DIP Episode 486 - USMLE Step 2/3 Rapid Review Series 103

Welcome, my name is Divine. This is episode 486 of the Divine Intervention Podcast. Into this podcast we're going to be continuing the Rapid Review series for the US Emily Step 2 CK. Step 3 exams. It's going to be series 103. Let's get right to it. What if they give you a question about a 79 year old female? Did you tell you that she's brought to the office because she recently passed out? And you're told that she has this ejection murmur at the right or personal border. Then you're told what is the next best stepping in diagnosis. Obviously without thinking too hard about this, it sounds like this person has a erotic stenosis. And maybe like Divine, you just say the person has an ejection murmur. It even tells us if it was a stolycoidastolic what's going on here. Well, the thing is this question give you too many patterns to make you... It doesn't seem very wise to neglect the erotic stenosis. First, it's an old person. You see the person had a syncopal episode. Erotic stenosis classically on the US Emily's when it causes symptoms. It's usually going to be syncopy or going to be like an general symptoms. So, we see the person is really old. You see a really old person with like an ejection murmur? It's probably going to be erotic stenosis, right? And when you know that erotic stenosis, again, it's a stolycoidjection murmur. And typically, we're going to hear it in the right or personal border, which makes sense.

If you analyze the direction of flow, the order brings blood from the left ventricle. And remember that the left ventricle is sort of kind of on the left side of the body. As blood is leaving the left ventricle and going into the arch, it takes off towards the right. It's like rightward oriented. So, if you have a stenosis of the erotic valve, you will hear a rightward oriented systolic ejection murmur. That's why it's the best at the right or personal border. If you really map out the anatomy of the heart, you see it makes a ton of sense. Now, one of some other things you may see with an erotic stenosis question, before we talk about the management and workup and whatnot, right? Again, first thing is first, it's a systolic ejection murmur, right? Because you really feel the effect when you're trying to eject blood from the left ventricle. So, that's in systolic ejection murmur. And many times they'll tell you that the presence of the urinary pulses are diminished. So, when you try to feel the urinary pulses, it'll be really, really hard to feel. They're going to be delayed. They're going to be diminished, right? Because blood is having a lot of trouble getting out of the left ventricle. So, that blood is not really going into the aorta and subsequently not into the grotesque. So, they're going to have like a delayed diminished urinary pulses. And you may also notice that they may have concentric hypertrophy of the left ventricle.

So, because it's so hard for blood to leave the left ventricle through the aorta, the left ventricle gets big and beefy to the regenerator of force to get blood out. So, you have concentric hypertrophy where you lay down your sacramenies in parallel. So, you're ultimately going to develop like a systolic heart failure because basically, the cavity size of your left ventricle gets smaller just because of all the muscle in the way. Okay. So, what are you going to do? Well, obviously you're going to do some kind of echocardiography. Whenever a person has a murmur that is symptomatic, you typically have to get some kind of echocardiogram. In the wonder device, what kind of echocardiogram do we get? Typically, we want to get a TTE, a transphoracic echocardiogram, a transphoracic echocardiogram. Okay. Transphoracic echocardiogram. Right. And many times that, you know, echocardiogram is going to show you the valve elitio. So, in this case, a person is going to be, you're going to see the eiotics stenosis. And many times when we're managing eiotics stenosis, you're going to check the valve area. You're going to check the valve area. So, how in the world do we manage eiotics stenosis? Well, obviously the person doesn't have symptoms. You don't usually have to do anything. But if they have symptoms, so like, say, for example, they have heart failure symptoms. So, let's say the ejection fraction is less than 50%. And I've talked about how you can get to heart failure with that.

Or they have angina or they have in syncopal episodes. You have to manage it. You have to manage it. Another way detail you may see is the valve area, although this one is a little lorry-yield. But if the valve area is less than one centimeter squared, that's also kind of worrisome. In those circumstances, you're going to make sure you go ahead and replace the valve. Because you remember in eiotics stenosis, the problem is you have calcification of the valve. So, most times you just have to go ahead and change out the valve. Just go ahead and do a valve replacement. Because again, remember the pathophys is calcification. And I think I've said this another podcast, but just bears repetition. Whenever you're a person having eiotics stenosis, in their late 40s, 50s, many times you're thinking about a bicospediotic valve. Remember bicospediotic valve? We tend to find that in Turner syndrome. Basically, you have, because normally the eiotic valve has three cosps. But if you have a bicosped valve, you're not have two cosps. I just like to think of it as like two residents during the job of three. Those two residents are going to burn out very quickly. So, same thing happens with eiotics, a bicospediotic valve. The calcification that happens in eiotics stenosis is just going to be accelerated. In a person that has a bicosped valve, because two cosps during the job of three cosps. So, the calcification will be accelerated. It will be pronounced.

And the person is going to get in a lot of trouble. The person is going to get in a lot of trouble. Now, one thing that I just maybe want to throw in here, because for instance, at the US and the US, they're pretty smart. They're pretty smart. So, they can make this a physiology question and make up a bunch of hours. And that can really mess a person up. So, let's not just talk about eiotics stenosis from the classic stuff everyone knows. But let's maybe discuss a few hours with eiotics stenosis. So, first things first, what's going to happen to your cardiac output? When you have eiotics stenosis. Well, obviously, your cardiac output is going to be diminished. Because if blood is not coming out of the left ventricle, like, quickly, then blood is not going to the eiotic output. Your cardiac output is going to get crushed. Your cardiac output is definitely going to get crushed. Now, what happens to the diameter of the area of the eiotic valve? Well, it's going to go down. It's going to go down. Because that's stenosis. That's why it's costanosis. That means there's a narrowing. So, they can frame this in many different ways. They can frame it as the radius. The radius is going to be diminished. The radius is going to be diminished. The valve area is going to be diminished. In fact, one of the ways we define eiotics stenosis is, say, for example, the person has, again, a valve diameter of a valve area of less than one centimeter squared.

That's taking us severe eiotics stenosis. We need to do something in that circumstance. Now, let me ask you this. What's going to happen to the velocity of the blood coming through the yore? What's going to happen to the velocity of blood coming through the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore? What's going to happen to the yore?

What's going to happen to the yore? What's going to happen to the yore? And to not just target it but to come out with greater speed, what do you do? Just going to put your finger at the tip of the hose, cover up some of the area. As you cover up some of the area, the velocity of the water coming out of the tip of the hose goes up quite significantly. So that's the same thing that happens in the yore? It's basically the blood that's coming out of your left ventricle. So that's coming out with higher speed because you've had this progressive narrowing of the lumen of the yore? So the yore, the blood going through the yore valve, the velocity is going to go up. And that's pretty high autolo. In fact, that's, believe it or not, one of the criteria that's also used to manage aortic stenosis. We say, wow, severe aortic stenosis is if your aortic valve, you know, the blood coming through the velocities like over 1 m per second, remember, velocity is measured in meters per second. So, you know, in those circumstances that does not go right? It just tells you that man, the snorling is too bad. And these are all things we can easily track, we can easily track this with imaging. So since it's something that's easily trackable, you can use it as a guide as to, but I got to manage this person or not. Again, honestly, this specific criteria for valve area less than this, velocity greater than that, you don't really need to know that, honestly.

That's more for like internal medicine boards, but understanding the concept is very, very helpful. And then another thing that may also help you is just kind of keeping in mind, they may ask you, oh, what will happen to the transvolvular gradient? Transvolvular gradient. Well, the transvolvular gradient, I would hope you're saying divine is going to go up. So let me explain what in the world is the transvolvular gradient. Well, the transvolvular gradient is basically the pressure difference between the left ventricle and just after the ureth valve. That's the easy way to think about this. That's the rough easy way to think about this. Transvolvular gradient. Look at the name transvolvular. That means it's the gradient. So that means the difference in pressure between across the valve. So just before you hit said valve, it gave the left ventricle and after it traverse said valve, you know, just distal to the ureth valve itself. The transvolvular gradient is going to go up again. Why is that? Well, again, you have a stenotic valve. So because you have a stenotic valve, it's really hard for blood to leave the left ventricle. So the blood in the left ventricle for you to try to come out is going to be pushed with such great force, such great pressure. So the pressure inside the left ventricle is going to go up a lot. Right?

But since almost like a little trickle of blood is coming out each time from the aortic valve, that blood coming off on the other side has very low pressure. Right? It has very low pressure on the other side of the problem. Right? So before the problem, I just like to think of aortic stenosis as a log jam, as a traffic jam. Right? Think about it for those that live in New York or California, probably have a very intimate knowledge of stuff like this. But the thing of this stenotic valve is like a semi that has stepped over on the highway. Before the semi, before the truck that has stepped over on the highway, you know, there's this huge traffic jam. But boom, the moment you go past that truck, you're like, gee, this highway looks so clear and clean because there's this huge backup. Right? So basically the pressure is proximal to the stenosis or high. The pressure is distal to the stenosis or low. So that's why the trans-volvular gradient goes up. In fact, as aortic stenosis gets more severe, the trans-volvular gradient should go up. Again, I know you mean some of you may not have heard of aortic stenosis in this light. But I promise you this is a light you want to understand. Even for, I mean, this is a step to step three podcast. But honestly, even people that are taking step one, this is these are principles. You want to make sure you understand because they can easily make these things ours. That's that's honestly the truth. That's honestly the truth. Okay. Okay.

So maybe one thing I should, I think, do that may be helpful is talking about some buzzwords related to these valve-vular problems. The buzzwords I'm just going to mention is this. Number one, remember I said aortic stenosis is the classification of the valve that causes the problem. Number two, when a person has a micro valve prolapse, the big buzzword you want to make sure you know is that this person has a mixed sum of the situation of the valve. And then another thing to kind of keep in mind is if a person has aortic dissection, aortic dissection, a bunch of disorders like urnus downloads, warfans, your tightest with tertiary syphilis, the pothophys there in those circumstances is going to be, the pothophys usually is going to be a person that has an assisted medial necrosis. So the media of the artery, necrosis, necrosis or degenerates, so it's easy for blood to just rip through that into the media and cause a lot of problems. And I guess if you're comparing aortic stenosis to mitro stenosis, because many times if you're testing valve-vular issues, usually focus on the mitral and aortic valves. If you're looking at mitro stenosis, obviously the big message there is, typically if you're looking at mitro stenosis, the murmur is going to be heard at the apex and you're going to hear an opening snap. It's going to be a dastolic murmur at the apex at an opening snap. So why is it a dastolic murmur?

Well, it's a dastolic murmur because you feel the effect when blood is trying to go from the left e-trum to the left ventricle. Well, blood is filling the left ventricle, that's clearly, clearly, clearly dastily. So it's a dastolic murmur with an opening snap. And it's heard based on the apex. The apex is where you hear a lot of mitral murmurs pretty well. And the thing is, there are some salient difference and obviously going to do an echo cardiogram. If a person is symptomatic, you're going to do an echo cardiogram. Now, the thing is, the management of mitro stenosis is a little different compared to aortic stenosis. Well, the thing is there's lots of very good integrations you can make here. So it's something I would kind of know and make sure you understand. So again, if a person has mitros stenosis and they have no symptoms, you don't have to do much of any treatment. But if they're symptomatic, right? So let's say they have in heart failure symptoms, they become insured of breath, they become in dysmics, right? In those circumstances, you want to do something called a valve-yloplasty, a valve-yloplasty, a valve-yloplasty, a valve-yloplasty, not necessarily a replacement. Don't get me wrong, can you replace the mitro valve? You absolutely can. But I will see on, for purposes of the USMEL exams, it makes more sense to do a valve-yloplasty.

You know, every time they see coming in your heart, but most times we do valve-yloplasty, do the valve-yloplasty, that's preferred just generally to a mitro valve replacement, because the valve-yloplasty works extremely well. Although one classic, because in a valve-yloplasty, essentially, what you're trying to do is, basically dilute the valve with a balloon, it works pretty well. You know, the outcomes are pretty great, even for years after a set procedure. But one thing our friends at the USMEL exam, through your way on an exam, or this is something I can easily see making a tweet to a surgery show for example, is what is like the acute complication of this management step of this valve-yloplasty. And the big thing I want to think about is mitro-rigorge. The thing is, it's one of these things that is easily testable, because it almost makes no sense, but it actually makes a lot of sense when you think about it, but basically think of acute mitro-rigorge. Why? Well, because if you're diluting a valve, that is the most. Well, the body is used to the valve being the most, right? That's one of the wonderful things about the body. The body is very good at compensating. But then if the body notices that, what happened? How did this thing that was the most suddenly become like, all of a sudden, over a few minutes or a few hours, just become wider? Well, the body is going to be like, ah, this is crazy. And you're going to have a lot of regurg, across that newly diluted valve.

But over time, it's going to resolve. It's not going to be a big deal, right? So, valveuloplasty is preferred to a mitro valve replacement for mitro stenosis. And the big complication of valveuloplasty is acute mitro-rigorge. That's kind of like the big complication I want to know for you, for your example. And then, people that have mitro stenosis, you generally want to give those people, especially if they get treated, right? Miter people that have mitros stenosis that get treatment, they deserve rheumatic fever per philaxis. Many times you're going to be on penicillin for about a month or thereabouts. Remember, penicillin is actually pretty good for treating a rheumatic fever. Although, if you have a penicillin allergy, you may have to consider other medications. And then remember that people that have mitros stenosis, especially if it has become symptomatic, chances are pretty good that they have e-fib. Remember, the B-S-Ris factor for e-fib is mitro stenosis, because if you have a stenosis mitro valve, your left e-trum has to get very strong, has to get beaten beefy, has to dilute, to get blow-through, said mitro valve. So, the thing that's going to happen is you can develop e-fib. You can develop e-fib. Remember that irregular, irregular murmur. So, those people's e-fib has to be managed. Anytime they're going to be on warfarin, you know, so they don't get a stroke.

And they're also going to be on some kind of drug like, you know, like a beta blocker or some kind of non-dihydroperidine consumption of blocker like verapamele or dealtiasin. And again, if you've studied developing heart failure from their mitros stenosis, you're going to go ahead and manage it. So, you know, beta blockers, remember beta blockers, getting proof surviving in heart failure. So, you're going to put them on a beta blocker. And obviously, if you have volume overload from that, you can put them on a diuretic as well. And again, don't forget, don't forget, don't forget, always give them that stroke-prophylaxis. Always, always give them that stroke-prophylaxis. If a person has mitros stenosis, they got to get stroke-prophylaxis. Especially if they have a fib. That's kind of like the big thing. Usually on the exams, when they give a person mitros stenosis, the person is going to have a fib concurrently. In those circumstances, put the person on a prophylaxis. Use warfarin. Use warfarin. They're like, oh, divine. Countries are do-acquired, no-acquired, whatever. No. No. Whenever a person has a fib and a mitros stenosis, pretty much, you'll only option is warfarin in terms of anti-clobulation for those people on the USM and the exams. On the USM and the exams. It's very important. I know some of the things I've seen in this podcast sound a little off-putting, but I promise you these things are very, very high-yield to know for your test.

I think I'm going to go ahead and pause here since this is a rapid review. Again, I promise you, please, make sure you listen to these things. If you don't understand a lot of the physiology, I was just going to go back and listen to this stuff. This stuff will really, really help you when you're exams. I promise you that. Again, if you're taking step two or step three or step one, I have a bunch of classes coming up. Starting tomorrow, that's Thursday. I have a test-taking class. First, I want you to step three on Thursday. Bio-stats class on Friday, that runs for four hours. Social sciences and ethics and QI and healthcare systems class on Saturday. Runs for five hours. Then a 20-hour review that takes place from Monday next week. It's Monday Tuesday. Thursday and Friday of next week. The all over Zoom. If you're interested in just shipping an email, these classes are not lectures. Basically, I'm going to see a lot of scenarios because that's more realistic to your exams. There's going to be lots of scenarios, lots of integrations. Then I have a bunch of diagrams that can really help to get home some very, very complex concepts for people. Then I have these podcasts on the media or apps. Apple Google Spotify. I have a You Tube channel, Divine Intervention, USM, and the podcast and videos. Then check out my other website, Divine Intervention Lifelessens.com. Many people say, oh, wow, Divine, I love your life lessons. Basically, I started a website.

I think it was last year, where every week, for the most part, I put two podcasts, where from a political perspective, I address a life lesson. There's more than 200 episodes on there. There's actually an Apple podcast associated with that, called The Divine Intervention Life Lessons Podcast. Please check those out. I think you're joining me today. Have a wonderful rest of your day. I'll see you in a piece of 487. So God bless you and bye for now. Thank you.

Systolic ejection murmur heard best at the right upper sternal border.

Diminished/delayed peripheral pulses and concentric left ventricular hypertrophy.

Balloon valvuloplasty (rather than replacement).

Acute mitral regurgitation (Mitr-rigor).

Warfarin (anticoagulation) to prevent stroke.

Necrosis of the medial layer of the artery (media).

Diastolic murmur heard at the apex, often accompanied by an opening snap.

Having a bicuspid valve (e.g., associated with Turner syndrome).

Valve area less than $1 \text{ cm}^2$.

To perform balloon valvuloplasty (or replacement if indicated) to relieve pressure backup.

Warfarin.

The left ventricle (LV).

Diastolic murmur heard at the apex, often accompanied by an opening snap.

Having a bicuspid valve (e.g., associated with Turner syndrome).

Valve area less than $1 \text{ cm}^2$.

To perform balloon valvuloplasty (or replacement if indicated) to relieve pressure backup.

Warfarin.

The left ventricle (LV).