they can get across a referring provider, they keep a running list and say, okay, you know what we're going to go ahead and reach out to this provider like in the very near future or they can have a secretary reach out to the provider, right? So the order and provider. So that's something high you want to keep at the bulk of your mind for example. And then what if they give you a question about a patient and this patient has this patient has a. Let's see. So they give you a question about a patient and or let me put it this way. Maybe this will be a little more helpful. It'll be too hard and it will take too much time to make up like a mental question like on the fly. But let me just talk you through this concept, right? So the thing is the radio nerve is one of those high-yield nerves that your friends at the MBM expect you to know for tests, right? I don't know, they just like this radio nerve business, right? So the thing is it's kind of high yield for the purposes of exams to know the different levels where the radio nerve can be all screwed up, right?

And they know how those things present. And again, I know people may be like, oh, the vine you're supposed to, you're about to go from one of those your tirades on like nerves and this and that and muscle and no. I'm not going to do that to you, right? I'm going to make your life simple. So here's how I'm going to make your life simple. So radio nerve, right? Basically, they have three radio nerve kinds of injuries. You can get on a test, right? You can get three kinds of re-earned injuries on a test. Now, the first principle, I guess let me teach you a principle so that it's much easier for you to remember, right? The first principle I think that may be helpful to keep at the back of your mind is that if you have a proximal nerve problem, you'll have the most number of deficits. It's like you're killing your killing the nerve from the origin, right? But if you have a more distal problem, you'll have fewer deficits, right? So I typically tell people learn things from the distal deficits to the proximal deficit and then you'll be set, right? So for the radio nerve, where can you kill the radio nerve? You can kill the radio nerve almost at the hand, right? So the distal like for, because remember, if you look at your upper extremities, you have your arm first that goes from your shoulder to your elbow and then you have your forearm that goes from your elbow to your wrist and then you have your hand that goes from your wrist to your nails, right?

So to your fingers, or whatever. But so basically, right, you can kill the radio nerve at the distal forearm, you can kill the radio nerve at the elbow or you can kill the radio nerve in the arm, okay? So the thing is the radio nerve pretty much all it's whatever, all it's motor nerve function, it gives that off before it gets to like the distal forearm, like the distal like forearm, right? Just before it gets to the wrist, right? So usually if you kill the radio nerve at the wrist, the only problem the pressing will have will be like loss of sensation, right? In the radio nerve distribution of the hand, right? So what's the radio nerve distribution in the hand? Let's talk through that real quick, right? So the thing is remember your hand has the anterior surface like the palm, right? Like the place where you used to like, like if you want to like slap someone, right? Don't slap people you know, you could get arrested for doing stuff like that, don't do that, that's not that's not very prevent. But basically, right? Like the anterior surface of your arm, the ventral surface of your palm, right? Like your palm or surface. The first three digits, right? So basically your thumb, your index finger and like your your middle finger. The sensation for those three fingers on the anterior side is median nerve for your last two fingers, so like your pinky and your ring finger on the anterior side, that's on a nerve. And then if you look in the back, right? The dorsal side, right?

The side where you know, you draw blood from, right? If you look again, the first three digits like your thumb index finger, middle finger, that's radion nerve, that's radion nerve, okay? For sensation. But the last two is on and off. So on and off does the front and back for the last two digits. But for the first three digits, anteriorly the palm or surface, right? The ventral surface, that's median nerve, but for the back that's radion nerve, right? So basically, if you kill the radion nerve at the distal forearm, it's just sensation that will be lost. First three digits, back of the hand, right? Back of the hand, right? The side you've dropped from, the dorsal hand, right? But if you kill the radion nerve at the elbow, right? The key thing you're looking for is that, oh, the person has lost, the person has wrist drop, right? Don't forget, let poisoning also causes wrist drop, right? Let poisoning is like wrist drop, abdominal pain, and neuro problems on exams, right? So wrist drop, you know for sure that the person's, the person's radion nerve has been killed at the elbow, right? Well, don't forget, right? If you kill the radion nerve at the elbow, it's almost like killing, that's a more proximal lesion, right? So they will also have the sensory crap that I talked about a few minutes ago, right? But now let's assume you kill the radion nerve in the arm, right? And how can you kill the radion nerve in the arm?

You can do a bunch of things, you can have like crotch, you can have like crotch injury, right? So like we're like the person, you know, the tell you to use crutches, the searching wheel, you're like, oh, let me put it right on the axilla, that's not very pretty, right? The radion nerve runs through the floor of the axilla that can kill the radion nerve, right? Another thing is, let's say you go out and booze up, right? You know, you drink a ton of booze, right? And you have like that Saturday night pause where you rest your axilla over like a bench, you know, from being like stoned and everything. That will also cause a radion nerve injury, because again, the radion nerve crosses under the, under the, the crosses like right under the axilla, right? And then another thing is if you have like a mid-shuff fracture of the humerus, right? Mid-shuff fracture of the humerus, that will also kill the radion nerve, right? Again, you can get those kinds of problems there. Okay? So the thing you're looking for, like if you see this thing that you know, like basically what I'm saying is, if you see, I'm just trying to give you like the one big thing you should look for, now tell you that, oh, this is the location of the injury. If the triceps reflex is gone, the radion nerve has been injured above the elbow for sure in the arm, okay?

So, but obviously again, because that's a more proximal problem, in addition to the triceps being gone, they'll also lose, they'll also have wrist drop, they also lose sensation again, first three digits on the back of the hand, right? So again, those are all high yield things to know. And then I guess let's kind of talk about some of these humeral fracture patterns and how they would present on an end-bim exam, right? So the humeral fracture patterns, essentially the big thing you want to keep at the back of your mind with that is, you can fracture, so the humerus, if you're looking at it from like the shoulder down to the condal, just follow me progressively here, right? So there's the neck, there's the surgical neck of the humerus, right? Your neck is kind of like where your head curves to form the rest of your body, right? So you know, like the surgical neck, that's around the shoulder area, you can fracture there. And then if you go to the middle of like the straight humerus, you have the mid shaft, right? It's in the middle of the shaft, right? So mid shaft, and then just above those condals, you have the supra condal, right? So you can have a surgical neck fracture of the humerus, you can have a mid shaft fracture of the humerus, and you can have a supra condal of fracture of the humerus. When you fracture the surgical neck of the humerus, the nerve that's injured is the axillary nerve, right? So your deltoid terrestrial might not be gone.

So those people will have like a loss of sensation on the lateral arm, and then they'll also have trouble like AB ducting the arm, right? And then if you go to the mid shaft, if you fracture that that's a radio nerve problem, right? They'll have all these issues I've just discussed. And then if you fracture the supra condal of the humerus, that's a median nerve problem. And the reason I'm going in that order is if you notice surgical neck axillary, stash of the an A, mid shaft radio, stash of the an R, supra condella, stash, that's an M, median, that's stash of the an M. So you see it kind of spells out the word arm, ARM, and it literally follows if you follow the trajectory of your arm, right? So that's probably like a nice way to kind of remember all that, all that stuff. Okay, so that's what I'm going to talk about with those. And then I want to talk about my lopathy real quick, right? So my lopathy, right? So I don't know for whatever reason, whatever a person gets, and this I developed this point a lot more in my neural podcast, right? Like I have like eight neural podcasts, they're like super calm. That does essentially all you need plus like a question source and the four practice NV Me's for your neural shelf, right? But I mean, it's like what like couple hours of audio, super, super high yield, most of the stuff you'll see on your test, right?

But basically, if you want to know that a person has a lesion in the spinal cord, there are four hard signs that I whenever I tutor people one on one for these exams, I say like, oh, if you see one of these four hard signs, this person has a spinal cord problem. One is urinary incontinence, right? For presence urinary incontinence, usually the incontinence is an overflowing continent. So they can empty their bladder. So they'll have like a suprapubic mass or like lower abdominal pain in an NV Me question. That's one hard sign of my lopathy, okay? Remember, my lopathy means you have a spinal cord problem or adequate lopathy means you have a spinal nerve root problem, right? Again, so my lopathy one hard sign is urinary incontinence. The second hard sign is something I call a sensory level, a sensory level. So basically you pick out a level in the body, right? They'll tell you like oh, below the nipple or whatever, the person has lost all of one kind of modality. If you see that, that's what's known as a sensory level. Like, oh, below this specific level, the person has lost like pin prick below this level or like touch below this level, like all the way down. If you see that, think about a my lopathy. The third hard sign is the person having upper motor neurons symptoms in the lower extremities and low motor neurons symptoms in the upper extremities, right? So what do I mean by that? Again, if you look at the spinal cord, if you translate the spinal cord at a level, right?

The lower motor neurons at that level will be dead, right? But if you remember that, you also translate in upper motor neurons that are going to lower levels in the spinal cord, right? So those people have like lower down upper motor neurons symptoms, right? So just think the extremity and take the reverse. So if you see a person that has upper motor neurons symptoms in the lower extremities and low motor neurons symptoms in the upper extremities, right? That's a spinal cord problem. That's a my lopathy. Now, the third hard, the fourth hard sign that is like you see this, you're like, oh, yeah, this person has screwed up the spinal cord. Is if a person has three of these tracks injured at the same time on an NBME, not in the reward on an NBME, if you notice that the person has cortical spinal track problems, spinal thalamic track problems. And so cortical spinal track spinal thalamic track and also column track problems, all at the same time in one question, that's likely going to be a my lopathy, okay? That's likely going to be a my lopathy because usually whenever you're dumb, if it's elsewhere, right? Like it's, it you'll be hard pressed to on NBM Es to kill the medial and the lateral brain stems all at the same time. No, that's usually not the way questions work. So if you see a person that they've lost fine-touch vibration, perception, they've lost pain and temperature on the body, and they've also lost like they have upper motor neurons symptoms all at the same time.

Think about a my lopathy, that's a spinal cord lesion. So those are the four heart signs of a my lopathy on an NBME exam. Again, I know you may see, define why you're going to all this trouble. I promise you, this stuff is floridly high yield. I mean, I chewed a ton of people. This is like one of the concepts I go through with, I almost always go through it with a couple of people on a weekly basis, right? On a weekly basis is that I yield, right? Now, one of the things I want to talk about is what are the things that cause visual hallucinations on NBM Es? This is a high yield differential diagnosis, too. Where are the persons like seeing things that are not supposed to be there? Visual hallucinations on an NBME. The things you want to think about, one, you want to think about one of the stages of alcohol withdrawal, which is alcoholic hallucinosis, right? Those people tend to have visual hallucinations. What if they give you a question about like a grandma that took like code medicine over the counter and then persons like seeing weird stuff like monsters in the room? That's the laryum, right? The laryum, right? Remember from like anti-colonageic things, that's why you don't give anti-colonageic study out early. The laryum is also as with the visual hallucinations. And then one last thing on NBM Es is that because visual hallucinations is Louis body dementia, right?

Remember Louis body dementia is where people have, you know, Louis bodies from offers in Ukraine in the brain, but they will have visual hallucinations. And in addition to having visual hallucinations, they will also have syncopal episodes, so they keep falling over, right? Those are the three higher things on NBM Es that tend to cause visual hallucinations. And then what if they give you a question about a child that you know recently have like a viral operator infection, and then this child has like some joint pain, or send when the weird beer, but they tell you that oh, this joint is not red, it's not warm, and you know, the child is for the most part normal, other than saying oh, I had a quote a few weeks, a few days ago, my hip hurts, so my knee hurts a little. That's transient, I know, I guess you don't do anything for those kids. I mean, I'm mostly in doing things, you know, like tell them support if care, give them and says and they'll be fine. They'll be fine on NBM Es. And then, I think that's all I'm going to say. I just want to kind of keep this this part casual. Although I guess one other thing I can talk about, what if they give you a question about a child, you know, this child gets like recurrent lower respiratory infections, right?

And then they tell you that oh, like you look at an image of this child's chest, and you notice that this child, you see like like a consolidation, like almost like a streaky consolidation in the lower lung fields, or like in the middle lung fields, but usually it's in the lower lung fields on the right, okay, on the right. If you see that, you want to think about something called right middle loop syndrome, on an NBME exam, right middle loop syndrome, right middle loop syndrome for the most part, it's basically like something that it's like a diet that you want to keep at the back of your mind on NBME exams. These people tend to have other lectases, right? They tend to have other lectases, and then they tend to have like, what's this sort of thing? This is something that I think about. So they'll have other lectases and bronchiectases, yeah, that's a diet. So other lectases are bronchiectases, especially like again on the right side of the lungs, usually like lower on the image, think about right middle loop syndrome, right middle loop syndrome, yeah, that's kind of like a big thing when you keep at the back of your mind on exams.

Okay, so I'm going to go ahead and stop here because I want to run to a meeting, but as I do at the end of every tutoring session, you know, I go for one or one tutoring for pretty much any exam you take as a med student, step one, two CK, two CS, step three, pre-clinical med school exams, third year shelf exams, I have to turn up tons of people for that stuff. And then I also tutor if you're a medicine resident, I tutor for the medicine boards and the infreting exam, if you're a piece resident, I tutor for the piece boards and the infreting exam, and then I do these booster courses for step one, two CK and step three, they run for 20 hours, basically I review the most notes, the high yields in our rapid review format, usually with clinical vignettes. So when people are in their dedicated periods, usually it helps with giving them like a pretty, pretty majors score boost. Usually the first session I kind of use is to fill out the students see how they learn best and then they're remaining 19 hours. I mean, I teach you a ton of stuff in the first hour, what are many 19 hours is then like super, super targeted and I'll keep picking at your mistakes, picking at your errors, right, so that they become strengths on a test. So it's 20 hours, if you're interested in that just reach out to me either through the website or you can send me an email at divine intervention podcasts with an SADN.gmail.com.

And then if you have like a college buddy that is studying for like Genkame, OEM, Physics, Biocame, Histology, Physiology, I tutor for all those things, I tutor for the MCAT. And then if you're a med student applying to residency, so like an ERAS app or a college student applying to med school school like an MCAS app, I offer like consulting for this. So like, you know, like mock letters, mocking, I mean like rec letters, mocking reviews, editing personal statements, editing and filling out applications. Again, I've done this with tons of people. The vast majority of people have worked with a volmatch that their first choice. And again, even if you have like a tricky application like, you know, like low scores or you're an IMG or you graduated from med school many, many years ago, I've worked with people with all those problems that have all matched. Many of them believe it or not at their first choice, right? So again, I've been an admissions committee member before. So I know how these things go. I know how to prepare your application to put your best foot forward. And again, it's not just like, oh, divine only works with IM people. No, I've worked with people from practically every specialty, even vascular surgery, right? So again, if that's something you're interested in, just reach out to me and I'll be happy to point you out in the right direction.

Typically, when I tutor people like you either pay on an hourly basis or you can purchase a package of interest, any of those things, just reach out to me and again, I'll point you in the right direction. Please subscribe to the podcast. It's on Apple podcasts, it's on Spotify, it's on Google Play, subscribe to the You Tube channel. It's called Divine Intervention, podcasts and videos. And also please subscribe to the Word Press website. And again, I'll keep picking this podcast. Any support always helps tell your friends and everything. At least we have a ton of information on the podcast. It's like very comprehensive for most of the USML exams at this point. So yeah, interesting. Any of these things just reach out to me. And the lesson I'm going to give you for today is the value of is the value of quiet, the value of being quiet. Being quiet is this part of the Bible that says that a person that keeps his mouth, keeps his soul from trouble. The thing is, if you're the person that's like, talk, talk, talk, talk, talk, talk, talk, talk, all the time, you very likely want to see something that is inaccurate or you're very likely to see something that a person can use to get back at you in the future. The thing is, if people don't know your story, then they cannot like blackmail you or do this or do that to you. So it's just one thing, that's very helpful, very helpful life skill to have. Just keeping a low profile and keeping quiet.

The thing is, if you keep quiet, you are more observant. Again, I'm not saying to be like a hermit or be like a person that's not a team player. No, that's not what I'm saying. That's not what I'm saying. That's not what I'm saying. That's not what I'm saying. But the thing is you don't have to be the person that controls the conversation all the freaking time. Just watch your words. Be fuel with your words. When you're fuel with your words, it's almost like you're building up potential energy within yourself. Just don't be the one that talks all the time so you don't get into trouble. Because again, in the multitude of words, lies come. In the multitude of words, you see things that are not ideal. That's just my life lesson for today. Thank you for listening. I'll see you in the next podcast. God bless you. Thank you.

Coxac-E-B (Note: Coxac-E-A causes hand-foot-mouth disease).

Doxorubicin.

Wrist drop (and potential sensory loss over the dorsal aspect of the hand, first three digits).

Urinary incontinence (specifically an overflowing continent), Sensory level, Mixed UMN/LMN findings, or involvement of multiple tracts (e.g., corticospinal and spinothalamic).

Alcoholic hallucinosis, Strychnine poisoning, and Lewy Body Dementia.

Right Middle Lobe Syndrome (associated with other lectases/bronchiectasis).

ARM (Axillary $\rightarrow$ Surgical Neck; Radial $\rightarrow$ Mid Shaft; Median $\rightarrow$ Supra Condylar).

A spinal cord lesion/myelopathy.

Trastuzumab causes reversible cardiomyopathy; Doxorubicin causes irreversible cardiomyopathy.

Radial nerve.

The radiologist should call the referring provider (or have a secretary reach out) immediately.

ARM (Axillary $\rightarrow$ Surgical Neck; Radial $\rightarrow$ Mid Shaft; Median $\rightarrow$ Supra Condylar).

A spinal cord lesion/myelopathy.

Trastuzumab causes reversible cardiomyopathy; Doxorubicin causes irreversible cardiomyopathy.

Radial nerve.

The radiologist should call the referring provider (or have a secretary reach out) immediately.