DIP Episode 412 - USMLE Step 2/3 Rapid Review Series 82

Okay, welcome. My name is Divine. This is episode 412 of the Divine intervention podcast. And this is going to be a continuation of our Rapid Review series. This is going to be series 82. If you're taking your step tour, step 3 or complex level tour, three exams. Any time over the next few days, I have a review course taking place tomorrow and Friday. The 20 hour course is going to be spread over two days instead of five days. It's going to be for 10 hours on each of those days from 7 to noon and 1 to 6 p.m. A Pacific Standard Time. We'll also take some measured breaks in between, just to give people some time to cool off. But if you're interested or review more than a thousand concepts from Peds from internal medicine, surgery, OB-guine, psych, neurology, ethics, communications, biostatistics, multi-systems, processes and disorders. So if that's something you're interested in, just shoot me an email and I'll give you some more information. And you can sign up. We start tomorrow morning at 70 and Pacific Standard Time, which will be 10 a.m. Easter Standard Time. So let's jump right into it. So what if they give you a question about 61-year-old male and the tell you that he's been a smoker for the last 30 years, he smoked two packs per day and that he has noticed some blood in his urine and he has also been having some mild flung pain. Well, if you notice this and they can even tell you that, oh, that is sure, they tell you that he has also been having some bone pain, right?

And then they can tell you that extra or bone scantials like lady collisions, insertion bones or whatever, right? Or they can even see just image in general. And if you see that, what should you be thinking about? I really hope you're thinking about reno so, of course, synoma. Now, you know some people may be thinking bladder cancer, but I just added certain qualifiers here that should tell you that it's no bladder cancer. This is more reno cell carcinoma without those qualifiers. Well, the fact that you see the lyric bone lesions don't get me wrong, bladder cancer go to the bone, yeah, I can, but is that something you see on an in-beam example? Almost certainly not. So that's something that's really rare, right? So you see bone meds think about reno so, of course, you know, reno so, of course, you know, my love's to go to the bone. It loves to cause lyric lesions in bones. That's really high up to now. And remember, whenever you suspect that a person has reno so, of course, you know, the first thing you're going to do is you're going to do a CT of the abdomen pelvis with IV contrast. And you know, when you see it, they need to do an infrectomy. It's pretty high up to know that reno so, of course, you know, as you don't like biopsy, the carcinoma leave the kidney there. No, that's no smart. In fact, let me tell you this. There are certain cancers on in-beam exams that are diagnosed, like if you want to get a biopsy, the biopsy is taking the whole organ out.

Reno so, of course, synoma functions under that purview. Ovarian cancer functions under that purview. Testicular cancer seems to be a drain all malignancies, seem to just remember it as rhoda. I think there's a place in Spain known as rhoda. If I'm not mistaken, ROTA, and it'd be completely wrong though, but I feel like I've already somewhere in the few years ago about a place in Spain called rhoda, ROTA. But anyhow, so reno, cell carcinoma, ovarian cancer, testicular cancer, drain cancer, don't biopsy those things. Let her get the whole organ out and then send it off for pathological analysis. And remember, you can use analogs of interlooking to treat reno cell carcinoma. You can use interlooking to analogs. And remember reno so, of course, synoma has many associations, right? You can produce itpo, every through poe team, in a panheoplastic fashion, so it can cause a it can cause a person to have a polycyphemia. But remember reno so, of course, the number of the biggest risk factors smoking, right? Smoking is not good. Smoking raises your risk of many bad things in your life, right? It raises your risk of reno so, of course, synoma is literally the biggest risk factor for reno cell carcinoma, bladder cancer, myocardial infarctions, peripheral arterial disease, renal otter stenosis is the biggest risk factor for just many problems, right? So just be careful with smoking if you can quit.

And if you can encourage your presence to quit, that's probably one of the smartest things you can do for yourself or do for them. And then what if they give you a question about a 72 year old male, they tell you that he has been having lower abdominal pain and it tells you that his had days where he is gone without your needing. What is the first thing you think about? Well, I would hope you're saying, oh divine, this sounds a little bit like BPH, right? Benineprostatic hyperplasia, right? Remember, BPH is caused by the prostate brain so huge that it then begins to compress the bladder, right? And what's the thing that makes the prostate grow? Typically, it's going to be DHT, dihydrotestosterone. Remember, dihydrotestosterone is made from testosterone by the enzyme 5-alpha reductase. 5-alpha reductase pretty much helps you convert testosterone to DHT. And then that DHT is the thing that ultimately causes the problem, right? So how can you fix their problems? Well, the thing you want to keep in mind is if they have acute urinary retention, they are very symptomatic. Just placing a catheter, a suprapubic catheter, will be helpful. You just place it and drain their bladder and they'll feel great, right? But also for short-term treatment, don't forget your alpha-1 agonists like Tamsulosein, oprazocin, otterazocin, odoxazocin. Remember, Tamsulosein is the one that blocks the alpha-1 ED receptor, ED as an Anthony Davis.

Blox the alpha-1 ED receptor that prevents the bladder from draining. It doesn't really work in blood vessels, but the other ones like terazocin, prasocin, odoxazocin, those things have the ability to not just block alpha-1 receptors, which can open up your bladder and can help you pee better if you have BPH. But it can certainly also affect your blood vessels. Those alpha-1 drugs, right? They are very powerful viso-diiliters, right? They can be used as anti-hypertensives, right? But remember, because they are very powerful viso-diiliters, they can also vino-diilite and that can cause the patient to have like syncopy, syncopylepsisodes or those static hypotension, right? Like for example, if you really think about it, you can have problems like, what do I want to say? You see the person your eyes are out of bed and they kind of fall over, right? Because there's no blood supply to the brain. Because if you vino-diilite, you're going to kill preload. If you kill preload, then your brain is not going to be would or I mean, you're not going to be able to refuse your heart, your caracal will go down when your eyes from a from a supine position and then the person is going to have problems, right? So that's just something I want to keep in mind. These things can absolutely positively cause, they can absolutely positively cause a cause of problems, right? So I remember they also cause problems with other drug interactions, right?

Any other drug that's a viso-diiliter is not a good idea to combine with an alpha and blocker, right? So like nitrates and alpha and blockers, those things can cause dangerous blood pressure drops, combine an alpha and blocker with hydrozene, can cause dangerous blood pressure drops, combine in an alpha and blocker with cell dena phil, can cause a big, big, a rimber cell dena phil is a phosphodi-335 inhibitor. All those things can cause significant blood pressure drops. And even combining alpha and agents with certain drugs that are not classically thought of as viso-diilaters, but they can viso-diilite, right? Like those are tricyclic and anti-depressants. Remember they have anti-hamm side effects, the H is for anti-h1, the H is for anti-alpha-1, right? And then the M is for anti-muscarinic, right? Those anti-alpha-1 effects can absolutely cause it to have like really bad orthostatic hypotension, right? So the Mb is the love, love, love, love to test these drug interactions. So that's something you want to keep out the back of your mind for, for example. And then another thing I want to say is, we're also of course in Oma, I mean let me finish off this BPH business, so BPH we said that first, you should have an alpha and blocker, right? But again long term, you can try to shrink the prostate by giving a 5-offere adoptees inhibitor, right? Because remember 5-offere adoptees makes DHT and DHT's thing that causes the prostate to grow.

So you can actually attack the pathophysiology by inhibiting 5-offere adoptees, we drugs like Phenasteride and Dutasteride when you block those, when you block the enzyme, you'll make less DHT. If you make less DHT, the prostate can shrink in size over a month, it's not a long term measure. That's something it's pretty high you to know. And obviously if you try that and it doesn't work, then you need to then resect the prostate. You need to resect the thing that's literally squishing on the prostatecurythra that's making it hard for things to get out of the bladder. So you do a surgery known as TURP, TURP, a trans-urithral, resection of the prostate, TURP, trans-urithral, resection of the prostate. That's pretty high you to know, for example. And the one thing I guess a few things I wanted to say about R&SOKER's number that I forgot, don't forget that RCC has an association with one hip-olendal, right? Again, you've seen me see this genetic disease so many times on this podcast because it's just something that the imbim is love to test a lot, right? So VHL, remember it's a chromosome 3 problems and or a zomodomin and defect, right? And those people they tend to have like brain cancers, they can have hemontioblastomas, remember those are calcified brain masses that you'll find in the posterior fossa and they usually calcified. They usually calcified, you find them in the cerebellum, they produce a ton of hipo, they can cause polycythemia, right?

But people that have VHL, they can also have cysts in the pancreas, they can have pancreatic cysts, they can have kidney cysts, they can have bilateral R&SOKER synomas, right? That's a very good association to kind of keep out the back of your mind, for example. Now, what do they give you a question about a newborn and detail you that is a newborn male and in detail you that his scrudo-sac feels empty. And in DC, which of the following is this patient at increased risk of in the future? Well, the first thing you want to remember is first and foremost, this person has a cryptorchidism, right? Cryptorchidism, cryptorchidism. Remember, cryptorchidism is something that happens where your testes, they do not descend into your scrudo-sac during development, or your testes just don't drop into the scrudo. The scrudo-m is like the pouch that contains your testes, right? Well, the thing is, when a presian scrudo-chidism, you know, many times the testes will descend over time. But don't forget that when people have cryptorchidism, it actually raises the risk. Of developing testicular cancer in the future. Even if the testes ultimately descend, you still have an elevated risk compared to a person that was just born with regularly descended testes of developing testicular cancer. That's something you kind of want to keep at the back of your mind, for example, right?

I remember people that have cryptorchidism, I think one thing you want to keep in mind with them is that they can be infertile. Because, again, there's a reason why the testes are outside of the mainstream body, right? Because, you know, the scrudo-m and stuff is kept at a temperature that's like two degrees below core body temperature. That's like perfect for semen production. So, if you have one descendant testes, then your testicles are literally inside the body if you had core body temperature, it's really hard to mix semen under those circumstances. So those people are going to be infertile. That's something you kind of want to keep at the back of your mind for, for example. Remember, you know, some other people with testes related problems that just can make it, right? Think of a person that has, think of a person that has what I'm not trying to think about. Think of a person that has client-filter syndrome, right? Those people tend to have like infertility, right? They can reproduce what they are especially prone to infertility, right? You see many times they have like a micro-penis. I guess it's not really a testicular problem. Everybody have like a micro-penis. They have like polydeveloped reproductive structures. And again, if you're also thinking about infertility, don't forget cystic fibrosis. Little kids that have cystic fibrosis, right? Like especially the men, they have agencies of the vast difference.

Because of that, agencies of the vast difference, they're going to have a lot of problems conceived. And then what if they give you a question about a patient, they tell you that there's a 29-year-old male, and they tell you that you know, has a history of diabetes, that has been polycontrolled, and that was really simply studied on a medication, because he also has heart failure. And then they tell you that he's, he's been having like severe pain, inalpine and perineal pain, and his temperature is like 104. His wife has like 30,000. And they tell you that, you know, this increased local side alkaline phosphatize activity. And they tell you that he has like this bluish discoloration of his perineal region. If you see this, what should you be thinking about? I really hope you're saying, oh divine, this sounds an awful lot like phony's gangrene. Remember phony's gangrene is spelt as F-O-U-R N-I-E-R, whether an apostrophe and an S, phony's gangrene. It's a kind of necrotizing fasciitis. It's actually a polymicrobial infection that happens in the perineal. So how do all these things link together with diabetes and whatnot? Well, the first thing is diabetes compromises your immune system. You've seen me say this, factoid, so many times on those podcasts. People that have diabetes, they tend to get the worst kind of infection, so name being an exam, right? I mean, think about it. You see a person that has like, um, what's the name of this problem?

Uh, person that has mucomaricosis, uh, many times it's like in DKA, or they have some kind of phisiotibides that kind of gets them in trouble. So diabetes, that's why one of the reasons diabetes is not good, it can cause you to have very severe infections. Because we wouldn't have diabetes, have a lot of hyper insulinemia, especially the type two kind. Hyper insulinemia, so persistent immune system, so you can, can get in trouble. So this person has diabetes, right? And the affonies can grin. But what's this whole link with this drug? Well, remember, one of the drugs that I used in diabetes at the SGLT2 inhibitors, the SGLT2 inhibitors, or ending flossing, right? Calagely flossing, the pagly flossing, and pagly flossing. The inhibi, the SGLT2 transporter, which we find at the level of the proximal convoluted tubio of the kidneys. By blocking that receptor, you're literally dumping a lot of glucose in your urine, and that's great. But you can really begin to see that you're essentially organizing a party for bacteria. First, you have an increase risk of UT Is that kind of makes sense because you have sugar urine. But again, that sugar urine kind of coming out through your urethra can also smear on your perineum. And it can cause a very serious polymicrobial bacterial infection of the perineum. It can literally cause neck fasch of the perineum, right? Neck fasch mean neck, neckortizing fasciitis of the perineum.

And at that point, the thing that you have to do for those people is you need to deep-breed the perineum. You can imagine how that will go. You need to deep-breed the perineum, and then those people are going to need an IV antibiotic therapy, right? So that's just something you want to kind of keep on the back of your mind on exams, right? So these SGLT2 inhibitors, though, they are not all bad. They're actually pretty good. They're one of the drugs that improves survival in heart failure. Remember, those are, that's a claim that can be made by ACE inhibitors, aldustrin antagonists, beta blockers, by-deal, right? That's also my die nitrate and hydrozene, right? And also the ARMS, the ARBS combined with nebralizing inhibitors like falsartons, acobitrile, those things all improve survival in heart failure. And by the way, maybe one other thing I would say about improvements to survival in heart failure, think about placing an implanted, you know, implantable cardiovertile defibrillator, right? IC Ds, right? So the asserting patients with heart failure that deserve IC Ds, or people who just cardiac issues that deserve IC Ds, the classic ones you want to keep in mind on exams, or one, if you have had a prior MI, right? A prior MI coloring fraction, and your live ventricular injection fraction is 30% or less. So if it's 30%, that's included. Those people should get IC Ds, right?

And also if you have like class two or class three heart failure, and your injection fraction is 35% or less, then you absolutely deserve IC Ds as well. Those things actually improve survival in those patients. So again, going back to the SGLT twin inhibitors, right? So again, they're not all bad. They actually do improve survival in heart failure. It's one of those drugs that you can prescribe to people that have heart failure. So if you're able to have diabetes, and then those drugs also ask for their weight loss, because think about you literally losing sugar. So as you're losing sugar, you're also losing the something that can automatically attract water. So it actually causes you to lose weight. So it's very helpful from that perspective. So it does improve survival in heart failure, helps with weight loss, but don't forget the UT Is, don't forget the phonies can grin that you can get. And obviously those drugs, if your kidneys don't work great, that's kind of like one of the big limiting factors. If your kidneys don't work great, it's probably not the smartest idea in the world to be taken on SGLT twin inhibitor, right? Remember, certain drugs are a bad for people that have renal dysfunction, certain diabetes drugs. The SGLT twin inhibitors fall in that line, and also the metformin. Metformin is not good if you have a bad kidney. If you have a bad heart, you shouldn't be taking the TZ Ds, right? The Thaisolidine Dions. Okay, so I think I'm going to go ahead and stop here.

Again, as I do at the end of every podcast, I'll see probably more relevant at this time of the year. If you're taking, if you're applying for residency, and you need help with your ER As applications, I get to work with tons of people that are residents and attendings all over the country. I help with personal statements, for recommendation letters, supplemental applications, ER As applications. I've done this for years, and I've had many people that have been very successful working with me. I've worked with people from pretty much every discipline that exists out there. I've actually also been on an admissions committee at a top three medical school. So I know a thing or two about admission, I know a thing or two about programs all over the country. So if you're interested, just shoot me an email. I do also offer one on one tutoring for step one to step three and complex step one to three. I just don't tutor to women. And then also just in going through the ER As process, if you have issues with standardized interview formats like MMI, like multiple meeting interviews, and not a lot of people also struggle with Casper. Casper is like this new thing that's done by quite a number of residency programs, especially very competitive residency programs to see how you are in certain ethical situations. If that's something that's struggle with reach out to me, I have a lot of experience with that. I can certainly help you with things like that.

And then I also have these podcasts on Apple podcasts on Google podcasts and on Spotify, at least the most recent 150. If you want everything from episode one to this episode, episode four, 12, you've got to check on the website, Dividing Division Podcasts.com. If you actually subscribe with your Word Press account, you get an email notification whenever I make a new podcast. And then I also have a new website called Dividing Division Life Lessons.com. That's a website where I post the life lessons because many people have said, oh, divine, I really love the life lessons you put on the end of your podcast. So I said, it's not a new website. There's even an Apple podcast associated with it is called the Dividing Division Life Lessons Podcast. And it's an Apple podcast. And again, every week I post like two podcasts that address from a biblical perspective, just common problems that are faced by humanity. And then I also have a You Tube channel called Divine Intervention, USML podcast and videos. That's where I post the videos that I make. So subscribe, look for the channel, subscribe to it, any of the dates I make. There's a lot of really cool stuff on there. So thank you for listening to me today. Have a wonderful rest of your day. The life lesson I just want to leave today is be careful of destroying the future of others. Many people don't realize this, but just be careful of how your actions affect others. We kind of live in a world where people are really selfish.

They always just think about themselves and they don't think of the good or the well-being of others. So before you do certain things, I'm not saying you should don't love yourself, but just be careful of destroying other people's futures or destroying what other people have worked for. It's just not a good thing because at the end of the day, what do you so you will rip? You don't get ahead by putting other people down. You don't get ahead by messing up the destinies of other people. This is actually something that's pretty common in medicine, but to be honest with you, it's pretty common in the world we live in today. Like you see some people they believe by going through these sabotage roles and techniques, they can get into a residency program. You may succeed for a season, but you will not succeed for long by pulling other people down. You rise up by pulling people up. That's just the truth. You don't rise up by destroying other people. You see some people they are like, I will be successful regardless of the price. The thing is, some certain prices are not worth it. You see some people that will need to sacrifice their friendships for very little. That's not the way life should be. We just live in a world where people are just like very competitive. I like, no, you know what I will get ahead at any cost. Just be careful. We are stomping down on a person's destiny. At some point in the future, someone is going to stomp down on your own destiny as well.

Just be careful of pulling other people down. Help other people up. We are all here to help each other. We are not here to pull people down. Many people just, I don't know, especially in society these days, it's a very pervasive point of view that I can rise up by pulling others down. No, don't pull other people down. Pull other people up. That's your ministry. In making these podcasts, that's one of my goals. To pull other people up just education at least that's the area that I know that I can contribute to humanity. I'm not a singer or anything like that, but I know that by the grace of God, I'm a really good teacher. So for me, I see it as a ministry for me. It's not just, oh, to make podcasts. No, it's actually a ministry. It's actually a calling for me to teach people. Pretty much everything I've done, actually, at least I'll see over the last 12 years, has involved teaching of some sort. When I was in college, yes, could I just keep the knowledge to myself, do well on my exams, thankfully, which I did and kind of leave other people in the dust. Yeah, I can, but that's nothing I think to do. All through my time in college, there are a lot of people I worked with just to help them succeed. I would do all these tutoring sessions and everything for organic chemistry, general chemistry, physics, many different chemistry labs and many things. So a lot of people, it's your joy and your happiness, or at least that's the way I would hope that people think about life.

It should be your joy and happiness when you see other people succeed. When you see other people, wow, they got into med school, wow, they are succeeding and thriving as medical students. That's something that should be your joy and your pride. Your joy and your price should be like from affecting life positively because whether you like it or not, you're going to die very someday. It doesn't matter who you are. You can do everything. You can't to prolong your longevity. You can work out as hard as you want. It foot from the earth. I'm not saying all these things are good things to do, but one day is an appointment that no man will miss. You're going to die someday. At the end of the day, what kind of legacy have you left in the world? Have you lived in a legacy of pulling people down? Have you lived in a legacy of pulling people up? What's your legacy? Don't make decisions of your life based on just short, quick things. No, no, think long term. What kind of legacy do you want to live? How do you want to affect people's life positively? What's the point? Think about it. What's the point of going through your time on this earth and just never affecting any life positively? That's my definition of a wasted life to be perfectly honest with you. You need to affect life positively. You're here for a reason. You're not here by mistake. Just like my pastor in church says, you're not an accidental discharge from somebody. No, you're an actual human being. You're here to make impact.

You're here to make a change. I don't know why I'm rumbling like this, but I really hope that this message is mainstreamed to someone right now. You're not an accidental discharge. You're not here by mistake. You're not a worthless human being. There is actually treasure inside you. Share that treasure with the world and you'll see a life thicker than for the better. So thank you for listening to me today. Have a wonderful rest of your day. I'll see you in episode 413. God bless you. Bye for now.

Hematuria combined with lytic bone lesions (e.g., in the pelvis or spine).

These malignancies are often diagnosed by removing the entire organ (en bloc resection) to ensure adequate pathological analysis.

Testosterone $\rightarrow$ Dihydrotestosterone (DHT) via 5-alpha reductase. Inhibitors like Finasteride/Dutasteride block this enzyme.

Alpha-1 blockers (e.g., Tamsulosin) and phosphodiesterase inhibitors (PDE-5 inhibitors).

Severe polymicrobial perineal infection/necrotizing fasciitis due to glucosuria irritating the area.

Prior MI with LVEF $\le 30\%$, OR Class II or III Heart Failure with LVEF $\le 35\%$.

RCC; Chromosome 3 (Von Hippel-Lindau).

Renal cell carcinoma, Ovarian cancer, Testicular cancer.

Blocking $\alpha$-1 receptors in the bladder neck/prostate smooth muscle to relax and improve urinary flow.

Increased risk of testicular cancer AND potential infertility (due to temperature difference).

Blocking the SGLT2 transporter in the proximal convoluted tubule, leading to glucose excretion in urine.

Nitrates (Nitroglycerin) and PDE-5 inhibitors (e.g., sildenafil).

It is contraindicated or requires extreme caution because of its accumulation/metabolism issues when kidney function declines.

RCC; Chromosome 3 (Von Hippel-Lindau).

Renal cell carcinoma, Ovarian cancer, Testicular cancer.

Blocking $\alpha$-1 receptors in the bladder neck/prostate smooth muscle to relax and improve urinary flow.

Increased risk of testicular cancer AND potential infertility (due to temperature difference).

Blocking the SGLT2 transporter in the proximal convoluted tubule, leading to glucose excretion in urine.

Nitrates (Nitroglycerin) and PDE-5 inhibitors (e.g., sildenafil).

It is contraindicated or requires extreme caution because of its accumulation/metabolism issues when kidney function declines.