DIP Episode 480 - USMLE Step 2/3 Rapid Review Series 101

Welcome, my name is Divine. This is episode 480 of the Divine Intervention Podcasts. Today's podcast will be going over the Rapid Review series for the USMELIS step 2, CK step 3 exams. And this is going to be series 101. Big milestone there. So let's just get right into it. So what if they give you a question about a 22-year old male and he comes into the emergency room because for the past 12 hours he has been having severe knee pain. And they tell you that on physical exam the right knee is red, it's warm, it's erythematos. And then they ask you for your next best step in management. And obviously in that case you're going to think of Athos and Tses. But let me maybe present a different question to you. What if they tell you that this person that they show you the maybe player video or they show you pictures of the person's skin. This is how the USMELIS will do it. And you notice that this person has so many wounds on their skin. What should you be thinking about here? Well, I really hope you're saying that this person looks like they have a Les Ney Hansengrim. So when the world is Les Ney Hansengrim, well many of us have probably heard of it. You're basically going to see a person that has self-mutilating behavior and they have hyper-recemia. So this person obviously they have gout and I'll explain the pathophase they have gout. Well, this gout that they have, right, if you check their joint because really for a person comes in with a red hot tender joint.

The first thing you really want to do is to perform a Throcentesis. So if you perform a Throcentesis and get some fluid from this person, obviously you're going to see these needle shaped, right? These needle shaped negatively by a French enter crystal. So what's the pathophase behind Les Ney Hansengrim? Well, the pathophase is that you have a deficiency of an enzyme, a mutation known as a HGPRT, a one in the world of HGPRT Stanford. Well, HGPRT stands for Hypoxanthin Guanin, phosphorybosotransferase. Hypoxanthin Guanin, phosphorybosotransferase. When you have this screwed up, basically, your purine of salvage pathway is not going to work very well. So you can be able to salvage purines. So because you can not salvage purines, you will just be shunting everything towards the production of your acacid. And you're going to get in some very serious trouble as a result of that. So again, if you see a person that is very aggressive to themselves and they have hypoxanthin, they have gout, they have insensisidins, right? And sometimes they may not tell you that they are aggressive to themselves. They may just give you a derivative of that. Like for example, they can give you a picture and you'll see all these wounds on your skin, right? When you see something like this, again, think of Think of Lish Nyhan Syndrome, L-E-S-C-H-N-I-N-Y-H-A-N. I'm pretty sure this disorder, believe it or not, was discovered by a medical student back in the day.

I remember I think we were having an lecture when I was in med school back then. And there was a medical student from my school, you know, about obviously years before I attended, that discovered this together with I think some attended. And it's an excellent, recessive disorder, you know, is not something that I just put that medical student association to see if that can be a key you can use to remember, the key facts of this disorder in the future. Just think of some overachieving medical student that discovered a disease, you know, in people that would be young on your exam that are aggressive to themselves and have got, right? So it's an excellent, recessive disease. So please, please, please do not pick this for a person that is female on your exams. This is going to be a problem exclusively males on your test. That's very, very, very important. Okay, and then what if they give you a question about a 65 year old male, they tell you that for the past three months has lost a bunch of weight. And then they tell you that he tells you that he has had a lot of redness of his urine. And they tell you that this month has smoked three packs of cigarettes daily for the past 40 years. And then they then tell you that a biopsy was performed and they show you a histological image. And you know, by the way, histological images do pop up on the USM Ls.

But again, in my experience, if you read the question well, you can almost predict, even if you don't know what the histology is, you can predict that weight. This histology, they're trying to lead me down XYZ path. So they show you like a, they show you like a rhino biopsy. And you see a lot of clear things, you know, you just see like a lot of nuclei and you see a lot of clear white around it. And then the ask what's your diagnosis? Well, I would really hope you're picking the answer that says rhino malignancy. So let's talk about this in a little more detail. So what's going on with this person? Obviously, this person has a rhino cell carcinoma. And there are many ways they can test this thing, right? They can tell you a person has like a materia and then you they will give you that this person has a big time polysiphemia. Because rhino cell carcinoma can make evil in a panioplastic fashion. And when he makes that erythropoetin, that can cause you to have a polysiphemia. That's one. So you may wonder define what I show you on these on this histological image. Well, it will be clear cells many times on the histology when a person has rhino cell carcinoma, you're going to see clear clear cells. Now, so if you may be saying, okay, define how did you expect me to figure out that wait, this person actually does have a rhino cell carcinoma. Well, here's even if I didn't know the histology because that's the thing many people sweat histology. But many times you can be fine.

If again, you just apply a little common sense to the question that you're that you're reading. And just many people just get all emotional with these questions. They're not strategic. They're not methodical. I didn't get in a lot of hot hot water, but let me explain something here. If you look at this, you get in a question about a person that is old. That's number one. Number two, you get in a question about a person that has lost some weight. Okay, so that there's this probably cancer. Number three, you're told that the person has hematuria. Okay, well, that's going to narrow things. It's going to level the play field out pretty well. Right? It's going to pretty much limit your answer to rhino cell carcinoma or bladder cancer. And then number four, you're told that this person has smoked three packs of cigarettes daily for 40 years. That's a 120-pack year smoking history. Well, guess what? Smoking is the biggest risk factor for rhino cell carcinoma and also bladder cancer. Right? So just putting all those things together at least for me, taking an exam, I'm like, oh, wait. This is either going to be rhino cell carcinoma or bladder cancer. And then if you're playing odds, if you're thinking in terms of, you know, you're just like, wait, which one do have I usually seen being tested on many US Emily exams or many practice tests of taking? It's probably going to be rhino cell carcinoma. So guess what? Rhino cell carcinoma is going to be the right answer. Right?

And, you know, so that's the thing. So notice how I just used multiple clues to get to the answer. Even if you don't know the histology, again, this is something I teach people and is this whole concept of predictive, predictive question answering. Right? Where even if you don't know the image, they're presenting to you or the video, they're showing you or the audio, they are three in your way. If you just read a question well and think inductively, right? Think with wisdom, think with some reasoning, right? Just a little common sense and stop being emotional. You can usually arrive at the answer without a lot of stress. I mean, maybe like, oh, divine, your making it sound too easy. But to be honest with you, it kind of is. It kind of is. It's just many people to get emotional and they are not systematic like at all with any of these, any of these US Emily exams. So this person has renal cell, of course, in all right? This person has renal cell, of course, in all. And again, I said that, man, they got a biopsy. So just be careful. What kind of biopsy do you get if you suspect renal cell, of course, in all? I really hope you're not saying that, ooh, let's just biopsy the mass. No, you don't just biopsy the mass. No, what are you going to do? The thing you're going to do is you're going to literally remove the entire kidney that is suspicious. And then that entire kidney is the biopsy specimen.

Remember, renal cell, of course, in all is one of those cancers that you do not biopsy. The biopsy specimen is the whole organ. So if you ever want to biopsy renal cell, of course, you know, you need to get an effrectomy, you need to get an effrectomy to get your sample. Okay, don't go and say, oh, wait, let me take just a piece of the tumor. No, that is never the right call with renal cell, of course, you know, okay. Now, what did they give you a question about a patient? And they tell you that, oh, this is a three year old female. They tell you that she has a skin hypopigmentation, like general life skin hypopigmentation. And that, you know, she's three years old and she's developmentally delayed that she can. She has a very poor limited vocabulary. And then they tell you that she has an unusual smell, right? And of course, what answer of the USMEL is support? They will say, and they will say, oh, which of the following must be, which, let me just put it this way. They will put a bunch of answers and they will put an answer that are released to hearing loss, of course, right? Again, the USMEL is a pretty classic in many of the things they do. They will put an answer that says something related to hearing loss and getting a geometry, right? And then obviously, they will put an answer choice that relates to PQ, you know, phenokytonuria, right?

So maybe let me go over something here because again, these are a rapid review, but I really want to try to tie some things together for you here. So why may they put an answer that are released to hearing loss with this question? Well, they're going to put it because whenever you see kids that are delayed from a language perspective, one of the first things you think about is hearing loss. That's a very common concept that they love to test on the USMEL exams. Because if you think about it, if you cannot hear, then you cannot for need, if you cannot hear, you cannot speak. That's just a truth, right? Sometimes when you see a child that is completely normal in every other department, but their language is delayed, your next step on the USMEL exams is to get a geometry, just get some kind of hearing screen, right? Because many times when kids have poor language development, they actually do have hearing hearing loss, right? But this person just has a little more than that. That's why it's important, right? You want to again think globally on your exams, right? You see this person has poor language development, they have a developmentally delayed, they have general like skin hypopegmentation, right? And then they have an unusual order. And again, to be honest with you, the USMEL is, didn't even give you this unusual order, right? This is just me being kind of nice. It's a Thursday, candy end of the month, let's be kind to people today, right?

But the USMEL is, they will not always volunteer that information, right? I mean, maybe like, oh, divine. So how are you getting at PQ? Well, I'm getting at PQ, because this person has this unusual order, they have skin hypopeg, honestly, even just the developmental delay and skin hypopegmentation, generalized skin hypopegmentation should have taken you straight up towards PQ. You think, honestly, you don't need the order, you don't need the order, because that's one thing that puts people in a lot of trouble on the USME Ls. They're kind of expecting these picture perfect questions, they're like, oh, divine, I want these questions that are like gift wrap for me. I wish you all the best. No, they're not going to give you gift wrap questions. What are they going to do is they're going to give you questions. I need to put the clues you get together. It may be an incomplete thread of clues, but many times you'll still lead you overwhelmingly to the right answer. So how do they arrive at PQ? Again, developmental delay, the skin hypopegmentation is me describing albinism. Wait, what? Yeah, it's me describing albinism, because I also put maybe like, put divine. You know, skin hypopegmentation, naming the ash leaf spots of tuberous chlorosis. Okay. Well, the thing is the ash leaf spots. Look at the term ash leaf spots, ash leaf spots, ash leaf spots. So that means it's not the whole skin, right? It's not the whole skin, right?

So seeing that is generalized, the USME Ls are pretty much describing albinism. So this albinism, developmental delay, all those things you put it together, that's PQ. I remember PQ is a deficiency of phenol alanine hydroxylase. Phenol alanine hydroxylase. So when you have a deficiency of phenol alanine hydroxylase, that's how you get PQ. It's an ultrasonry-sensitive disorder. Although remember, you can also get PQ in a different form. Well, how can you? Well, the way you can get PQ in a different form is if, for example, you have, because phenol alanine hydroxylase uses a cofactor. That cofactor is known as BH4. BH4. Tetrahydrobiobtering. Tetrahydrobiobtering. If it's not there, then guess what? Phenol alanine hydroxylase will not work. So you can get PQ if you don't have the cofactor. And that cofactor is made by a special enzyme known as CHB reductase. Tetrahydrobiobtering. Reductase. Tetrahydrobiobtering. Reductase. So, it's made by that enzyme. So if that enzyme also does not work, you can get PQ. And again, there are many ways they can go with PQ. Or why does this person have this skin hypobicmentation? They can ask you a question from that. And again, it's because they cannot make melanin. It's literally because they cannot make melanin. Because if you think about it, that PQ pathway, you go from phenol alanine to tyrosine. And that tyrosine throughout series of steps is made into melanin. So if you don't not make melanin, you're going to have skin hypobicmentation.

You're going to have skin hypobicmentation. That's what I'm saying. And then they may ask you what should be supplemented in this person's diet. Well, I hope you're going to see, obviously, you're going to put that answer that says, supplementile phenol alanine. And many people, you know, in the heat of an exam, in the emotional exam, do pick that answer and then you'll notice that, gee, how did I get this stuff wrong? No, you're not supposed to supplement phenol alanine because guess what? These people literally lack the enzyme. So since they lack the enzyme, if you give them phenol alanine, it's almost like you're worsening your problem. They're not able to metabolize that phenol alanine. They'll build up cause even more symptoms. But what are you supplementing these people's diets? You need to supplement the stuff that comes right after phenol alanine. Well, what is that stuff? That stuff is going to be tyrosine. Tyrosine becomes essential. Because normally tyrosine is not an essential amino acid. Because your body can make it on its own. Your body literally converts phenol alanine to tyrosine with phenol alanine hydroxylase. But if you don't have phenol alanine hydroxylase, you cannot make tyrosine anymore. So tyrosine becomes an essential amino acid. So these people, these people that have PKU, tyrosine absolutely positively needs to be supplemented in their diets. Okay? Tyrosine needs to be supplemented in their diet.

Please don't pick the answer that says to supplement phenol alanine. Sounds like an intuitive thing. It'll be flat out wrong on your exams. Okay? It'll be flat out wrong on your exams. And I guess this is what I'm talking about. Albinism. Let's maybe ask ourselves what are the classic situations on the USME Ls? Are we really test albinism? And one way they're going to test this is again, if a person has PKU, that's one scenario. And that scenario can be a person that has albinism. And they have a lot of recurrent infections. Well, that's going to be Chidiyaki Gashin. Chidiyaki Gashin. Chidiyaki Gashin. Chidiyaki Gashin. Okay? Okay. And so kind of put a lot in that albinism concept in your mind. Or something that they can test in many, many, many, many different ways. Well, the person can just have good old albinism. Right? Good old albinism where, you know, they have like a tyrosine. It's deficiency. So they're not able to make, they're not able to make melanin. And then they get in a lot of trouble. Okay? So again, if you love the integrations I'm giving here, I think you really love the courses that I teach. I really have a class study like literally the first day of September, literally tomorrow. It's an MBB test taking strategies classes for step one to step three. And then about two weeks from now, I have a step one class. It's a 25 hour classes for people taking step one or people that are taking step two, step three. They have very poor foundations from step one.

Let's see, you really struggle during your divi-gate period for step one. Or you barely pass step one or you've taken step one multiple times. You really benefit a lot from that class. And then the week after that, I have a 20 hour step, two step three course. And then actually, I believe it's on the 15th and the 16th, if I'm not mistaken, I have a biostatistics class and a social sciences and ethics class. Those are first step one to step three again. Lots and lots and lots of people are taking these classes. And they have found them to be tremendously helpful. I get emails every week. I've got in tons of emails this week. A few people that have got in like 270s, 260s, very, very high scores. And these are all people that took my course. Okay, so let's jump right back into it. Now, what do they give you a question about a person? And they tell you that this person is a landscaper. And this person is a landscaper in Wisconsin. And this person has been having fevers, fever, fever, fever, fever, fever, fever. Right? But they tell you that this person doesn't have this person, because we have fever, fever, fever, fever. Right? And you also notice that, you know, a person has been having chills, having a lot of myeloges, having a lot of headache. Right? And they tell you that this person just has a mild rush on their trunk. But I do remember being bit by any kind of tick. Right? And then they tell you that, oh, they show you a histology image.

And this histology image, they tell you that, you know, a smear, right? A peripheral blood smear shows the following result. Right? And in that peripheral blood smear. So this is one of those rare situations on the exams where knowing exactly what you're dealing with kind of matters. Right? So show your blood smear. And then they will show you like a nucleus that looks like a kidney bean shape. And then you see like one circular thing next to it. And you see something like this. What should you be thinking about? I really hope you're seeing divine. I think this person has perluciosis. You're like, whoa, the vines slow your roll there. What do you mean by eluciosis? Okay, so let's explain. Right? The thing is this is a time-honored thing our friends at the MVM is due to people all the time. Right? And they know that people will massively struggle with this. So it's just something you want to kind of keep at the back of your mind. And that's this whole anaplasmosis, early ciosis, babisiosis, business. Right? So how did I use the clues here to know that it's early ciosis? Well, first things first, this person works in Wisconsin. Right? That was consen association. Just that Midwest association is pretty strong for early ciosis. Right? Notice I didn't see anything about the new England area. The new England area is going to be more where you're going to see babisiosis, anaplasmosis, and line disease. That's where you're usually going to find those things. Right?

Because remember anaplasmosis, babisiosis, and line disease, right? And then you're probably going to find a new England area, which is where you're going to find the new England area. Right? So the new England area, which is a new England area, which is a new England area. Right? So the new England area is a new England area. So the new England area is a new England area, which is a new England area. Right? So the new England area is a new England area. Right? So if you're a Milwaukee Box fan, you know, Wisconsin, just kind of make that mental mental association. That's one. But the thing is, honestly, the USML is sometimes they'll put one crazy clue and then you'll put a bunch of like one crazy clue that doesn't fit the pattern. Right? So say for example, like right in an early ciosis question, making about new England, but pretty much everything in the question is like specifically going for early ciosis. Right? So how do you differentiate these things? The first thing is, if they want you thinking of early ciosis, the person may have a rush, although rushes are not always common with early ciosis, but who to have early ciosis, they may have a rush. They may have a rush. In ana plasmosis on your exams, they should not have a rush. That's something I kind of want to keep out the back of your mind on exams. In early ciosis, they should have a rush. They quote, let me put it this way, they could have a rush, not always, but in ana plasmosis, they should never have a rush.

Now, this is one of those situations where the biops, like the blood smear is actually quite helpful. Right? When people have early ciosis, we will have early ciosis and ana plasmosis, you're going to see more reala. Basically, these things look like more berries. You're going to see these more berry-like inclusions in the cytoplasm. These are not inclusions in the nucleus. If you're thinking of inter-nucleus inclusions, they are thinking about CMV, outside of nucleus, CMV. No. In this case, we're thinking about inter-cytoplasmic inclusions. They are morally, they look like more berries. The thing is, the blood smear many times is the dead-giver one, the SNL is not awake, and they don't have ana plasmosis. In ana plasmosis, they morally, they grow inside neutrophils. The thing is, but you can use the little information you have to arrive at the greatest number of results that you can. For example, neutrophils. Many people have heard of hyper-segmented neutrophils with B12 or fully deficiencies. The nucleus of a neutrophil is going to have many segments. You're going to have multiple segments. You're going to see almost like four nuclei. They're kind of strings together. That tells you that this is a neutrophil. If you see morally, green inside neutrophils, that's an ana plasmosis. In early care, those morally grew inside mono-site. Remember mono-site at the ancestors of macrophages.

Macrophages by definition, usually on the USML Es, you're going to see like a kidney-beenshaped nucleus. Literally the nucleus look like kidney-beenshapes. If you see that, that's absolutely positively relicoses. They say, oh, divine. How about... Babysiosis, I'll talk about that in a bit. But also, don't forget, another key difference in point is what transmits these things. What transmits these things. An aplasma is carried by the exodistic. I already said that already. But early care is carried by the lone star tick. Early care is carried by the lone star tick. How in the world do you treat early-chieoses? Early care is carried by the lone star tick. Although an aplasmosis is also carried by the lone star tick. So early care is carried by the lone star tick. Let me just say something here. Friends at the NVM Es, sometimes instead of using the term mono-site or using the term macrophage, they may also use the term mono-nuclear cell. If you see the term mono-nuclear cell, I want you to think about a macrophage. Again, the thing is, you may wonder, why do you always on your podcasts love to give many different names for the same thing? I'm not doing that because I like to hear myself talk. I'm doing that because that's something the USML is does. They do all the time. This is something that I do very heavily with my review courses. And I teach my test against fellow Gis-class. The USML is the love derivatives. They love derivatives.

They know that we live in anarchy generation. So what do they do these days? They tick what you know and they just describe it in multiple ways. Or they tick what you know and put something that is little off-putting. For example, who is going to be taking step two, step three and expecting some histology image? But the thing is, even if you don't know the full histology image, you can put two and two together. Basically, the USML is the only way to be able to arrange pieces, almost like pieces on a chess board and get to a final solution. So again, you can just be thinking in one dimension for your USML exams. I promise you, you're in for a pretty strange exam. That's just FYI. So that's the thing. So that's why they love these derivatives thinking. Because think about it. Why don't make everyone's life easier and just call it a monocyte? But no, they can call it a monocyte, they can call it a macrophage, they can call it a mononuclear cell. Same thing with an aplasma. You know, they can say, oh, neutral fill. They'll tell me everyone's like easy. They can call it a polymorphal nuclear lucosite. So another name for a neutral fill is a polymorphal nuclear lucosite. Well, why is that? Because if you look at a neutral fill, they have this segmented nucleus. So look at the name polymorphal. So polymorphal, poly means multiple. Morphal means morphology, nuclear lucosite. So that means, oh, with this lucosite, the nucleus has multiple morphologies.

That's just something that tells you that, oh, wait, I'm dealing with a neutral fill. Okay. So let's talk about a babesiosis. Because I said I'm going to talk about babesiosis. But what's the deal with babesiosis? Number one, that one is actually pretty easy to differentiate. It's carried by the exodistake. But it doesn't affect any white blood cell. It goes after red cells. So we're going to have babesiosis many times on your exams. They will absolutely positively have anemia. They'll usually have anemia. So they may give you like an indirect hyperbularbeneemia. So you see a person that goes to the New England area, why they've been bitten by a tick? Are you seeing direct hyperbularbeneemia? You really shouldn't be thinking about like an aplasma or a Lyme disease. No, you really want to be thinking about babesiosis. Because babesiosis goes specifically after those red blood cells. Remember on thisology, you're going to see that multis cross pattern. You're going to see that. You're going to see that multis cross pattern. You're going to see that multis cross pattern. Okay, I think I should probably go ahead and stop here. I feel like we've kind of hit on a lot of stuff today. But again, I do hope you find this podcast to be helpful. Again, I offer one I want you to read for all the US Emily exams and medical school exams and shelf exams. I help with ear-ass applications, personal statements, rec letters, mock interviews and things on that sort.

I offer review courses for step one, 25 hour course, step two, step three or 20 hour course. And then I have classes for step one on the way to step three. They're two and a half hour in BME testing and strategies class, the four hour bio statistics review on the five hour social sciences ethics and quality improvement class. Again, many people have taken these classes and they've done extremely well on their exams. And the classes are not lectures. They're almost exclusively all scenarios. Because that's something that's more realistic to what your exam will look like. And then I have these podcasts on the major apps Apple Google's 45 have a You Tube channel, Divine Intervention US Emily podcast and videos. That's where you can find the videos that I've made. And then finally, I have a new website called Divine Intervention, Life Lessons.com, Divine Intervention Life Lessons.com. So just check that out. Many of you don't know Christian. So from a biblical perspective every week, I upload two podcasts that address a life lesson. We have more than, I think, 210 podcasts on there right now. And there's actually an Apple podcast associated with that called the Divine Intervention Life Lessons podcast. So thank you for listening to me today. And again, I promise you this stuff I went over in this podcast. Maybe like me. The why you were a pretty basic sciencey today.

What I promise you, friends at the US Emily's first step, two step three, you'll be coming a little more basic sciencey, especially over the last few weeks to month. So just FYI, something you want to keep at the back of your mind. Well, I will see you in the next podcast. That'll be episode 481, God willing. Have a wonderful day. God bless you and bye for now.

Deficiency in HPRT (Hypoxanthine Guanine Phosphoribosyltransferase), impairing purine salvage.

Males, because the HPRT gene is X-linked recessive.

Older male, weight loss, hematuria, and a history of smoking.

The entire organ (nephrectomy), not just a small piece of the mass.

Supplement Tyrosine; do NOT supplement Phenylalanine, as this worsens the metabolic block.

Ehrlichiosis (or Anaplasmosis), transmitted by the Lone Star Tick.

Infection targeting red blood cells (RB Cs) resulting in multishaped cross patterns.

Hypoxanthine Guanine Phosphoribosyltransferase (HPRT).

Self-mutilating behavior, gout, and hyperuricemia.

Older male, weight loss, hematuria, and smoking history.

To prevent sampling error and ensure adequate staging of the malignancy.

Tyrosine; because it becomes an essential amino acid when PAH deficiency blocks its synthesis from phenylalanine.

Ehrlichiosis (or Anaplasmosis).

Infection targeting red blood cells (RB Cs) showing multishaped cross patterns.

Hypoxanthine Guanine Phosphoribosyltransferase (HPRT).

Self-mutilating behavior, gout, and hyperuricemia.

Older male, weight loss, hematuria, and smoking history.

To prevent sampling error and ensure adequate staging of the malignancy.

Tyrosine; because it becomes an essential amino acid when PAH deficiency blocks its synthesis from phenylalanine.

Ehrlichiosis (or Anaplasmosis).

Infection targeting red blood cells (RB Cs) showing multishaped cross patterns.