DIP Episode 454 - USMLE Step 2/3 Rapid Review Series 94

All right, welcome. My name is Divine. This is episode 454 of the Divine Intervention Podcasts. And this podcast will be continued in the Rapid Review series for the USML step 2, see his step 3 exams. This is going to be series 3. Now what if they give you a question about a 45 year old male, the telly that he presented four days ago with ST segment elevations. And then now he's profoundly short of breath, his gaspin for air, he's not doing well. And the telly that he has, that his neck is bulging by lateral and you're also giving a blood pressure and he's like precipitously low. The telly that he's poppable, that his reoposis are 3 D barely poppable. And then notice that they are crackles when your school takes the lungs. And the telly that a discernible signal is hard to obtain with an e-heachy. When you see something like this, I really hope you're probably thinking about one of these complications of an MI. In my complications, you're very regulated tested on exams. But the big one I want to focus on here is a free war rupture, a ventricular free war rupture. So how does this stuff usually present? Well, what we typically present is you see a person be a few days after they've had an MI. And then they will have signs and symptoms of cardiac tamponaut. Signs and symptoms of cardiac tamponaut because again, when the free war ruptures, that blood is going to find its way to the barricardium. It's going to cause tamponaut physiology.

And remember, cardiac tamponaut has a classic triad. They'll have GVD, they'll have more food heart sounds, they would have hypotension. But the thing is the USML is again, they love to use surrogates. The basic stuff you know, they just try to take things a step further to see if you truly understand what you're talking about. So like for example, GVD, they could, again, instead of saying that a person has GVD, they can see the person has a bilateral neck bulge, right? A bilateral neck bulge, what you can see the person has more permanent neck veins. You can just use some kind of surrogate for jogalovinos distension, some kind of surrogate for jogalovinos distension. It's just one of those things you want to keep in mind. And then you know, hypotension. Again, you can give an actual blood pressure if you want to make people's lives easy. Or alternatively, if you want to see if people understand, you can just give some surrogate for no blood pressure. Like you can give antecedents of prearion and acute kidney injury, right? That's probably one of the most common kinds of kidney injuries you see very early in cardiogenic shock, because you know, you effective arterio blood volume is very low. You're kind of coupled with it's down to a triple. So you're barely profusing the kidneys. But when you don't profuse the kidneys, then you're going to have a prearion and acute kidney injury. Or you can tell you that some peripheral extremity pulse is barely perceptible.

Like the radio pulse, femoral pulse, radio pulse, heart to detect. Well, what would those things be? Heart to detect? Those things would be heart to detect. If your heart is not emptied properly, if your carcass put is in the toilet. So like for example, they can give you 3 D radio pulses in many disorders. Not even just cardiogenic shock. They can even give it to you in a urethic stenosis. Because again, like for example, they know, every medicine knows that in a urethic stenosis, you're going to have a 3 D carcass pulse. Well, you think that that 3 D pulse is just reserved for the carotids, especially when you have severe urethic stenosis. You're not going to be profusing your extremities very well. You're going to have 3 D pulses in many other places. So just something to keep in mind. The NBM is the level of love surrogates. Or instead of saying more food heart sounds, you can use a surrogate for more food heart sounds. Like for example, they can tell you that you see electrical alternates. Because the reason you get electrical alternates in cardiac tampon had is the heart is dancing and fluid. Sometimes, dancing is close to the chest while you get a big QR signal. Sometimes, it dances when you get a small QR signal. Or you can tell you that the person has a barely perceptible signal on an EKG. Well, the reason you can't get much of any signal is that the heart is getting a lot of fluid. So your not surrounded by fluid. So you can capture much.

So you can just keep these things in mind. And cardiac tampon had as many of you know, we're going to treat it with a period of cardiac synthesis, right? And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind. And then you can just keep these things in mind.

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In general, you can't just get COPD from smoking people like COPD, as they were smoking usually get it like much order 50s, 60s kind of deal. You need to really smoke for a long period of time to give you a long chance to get COPD not saying as an encouragement to smoke smoking is bad right means the biggest risk factor for many bathrooms like credit and fortunes, pancreatic cancer, renal cancer, bladder cancer, lung cancer, smoking is horrible. You should know that already. So, but you see this person, even if they smoke three packs of secrets daily for 10 years, that's a 30 pack year history, right? If you're getting COPD from that, you got an alpha one antitripsin deficiency because actually people don't have alpha one antitripsin deficiency. They have a normal life expectancy just to smoke. But if they smoke, it really puts them in a dip in deep dire streets. Well, why is that? Think about it. We know that the loans are predisposed on our produce and type produce business. Previous are not good for your loans. They literally chop your pulmonary pyrepointer. Antiproduce is protective from that. Okay, so if you really think about in the in the Zima in that light, you'll get your analysis correctly a lot of the time. So, actually, probably most of the time. So, basically when people have alpha one antitripsin deficiency, that antiproduce that's at a work. They have very little antiproduce because basically alpha one antitripsin is an antiproduce.

So, these people's alpha one antitripsin is mis-forted. So, because it's mis-forted, they're literally unable to deal with the produce problem in the loans. And that's obviously not a good thing, but that's not deadly. You can have a normal life expectancy with that. But if you then decide that, you know what? I'm going to start smoking. Well, smoking, you put a lot of dust particles in your lungs. Your body has to clean that up. The clean up crew are your micro-fuges. Your dust cells, your viola micro-fuges. Well, what do those things elaborate? One of the things they elaborate are antiproduce. So, when you release antiproduce, I mean, sorry, one of the things they elaborate are produces, produces. But when you elaborate those produces, that's going to be problematic for you. Those produces will drop your mox. So, you're being basically shot in two fronts. One, increasing the amount of produce. And then two, you have an antiproduce deficiency. That's not going to be very good for a person. So, that's how people get into trouble with affluent antiproduce in deficiency. You can cause this panoramic acid in fizzema. And then we see the existence of right heart failure. Because again, if your heart is not working great, everything that drains into it is going to be distended. Your jugular veins are going to be distended. You're going to have this thing that sometimes they call cardiac cirrhosis. Because your hepatic vessels are congested.

Because again, remember your hepatic vein ultimately is what becomes the IVC. If you're in a cave, those are just not good things. That's why those people have hepatic spleen amygdalae. They can even have acides. Again, it's not everyone that has acides that has cirrhosis. They have acides for many different reasons. In fact, let's maybe kind of delve a little deep into the mechanisms of acides. Because again, you know, the opus of a person has some fluid wave, blah, blah, blah, blah on exams. And he just kind of throws people for a loop. You know, you don't have to be thrown for a loop essentially. So, how do we know that a person has acides? What's the thing that kind of leads us down that path? Well, the thing that's going to lead us down that path is, again, you're going to see a fluid wave on exam. But there are many causes, right? You know, probably one of the more common causes is you got cirrhosis. If you have cirrhosis, well, your hepatic veins and everything is going to be congested. So that's going to raise the hydrostatic pressures of your mesenteric vessels, of your portal veins, everything. So, you know, fluid is going to extravacize. You're going to have acides granted. Well, if you see acides though, that develops very suddenly, very rapidly. You want to be thinking about along the lines of something like bot-kiaris syndrome, bot-kiaris syndrome, bot-kiaris syndrome, bot-kiaris syndrome. Right? That's what you have from bosses of the hepatic vein.

Remember, we're classically finding bot-kiaris in people that have paraccessimal, nocturnal, hemoglobinaria, or people that have polycyphemia variant. So, when you have all those problems, you have hepatic vein thrombosis, you can get in trouble that can cause acides. Another thing that can also cause you to have acides is, again, if your heart doesn't work, if your heart doesn't work, fluid is going to back up enough into your... into your... what is it called? Fluid is going to back up enough into your heart and then into your IVC and then ultimately into your pulmonary... I mean into your portal vessels, that's going to cause you to have acides. So, we've looked at many things that can motivate the hydrostatic pressures, right? We're going to get acides if the hydrostatic pressures in your portal system goes up. But, how about oncotic pressure? Well, if you have decreased oncotic pressure for any reason, right? That can ultimately cause you to have acides. So, say, for example, you have a... a phytoc syndrome, or if you're in a set out of a lot of your opium, well, you're not going to have that oncotic pressure to give fluid within your vasculatory. If you can't keep fluid within your vasculatory, then that will not be good. So, your mediteric vessels will not have enough opium in them. So, they will have no incentive to keep fluid in house inside the limit of the vessel. So, you're going to have a lot of fluid extraversition. That's going to cause you to have acides.

That's going to cause you to have acides. And then, a second thing that I would also include, you know, let's say, for example, you have Quasciochor, you're an idiot enough protein, you have a protein mammal nutrition. Again, opium is a protein, you're going to get in trouble. And also, people that have liver disease, cirrhosis. Again, when you have cirrhosis, you're going to have your body congestion. But another mechanism behind the acides and cirrhosis is your liver doesn't work. Who do you think makes albument? You'll liver. Good. So, if you can make, if your liver is not working, you're not going to make albument. You're not going to have enough oncotic pressures. You're going to have acides. That's going to put you in some very, very serious, significant problems. And then, if you also think of a person that has, like, just any disorder, or even cancer, cancer, doesn't necessarily mess with your oncotic pressure, but especially ovarian cancers. Ovarian cancers are pretty notorious for causing acides. They cause these very thick acides. Because many times the tumors can make like miosin, especially when they spread to the omenum. And that can just really, really mess a person up. To be honest, we feel limited to this.

If you see a woman that is middle-aged or older on your endemic exams, and the person has been losing a lot of weight and they feel full very early, and they tell you that they have acides, the first cancer you really need to be thinking about is ovarian cancer. That's a super, super, super classic presentation of ovarian cancer on the USMN exams. That's just a truth. That's literally just a truth. So, that's something I kind of put in mind if I were you on exams. I keep that in mind if I were you on exams. Okay, so let's go ahead and keep going. So, what do they give you a question about a patient that has a histral multiple myeloma? And then they tell you that this person for the last two, three weeks, the person has been shown a breath. The person has a lot of exercise intolerance. And they tell you that on a quotation of the chest, you hear an S4, heart-solid. And then they tell you that the person has GVDV. Notice a lot of my vignettes there, like GVD Vignettes. Right, so the person has GVD, yada yada yada. Again, the other histral multiple myeloma. I want you to be thinking about it. And I'll hope you're saying ovarian, the person probably has a restrictive cardiomyopathy. Remember, restrictive cardiomyopathy can be caused by amyloid. Because people that have multiple myeloma, remember the problem with myeloma is you have plasma cells that are kind of going to rye. And when they go rye, they start pumping out a ton of monoclonal antibody. Right?

A monoclonal antibody from one ancestor, if you may. So, they'll make a lot of amyloid, a lot of antibodies. And then those light chains, the Bames, Jones, proteins, they can come together, group together, form amyloid. And when you see that amyloid, remember amyloid can deposit in the heart. And it can cause a bunch of problems. You can cause restrictive cardiomyopathy. That's why they have that S4 heart sound. Because it makes the heart stiffer. Remember, restrictive cardiomyopathy, typically you're going to have a dastolic dysfunction. Your heart can not relax very well. So, when you have that stolic dysfunction, you will almost always have some kind of S4 heart sound. Stolic dysfunction on the lithet cardiomyopathy is the one that's typically, as there's more of an S3 heart sound. So, it's going to be an S4 heart sound. Now, when people have restrictive cardiomyopathy, especially from amyloid doses, they can also have cardiac conduction abnormalities. They can have cardiac conduction abnormalities. Right? So, like for example, you may notice that these people, they start having heart blocks, they start getting dangerous arrhythmias. That's again because of the amyloid depositioning their heart. And again, sometimes they don't have to tell you that the person has amyloid doses in their heart. They can just say that an endomine or cardiomyopathy was performed. And then, a biopsy specimen, when exposed to concrete, apograin by refringence was observed with polarized light.

When you see stuff like that, that's amyloidosis. That's amyloidosis. So, just going to keep those things in mind. Remember, an euphrodite syndrome, amyloidosis can cause many, many problems. Many, many problems. But again, restrictive cardiomyopathy is kind of a big one. Kind of a big one, kind of a big one. So, just going to keep that in mind for exams. And really, like, especially when you have like other osseus-related disorders, those osseus-related disorders can cause restrictive cardiomyopathy. Like, structoid doses. Structoid doses, right? Oseus. That, you can see granulomas in the person's heart. If I see a lot of granulomas in the person's heart, I really want you to think of structoid. I'll say that again. They give you a question about a patient that has hypercalcemia. It has a lot of granulomas in their heart. Think of structoid doses. Think of structoid doses. But again, please, don't use this to say, oh, I heard you find saying, if I see granulomas in a person's heart, that means they have structoid. No, no, no, no, no, no, no. Look at the qualifiers I gave. Look at the qualifiers I gave. So, they give you a person that has hypercalcemia. And then they have granulomas in their heart. Think of structoid. Again, the USMLE's many questions are not driven by one detail. To be the end oboe for the answer. They're going to give you context. Hypercalcemia, because remember, it's structoid.

Those granulom- those macrophages of the granulomas, they express a lot of one alpha hydroxylase. That's going to cause you to make a lot of calcium trial, which is 125 dihydroxy vitamin D. So, you're going to make a lot of vitamin D. You're going to have hypervitamine, noces D. That's going to cause you to have hypercalcemia. They can even give you hyalurgylumphadenopathy, bilateral hyalurgylumphadenopathy. They'll just give you some supporting evidence that this person has structoid doses. Because let me tell you this. And all the disorder that can cause granulomas in people's hearts. But let me tell you that, ooh, you know, you do an endomaric cardiobyopsy. You find granulomas in a person's heart. And sometimes they won't even tell you granulomas. They'll just see you find epitheliod macrophages. Whenever you see the term epitheliod macrophages, or you see terms like histiosides, they're basically referring to a granuloma. Especially when you see them in groups. They form these giant cells. They form these giant cells. It's like a big, it's a big congregation of macrophages. And in detail, that endomaric cardiobyopsy also see a lot of eucenophiles. When you see stuff like that, right? And they tell you that this person has a pretty storied history of asthma and allergies and yada yada yada. They want to think about churx trials. Eucenophilic, look at the name granulomatosis with polyangitis. So, eucenophilic granulomatosis. So, you see granulomatosis, right?

A lot of granulomas. We see a lot of eucenophiles as well. That's churx trials. That's IgP. That's one of those are PNK associated disorders. Although, remember, you can also see eucenophiles in the heart when a person has rejection. When a person has rejection, believe it or not, you can actually see many times you can see lymphocytes, but you can also see eucenophiles. Don't forget that actually, eucenophiles are actually part of what you see on the bio of a person that has rejection. But again, a person that has rejection, they will give you some post-medical history of some bad organ. And then, in this case, it's going to be about a heart rate. So, I can just use your context. That's one thing that just kills people on USMLA exams. Especially people that are on key, again, I'm not trying to preach against them. On key is actually one of the best inventions in medical education, but I feel like people take it a little too far. They're like, almost like do what I like to call one to one learning. So, they literally will memorize one thing. They'll memorize one thing, and they'll say this one thing is always a pseudo-disorder disorder. The problem there is you memorize that thing, but then you've lost all context. You've lost all context. That's why, again, I love, love, love, things that present a fact or the presenter vignette behind it. That is probably one of the most, at least in my experience, one of the most realistic ways of preparing for the USMLA exams.

Context, context, context. That's why whenever I give presentations or whenever I speak to people on the USMLA exams or introduce a concept, I try my best to just go ahead and drop a vignette behind it. Because it will just make it much more readable to you. That's just a truth. Even in my review courses, I follow the same bit. I don't just say, if you see, boom, this is this. No, no. Throwing a vignette behind it, throwing some context. Because that's your exam is not going to be a list of buzzwords. It's not going to be a list of singular terms. No, it's going to be every single question is a vignette. That is supposed to abstract from to answer the question. Since this is over 20 minutes, I'm going to go ahead and step here. Again, I have one or one to learn for all the USMLA exams. Step one, just step three, prickly and gourmet school exams, 30-ish of exams. I have review courses for all the USMLA exams. Step one, just step three. And then, if you're interested, I literally have podcasts I've made where I'll climb those. If you're interested in any of those, just shoot me an email through the website. I have a bio statistics class that I teach. And again, it's field-revenience. It's not just me three formulas that you know. If I really use formulas in the class, you're going to truly understand bio stats. I have a social sciences quality improvement and ethics class. That's actually coming up this Saturday from 3 to 8 p.m. Pacific Standard Time.

That stuff is about 10% of the exam these days, 10 to 15% of the social sciences, QI, ethics and healthcare systems and communication stuff. So, I detail all of that in that class. It's for step one, just step three. And then, also, I have an MB Me testing strategies class. And then, I have these podcasts on the major apps, Apple Podcasts, Google Podcasts and Spotify. So, just check those out. At least you're going to see the most recent 150 podcasts on those apps. If you want everything from a episode one to four fifty four, then you've got to check the website. Devine Intervention Podcasts.com. If you check that website, you don't even need to sign up. Just look for the episode you're looking for. Download what you're doing and leave. Although, if you have a Word Press account and you subscribe, you get an email notification whenever I meet a new podcast. And then, I also have a You Tube channel, Devine Intervention, Life. USB Podcasts and videos, Devine Intervention, USB Podcasts and videos. That's where you find the videos that I make. And then, finally, I have a new website called Devine Intervention Lifelessens.com. Devine Intervention Lifelessens.com. There is an Apple Podcast associated with that. Call the Devine Intervention Life Lessons Podcast. Pretty sure we have almost 180 episodes. I post two podcasts every week. And from a biblical perspective, I address a life lesson. Again, many people have listened to these podcasts and found them to be tremendously helpful.

So, thank you for joining me today. I will see you in the episode 455. Have a wonderful rest of your week. God bless you and bye for now. Thank you.

The triad is decreased venous return (GVD), muffled heart sounds, and hypotension.

Bilateral neck bulge (surrogate for elevated JVP), pre-renal AKI/oliguria (surrogate for low effective arterial blood volume), or barely perceptible peripheral pulses.

Plasma cells overproduce monoclonal light chains (Bence Jones proteins) which aggregate and deposit as amyloid in the heart.

It occurs when right-sided heart failure is caused by a pulmonary issue (e.g., COPD), distinguishing it from left heart failure.

1) Increased hydrostatic pressure in the portal system (e.g., cirrhosis); 2) Decreased oncotic pressure (e.g., hypoalbuminemia); or 3) Liver failure leading to decreased albumin synthesis.

The presence of hypercalcemia alongside granulomas strongly suggests sarcoidosis, as activated macrophages express 1-alpha hydroxylase, leading to excess Vitamin D and subsequent hypercalcemia.

Bilateral neck bulge or prominent jugular veins.

Restrictive cardiomyopathy; the S4 sound indicates impaired ventricular relaxation/diastolic dysfunction.

Chronic pulmonary disease (e.g., COPD).

Weight loss, early satiety, and thick/exudative fluid accumulation.

Amyloid fibrils formed from misfolded light chains (Bence Jones proteins).

Granulomas + Hypercalcemia.

Bilateral neck bulge or prominent jugular veins.

Restrictive cardiomyopathy; the S4 sound indicates impaired ventricular relaxation/diastolic dysfunction.

Chronic pulmonary disease (e.g., COPD).

Weight loss, early satiety, and thick/exudative fluid accumulation.

Amyloid fibrils formed from misfolded light chains (Bence Jones proteins).

Granulomas + Hypercalcemia.