DIP Episode 610 - Imaging and The USMLEs (Part 1)

All right, welcome to episode 610 of the Divine Intervention Podcast. Into this podcast we're going to be addressing a very high-yield topic that I title, Imagine and the USML Es. Imagine and the USML Es. The goal of this podcast is to provide a range of scenarios for specific things you mission you exams. I've got a lot of questions from people on this and I've decided to make a podcast on it. And honestly this is very likely going to be a series. And this is one of those things that are kind of difficult to prepare for. In fact, these are my best efforts to expose you to different things. And it's like, hmm, okay, where would I make this decision on the USMLE exams? So this is one of those things that you either know or you don't know. There's not much in the way of testing in principles that can get you to this. So let's get right into it, right? So what if they give you a question about a lady that is, 42 years old and she comes for her primary care visit. And you're told, oh, which of the following screening modalities, right? Or screening procedures is recommended for this patient. I would really hope you're saying that, or this is going to be a mammogram, right? So remember, mammogram film, the USMLE exams, is going to be done for women that over the age of 40. You're going to do it roughly every year or two as a means of screening for breast cancer. Now, the USMLE is they're not stupid.

So sometimes, instead of calling it mammography on the exams, they may call it breast radiography. They may literally call it breast radiography, right? Or they may call it an x-ray image of the breast. Just remember, literally mammography is taken an x-ray of the breast. That's literally what it is, right? And again, do not forget, we started at age 40. I know some people will tell me that USPSTF said this and blah, blah, blah, blah, blah. For the USMLE exams, this is Divine Speaking in June of 2025, you want to start at age 40. All right. Now, since we're talking about breast imaging, how do we evaluate breast masses in women under age 30? How do we evaluate breast masses in women under age 30? Well, I hope you're saying that it's an ultrasound, right? So if a woman is under age 30, you want to use an ultrasound. A body for women is over age 30. You want to use a mammographer, right? And the thing is, our friends at the NBM is they can actually create a bio-statistic question from this factoid that I just discussed, right? So they can say, oh, that what is the, you know, they will give you a question about, you know, a lady that is, you know, like 25 years old, for example, has a breast mass and is getting a breast ultrasound. And then they ask you which of the following is the most likely, is the most likely a reasoning or the most likely, you know, thought process behind choosing this imaging modality in this patient population?

Well, I would really hope that you're saying that and you know, they will provide a series of statements, right? Like they can say that, you know, compared to mammography, right? You know, it has a, you know, you know, compared to mammography, it has a better sensitivity or a better negative predictive value in this population, right? Or you can say that, oh, which of the following factors, you know, makes the physician not pick mammography as the modality in this 25-year-old female? Well, it's because mammography in younger females, in women that under age 30, right, has a reduced sensitivity. It is not a sensitive. So because it's not a sensitive, it has a very low negative predictive value. Make sure you understand this. Whenever a test is not very sensitive, it means that the test is very poor at catching people that are sick. If a test is very poor at catching people that are sick, that means negative results from that test are not very reliable, right? So the test has a low negative predictive value, right? So please make sure you understand this. We choose ultra-sonography in women that under age 30 because ultra-sonography compared to mammography in this population has a better sensitivity and has a better negative predictive value, right? Because again, remember a woman that is under age 30 likely has denser breast tissue, denser breast tissue, right? But if you're over 30, we're going to evaluate that breast mass with a mammogram, right?

Okay, what if they give you a scenario about a lady and you're told that she has a, you know, that for the last, you know, couple of days, she has noticed this reddish discharge from her left breast? Well, obviously that's going to be an intra-doctor papilloma. What are you doing in that situation on your exams? Go ahead and get a mammogram. Again, that's another indication from mammography on the USMEL exams, right? Now there's one bizarre scenario that is now showing up more and more frequently on the exams, right? And they can give you a question about, you know, an individual, you know, lady that has a breast mass, right? And you're told that, ooh, she got a mammogram like three months ago or four months ago and it was unremarkable. What should be your next step on your test? Your next step on your test should be to get an ultrasound. They love to do this to people and many times the lady that has this issue will be somebody over age 30, right? Because they're trying to see if you'll say, oh, let me go back and pick, let me go back and pick mammography again. No, if you've had mammography within the last few months and you need to evaluate a breast mass, please do not do mammography again. Please do not do mammography again. Get an ultrasound. Even if the lady is over age 30, this is extremely important to know for your exams, right?

Another classic situation you may see on your exams is, they may give you actually some scenarios on your test where breast MRI is the right answer, right? So what are some situations on your exams where breast MRI may be the right answer? The big, big, big one to know is to use it to screen people that are at high risk for breast cancer. If a person has like a high risk for breast cancer and basically like if you see me say the words high risk with breast, think of a person that has some kind of genetic syndrome that predisposes to breast cancer like the breast commutation for example. People that have the breast commutations, when do they start breast cancer screening? They start at age 25. Remember starting at age 25, they get annual breast MR Is, annual breast MR Is. And then between the ages of, you know, so they do that till age 30, but once they hit age 30, once they hit age 30, they begin to have mammograms added to that. That's something that's pretty high you to know for your exams. That's something that's pretty high you to know for your exams. So they have breast MR Is starting at age 25 to 30. And then mammograms start at each, so 25 to 30 just breast MR Is. And then starting at age 30, in addition to those annual breast MR Is, they, in addition to those annual breast MR Is, they do get mammograms. They do get mammograms, they do get mammograms. So that's pretty high you to know for your exams. Now, another classic scenario you may see on your test.

So again, don't forget breast MR Is, people that are high risk for some genetic cancer syndrome. Now, what if they give you a question about a patient and you're told that this patient, you know, is like a 45 year old female and she came in with a poppable breast mass, right? You know, she came in with this mass, you know, upper out of caution of the breast. And you're told that, ooh, she, she, you know, mammographic evaluation was done and it failed to show any lesions. And then they ask you, what is your next best step? Well, your next best step on the exams should be to go ahead and get a biopsy. Okay, go ahead and get a biopsy. This is super high you to know for your exams. If a person has a poppable breast mass, even if the image is negative, typically on the exams is going to be a negative mammogram, go ahead and proceed to getting a breast biopsy. Get a biopsy of that mass. That's extremely important. Now, one other thing I think I want to say about breast is differentiating a malignant breast lesion from a benign breast lesion. Because the thing is sometimes our friends at the NBM is they will give you characteristics of something and then based on those characteristics, you know, you'll notice that they end up putting some of those characteristics as answer choices. And then they want you to try to decipher. Okay, based on will this characteristic push us more towards considering this thing as a benign lesion or considering this thing was a malignant lesion.

Like literally in the Q stem, let's say they are describing like a breast mass on mammographic image, they'll give you like five characteristics of the breast mass. And then of those characteristics, they'll put five of them as answer choices. And then they'll want to do basically pick one of them. They'll want you to pick one of them. Right? Literally, they want you to pick one of them as, oh, the thing that will tip you towards, oh, this is more benign or this is more malignant. So this is something that's actually very important to know. So what are some things you'll see on imaging. Now tell you that this breast mass is probably going to be malignant. Well, if for example, the mass is irregular, the mass is irregular. I'm kind of worried that this thing may be malignant. If the mass has speculated margins, for example, right? Has speculated margins, for example, then it may be malignant. If the mass is radial dense, a radial dense mass in the breast is more worrisome for malignancy than a radial loose end mass. Right? And then I like to use this term, a mass that varies, a varying mass. Right? You may wonder, if I were in the world, do you mean by a varying mass? What I mean by a very mass, maybe let me give you an example. So many of us know that in melanomas, one of the things we're worried about with melanomas is if the person has a mass that seems to, you know, like just have like different colors, right?

We know that in melanomas, typically if it has like one color, you know, we're probably less worried that it's melanoma. But if it has like all these color variations, that is like super, super, super worrisome. Right? You know, just has this color variations where like, oh, this is not good. Right? So the thing is, if you have a breast mass that is, again, it kind of goes along with this theme of being irregular. You know, it has like multiple shapes, almost like fused together. You know, it has like multiple, like one side is this size, the other side is this size. That is more likely to be a malignancy. Right? And then one other thing to keep in mind, especially with calcifications in the breast, is that if they use any of these four terms, a breast calcification that is linear or course or segmented or clustered that is highly, highly worrisome for malignancy. I'm going to say that again, if you have a breast mass on the USMLA exams that is described as having linear calcifications or course calcifications or segmented calcifications or clustered calcifications, those are very, very worrisome for malignancy. So now let's look at things from the flip side. What are some things you may see on mammographic imaging that tell you that, hmm, okay, this thing is likely going to be more on the benign side of things. Well, if the legion is, let's kind of follow the same trend we did with malignant. If the legion is round or oval, right? You're told that it's well circumscribed.

It's well defined. Right? That's less likely to be a malignant legion. If the legion is radial loosened, that is very high. You know, it's radial loosened, right? Many times if something is radial loosened, it either contains oil or fat, right? So for example, like an oil system, the breast or a lipoma, right? Like a small fat mass in the breast or galactosell. Galactosell on mammographic imaging, they tend to actually be radial loosened. Right? And then what kind of calcification pattern will tell us that, yeah, this thing is probably benign. Again, remember, don't forget what I said from malignant calcifications. Linear, coarse, segmented or clustered. Right? But for benign lesions in the breast, if you see the term popcorn calcification, popcorn calcification, or they tell you the term layering calcification. Right? So they tell you that, ooh, these calcifications have like a T-cop orientation, or they have a crescent shaped orientation. That is something called like milk of calcium. It's a super benign breast finding, right? Or they tell you that you have like calcification in a vascular pattern, right? Calcification in a vascular pattern. So it's almost like the calcification is outlining the path of a blood vessel. That tends to be more of a benign lesion. And also just a scattered calcification. Calcifications that are scattered, right? They're not like linear or segmented. Yeah, those are more likely to be benign, right?

Because if something is almost like counterintuitive, but it actually makes sense if you think about it. If a calcification is scattered, it's less likely to be some kind of coherent mass, right? It's less likely to be some kind of coherent mass. So just something you want to keep at the back of your mind, for example, right? So again, what is the calcification pattern for something that is malignant in the breast? Linear, coarse, segmented or clustered. Now, what's the calcification pattern for something that is... So what I just said nice for something malignant for something benign, popcorn calcifications, layering calcifications, right? So layering, they look like tea cups, right? Or they have this crescent shape, right? Or a calcification in a vascular pattern or a calcification that is scattered, right? That tends to be more benign, right? And since I'm kind of talking about this concept of popcorn calcifications, where else do we see popcorn calcifications? And that tells us that we're dealing with something benign on the USML exams. I'd really hope you're saying, oh, divine, it's in the lungs. If a person has a lung mass, if a person has like calcifications in the lungs, and you see that it has this popcorn orientation, that mass is almost certainly a pulmonary hematoma, a pulmonary hematoma. Very, very high-yoda solution to know for your exams. See, to be honest with you, these things are things that you either know or you don't know, right?

It's almost like learning risk factors or prognostic factors, right? So please just make sure you know the stuff for your exams, all right? So next thing I want to talk about, right? So what if they give you a question about a patient, and they tell you that this patient presented with shortness or breath, chest pain, and you know during the person's hospitalization, you know, the deal of a lot of culture that grew, uh, gram positive, uh, coxine clusters, and that, uh, you know, echocardiographic emission of the person's chest, uh, disclosed vegetations in the tricospid valve. And then you ask, uh, which of the following is the most appropriate next step in management? And the thing is you notice on your exams that they don't provide any anti-biotic answers. Like, huh, that's weird. This person has endocratitis. Why are they not giving me an answer that involves giving anti-biotics, right? And then you notice in the answer choices, they provide a series of like procedures or interventions, right? I will strongly strongly encourage you to pick the answer choice that talks about insertion of a central venous catheter, insertion of a central venous catheter, right? What's a central venous catheter? A central venous catheter is what many of you know as a central line, right? Many times he's going to be inserted in a vein. It's going to be inserted in a vein, right?

You can have like a femoral central line, you can have a joggele vein central line, you can have a so cleave and vein central line, right? Although we try to avoid the femurals, right? Because that's a very dirty area. That's like your growing area probably has the highest risk of a central line, so she had bloodstream infection, a clopsy, right? So why are we inserting a central venous catheter for this person? We're inserting it for this person because the person is going to be getting antibiotics for a long time, right? Whenever a person is going to be getting a long range of antibiotics, many times they're going to get this for like six weeks, for example. You typically want to give those antibiotics through some kind of central line, right? So what are the classic infections we do this for? It's going to be for something like endocratitis or something like osteomyelitis, right? A bone infection, those people tend to require central lines because they're going to be getting antibiotics for a really long time. Now what are some other indications on the USM List for central lines? Well number one, if a person has is getting a chemotherapy, right? For a person who's getting chemo, right? Again, many times they're going to have to get it for a long time, they're going to need a central line. For a person who's getting TPN, total parental nutrition, that person's going to have to get that TPN through a central line.

And remember, what is the most common complication of TPN administration? I really hope you're saying, ooh, divine, it's a central line associated with bloodstream infection. Well, why is that? Well, think about it logically. You literally put in food down a vessel. What do you think is going to happen to that food? Do you really think that it's only you that wants that food? Do you think the bugs do not want that food either? Sure, they do want that food, right? So the most common complication, this is very, very high yield. The most common complication of TPN insertion is going to be a central line infection. They will try to confuse you and put a calculus-colysis status. I would not be a calculus-colysis status if central line associated with bloodstream infection is a provided answer. So make sure you know that. So for a person who's getting chemo, a person who's getting TPN, getting antibiotics for a long-term infection, think of a central line, think of a central venous catheter. And again, they can tell you that, ooh, a person that has a central line, you know, now has a fever, the person has like severe pain at the central line insertion site, and the person has a local site tool says, right? That's going to be a central line infection, right? When you suspect a central line infection, you got to get a culture from the central line, you got to get a culture from another peripheral vein in the body. Very high yield to know that stuff for your exams, right?

And then they can even give you a question where they tell you that, you know, you have a patient that, you know, has a central line placed. And then the person is having very severe pain, right? Having very severe pain at the central line insertion site, and then they tell you that you perform ultrasound or geography, and you notice that there's no flu within the line. Within the line, within the vessel that the line has been placed into, they can say like, you know, for example, let's say you have a jog la venous central line, and then the person starts having like neck pain, and your tool that ultrasoundography feels to disclose vascular flu within the jog la ven, in that case, what do you want to think about? You want to think about a thrombosis, right? The person has literally thrombosis, that jog la venous central line, right? Keep that at the back of your mind for your exams. That's actually a very high yield presentation to know, right? So don't forget that central lines can be come infected, central lines can become thrombost. When you see the terms absence of flu, especially in the line, especially in the central line, think of a central line thrombosis. Now, what if they give you a question about a patient, and they tell you that this patient, you know, came into the emergency room, and this patient has like very significant for the last like 12 hours, they've had very significant pain in the right lower extremity, right?

And they tell you that their temperature is 100.5 degrees Fahrenheit, and you know, they tell you that, ooh, you know, the, you know, the one leg is bigger than the other or whatever, right? And the person has just taken like some kind of a plane ride or a long car ride or whatever, right? Obviously, you're thinking about a DVT, right? And then they tell you that, ooh, that 12 days ago, the patient was treated for a very significant GI bleed, where he was more dynamically unstable. And then they ask which of the following is the most appropriate next best step in management? I would really hope you're picking the answer choice that involves placing an inferior in a cave filter, an IVC filter, an IVC filter. This is very high yield to know for you exams. If they give you a question about a person that has a DVT, and the person has some kind of contraindication to anti-coagulation, you know, let's say they've had like recent major surgery, right? Or let's say, major surgery is usually not going to be the contraindication. The contraindication to anti-coagulation, they're going to throw you exams, is that the person has had like really, really bad hemorrhage, very recently, or ongoing really bad hemorrhage. Then in those circumstances, I was strongly encouraged to pick the answer that involves placing an IVC filter, involves you placing an IVC filter, and if you're having a cave filter.

Now, one of the questions I get with vascular themes, or you miss your exam, is when should you do an embolectomy on your test? Embolectomy sometimes is the right answer, right? So basically, like, bringing out an embole from a vessel, it's going to be the right answer in certain very specific situations on your exams. Say for example, if a person has a PE, a pulmonary embole, and it's a saddle embole, in those circumstances, you absolutely should do an embolectomy on your test. I would not pick TPA for that person, it's a big, big, big lesion. Many times, if you have a saddle embole, you're going to die pretty quickly if we do nothing. So we're going to go ahead and do an embolectomy in those circumstances. Another classic situation is they'll give you a person that has a history of AFAB or RISEN MI, and then they have like sodium onset severe, low extremity pain. And then you notice that all the arterial pulses in that extremity are disappeared. That's obviously going to be acute limb ischemia. In those circumstances, you need to do an embolectomy. And then another situation where you may do, yeah, those are probably the two situations where you do an embolectomy on your test. Now, don't confuse embolectomy with embolication. Embolication is where you directly induce an embole in a vessel, typically to stop bleeding. Many times on the USML exams, they're going to do angiography of the embolication.

It's like an interventional radiology procedure when a person has like really, really nasty GI hemorrhage, really bad GI hemorrhage. And you notice that the person is very unstable. That person typically is going to need some kind of angiography with embolication, especially if they have like really bad GI bleeding from some kind of hematoma or from some kind of, you know, just bleeding from a mesenteric vessel. In those circumstances, you probably want to go ahead and do angiography, right? Vascular angiography with embolication. That's very high yield to know for your exams. And then what are some situations where we use TPA, right? On the exams. And again, many times they're not going to call it TPA. They're going to call it things like streptokinase or your kinase or do we call it like otte plays or tenet plays, right? So TPA, when you use TPA on your exams, remember we're going to use TPA for strex. What kind of stroke? Well, I hope you're saying divine and ischemic stroke and ischemic stroke where you're less than four and a half hours from when you presented with a stroke. In those circumstances, yes, you should absolutely give TPA, right? And also you can give TPA when a person has M and M I, right? Am I calling it infarction? And they're more than two hours from a PCI capable facility, right? More than two hours from a place that can do, you know, do angiography with ten policemen in the heart, right?

Now, one of the weird scenarios you may see on your test, I don't think many resources emphasize this, but this is actually pretty high yield to know for your test. If they give you an acute limb ischemia question and embolectomy is not a provided answer. In those circumstances, I will strongly encourage you to pick the answer that talks about TPA, right? Remember, don't forget the management of acute limb ischemia. You're going to start off with anti-coagulation first, right? You're going to start off with anti-coagulation first and then you do the embolectomy, right? Although before you do the embolectomy, you need to do a CT angiogram of the low extremities to find where the emboleus is, right? But if you don't see embolectomy as an answer, I highly, highly encourage you to pick the answer that talks about TPA. You can absolutely use TP As for acute limb ischemia on your exam. Now, what if they give you a question about a patient that gets TPA? They got TPA hours ago. And then you were told that over the last, they didn't tell you that the patient has started having like a red urine, right? Especially for a acute limb ischemia, right? The person got TPA or whatever. And then they tell you that the patient now has red urine and you notice that the person's, they give you an EKG and it shows you like a white curus complex and topic T waves. And then you see the creatinine is 2.5.

When you see something like this, I would really hope you're thinking of the answer that talks about a reprefusion injury, reprefusion injury, right? So when you restore vascular flow to part of the body that was ischemic, sometimes you can, especially when you do like a delayed intervention, right? Let's say the person's symptoms started like five hours ago, whatever. And you're just now reprefusing it like a late stage of perfusion that can cause reprefusion injury, right? That can cause destruction of the muscles, right? Because as you restore perfusion, you bring all this oxygen and blood back, right? You can generate a lot of friar articles that can cause a lot of tissue damage, right? So as you damage all those tissues, the intracellular ion in those things is going to get released, right? So you're going to have things like hyperkelimia, right? Sometimes they can have like wrapped in my all assess, right? That can elevate their creatinine, right? They can have like renal failure and all those things. When you see stuff like that, think about reprefusion injury, think about reprefusion injury, right? And obviously for the person who has hyperkelimia and they are beginning to have like EKG findings, your next step is going to be to give them calcium gluconics to stabilize that, myocardium to stabilize that, myocardium. All right, so I feel like I've given a lot of detail in this podcast, right? So let's kind of put a pen here.

God willing, I should, I feel like there's a lot of meat still left on this bone, right? With imaging. And if you notice again, it's titled an imaging podcast, right? But I'm also doing a lot of vascular discussions because many times on the US ML is imaging and vascular studies, they kind of all go on and on, right? So let's put a, let's put a pen here. We're going to pick pick up from this in probably in the next podcast actually because this is actually a very high your topic that is beginning to show one more on the US ML exams. And again, if you love the way I teach you love the way I make integrations, then you're going to love my classes. I actually have classes that start today for this month with a test taking class. Two and a half artistic in class for step one to three tomorrow. I have a bio stats class for step one to three on Thursday. I have a social science and ethics class for step one to three. That's a five hour class. And then on Friday, I have a last mini review for step two and three specifically that again, many people have taken on found to be extremely helpful. Obviously, that also applies to level two level three level one. And then next week, the five days next week, I have a 20 hours step to step three review. Again, I've had many people take these classes and like literally recent testimonials. I've had people take my classes and get like in the 270's in the high 260's like literally very recently.

I literally got an email from somebody yesterday that got like I'd you know just trying to keep privacy of the person here. But the person got like very high 260's. Much higher than all their practice tests. And the person took one of my classes. And this was a class they took like within the last few weeks here. Right. So many people take these classes and do really well with them. And then also for one or one to learn for all the US Emily and complex exams and I help with your applications, personal statements, more interviews and those things. And I have this podcast on Apple Google and Spotify. So check those out. I have a You Tube channel where I post the videos that I make, check that out as well. And then I also have another website titled divine intervention life lessons.com. Divine intervention life lessons.com every week. You know, many of you know I'm a Christian, a Christ follower. Every week I post like two to three podcasts were from a biblical perspective address life lesson. Many people actually listen to these podcasts and find them to be helpful. Actually have almost 350 podcasts on there. Divine intervention life lessons.com. There is actually an Apple podcast associated with that called the Divine intervention life lessons podcast. So thank you for listening to this podcast. God willing. I'll see you in episode 611. So have a wonderful day. God bless you. Enjoy your day. And bye for now. Thank you.

Ultrasound. Mammography has low negative predictive value in this group due to dense tissue.

Linear, coarse, segmented, or clustered calcifications.

Long-term antibiotics (e.g., endocarditis), Total Parenteral Nutrition (TPN), and Chemotherapy.

An Inferior Vena Cava (IVC) filter.

Central line associated bloodstream infection (CLABSI).

Annual MR Is are performed from age 25 to age 30.

Popcorn calcifications, layering calcifications (teacup/crescent shape), or vascular patterns.

Acute ischemic stroke.

Administering TPA (thrombolytics).

Endocarditis or Osteomyelitis.

Absence of flow within the vessel/line.

Biopsy (of the mass).

Popcorn calcifications, layering calcifications (teacup/crescent shape), or vascular patterns.

Acute ischemic stroke.

Administering TPA (thrombolytics).

Endocarditis or Osteomyelitis.

Absence of flow within the vessel/line.

Biopsy (of the mass).