DIP Episode 582 - USMLE Step 2/3 Rapid Review Series 120

Welcome, my name is Divine. This is episode 582 of the Divine Intervention Podcasts. In today's podcast, we're going to be continuing the series on the USMEL Step 2, CK Step 3, Rapid Review. This is going to be series 120. Again, these podcasts is pretty high yield. There's something you should not ignore. I think it will help you tremendously on your exams. So let's jump right into it. So what if they give you a question about a patient and you're told that this patient, they give you like an image and they tell you that this patient for the last, it's a newborn. And this newborn had a lot of seizures within the first few hours of birth. And they give you a chest x-ray and you notice on the chest x-ray that, you know, it's just all black and you notice that you, they tell you that you see a reduced a super-media-stinal or radio density. What should you be thinking about? Well, I would hope you're saying, ooh, Divine, this is a de-George syndrome, right? So remember, in de-George syndrome, your third and your fourth foreign geopolitics do not form. So if you're third and your fourth foreign geopolitics do not form. You do not form a parathyroid gland, and you do not form a thymus. Make sure you can recognize a thymus on a newborn chest x-ray. You know, many of you know it as the sales sign. It's not enough to just know the sales sign. Make sure you can recognize it.

And one thing I've always encouraged people to do is when you see a newborn chest x-ray, just always look at the very tp top. Because I don't know for whatever reason, the tp top of chest x-rays is like one region that many people just ignore. But many times our friends at the MBM Es have some very interesting things that they love to hide there. So just be careful. Getting the habit, because many of us, when we, is almost like a human bias. When we see a chest x-ray, the first thing we want to look at is, oh, look at the heart, try to look for the order and all those things. There are many things you should be looking for when you're looking at a chest x-ray, right? But I encourage you, because it's an often missed region. Look at the top. Look at the apex of the logs. Because there's a lot of things that could be there. You know, they could hide no thymus being there, right? This case is about the George syndrome, but there are many things that can cause a person to have no thymus. Right? So for example, if a person has severe combined immunodeficiency, they will also have an absente cell sign. Right? So it's just something you want to keep at the back of your mind on exams. Right? So this person, obviously, that has the George is going to have recurrent infections, because they have basically no t-cells. Right? Remember, your t-cells really help with cell-mediated immunity. So if you don't have that, then that's a problem. Right?

You're going to struggle with a lot of cell-mediated-ability problems, a lot of issues with viral infections, a lot of issues with fungal infections. You know, many times you see these kids that have the most sisters, Jervetsi, pneumonia. Sometimes you'll notice that they have, you know, oral candidises, throsh and all these problems. So your next question may be, divine, why is it that this child had several seizures after birth? Well, this child had all those seizures because of hypocalcemia. Right? Because if you think about it, people that have the George syndrome, they have primary hypoperthyroidism. And if you have primary hypoperthyroidism, you will not make PTH. So if you don't make PTH, you will not have the ability to raise your serum calcium levels. And hypocalcemia can absolutely cause seizures. You know, and they may not just give you that. They may even give you like an EKG from the child. And you may notice that the QT interval is prolonged. When you see all those things, think of the hypocalcemia. Right? Think of the hypocalcemia. Right? Because the child will, you know, probably have other problems like they may have like tetany and all those things. You know, so just something you want to keep out the back of your mind for, for example, right? They may have like muscle weakness. Because remember, you need calcium for muscle contraction. Right? They may have cardiac arrhythmias because your heart literally needs calcium to contract.

So it's just something I want to keep out the back of your mind as you're studying for your exams. And one thing I also want to say is, they may give you a picture of a child that has a George syndrome. Right? Because you know, like all these, sometimes you either give you a picture of video, these video-based questions. And you may notice that, oh, wow, okay, I see clef-lipp clef palette. Right? So again, make sure you can recognize clef-lipp and clef-palette. You know, sometimes they will give you a picture. The USML is the never-sees to amaze me. They can give you a picture and then ask you which of the following additional findings will be found. So which of the following will be found on further diagnostic testing of this patient? And I really hope that you're thinking of the answer or you're picking the answer that talks about congenital cardiac disease. This is actually very high yield to know. The thing is the USML is they are not stupid, right? They recognize that many people are on key warriors these days. So what do they do? They will test something and then they will ask you about something related to it that you're like, wait, I'm already thinking about this thing. Because think about it, I'm sure many on key decks, you're like, ooh, the George syndrome third and fourth-firing keoparkets failed to form. No timers, no parathiric lands. Great, awesome. But they can give you a full-up question. Many times they can make these things like two-part questions.

Those questions where you got to click on something before you see the next one. And they can say which of the following should be what else should the patient be examined for? You should examine this person for congenital cardiac disease. Or they may even say which of the following additional forms of diagnostic testing should be performed. You want to pick the answer that says echocardiography. Because remember people that have the George syndrome, the George syndrome has a very, very, very solid association with congenital heart defects. They can have things like tetralogy of fallow. They may have things like troncosateriosis. Remember in troncosateriosis, it's almost like you have this common drainage from the heart. Tetralogy of fallow, remember they have four findings. They have the pomonic stenosis. That pomonic stenosis, basically. And you may wonder what causes it. Well, the thing that causes it is basically your membrane of the interventricular septum. It doesn't grow down proportionally to meet the muscular interventricular septum. So it's almost like it's just one of these things I have to kind of diagram out. But it's something you can also kind of imagine. But basically, I just like to think of it this way. The pathophys of the George syndrome is of a tetralogy of fallow is as follows.

There's a part of your interventricular septum that is supposed to come down and is supposed to give you know, appropriate amounts of space to the yoder and appropriate amounts of space to the pulmonary arteries. But it does not. It ends up giving too much space to the yoder and too little space to the pulmonary arteries to your pulmonic system. So because you're getting too little space for your pulmonic system, you're going to get pulmonic stenosis. And then after you get pulmonic stenosis, well think about it. It's going to be hard for your right ventricle to pump out blood. So you're going to get a right ventricular hypertrophy. And also just because of the way that division happens, you have a VSD, you have a clear-vious communication between your right and your left ventricles. And then you also have an overriding in the yoder. It's almost like your yoder is like picking up from both your right and left ventricles. Those are the four findings of intertrology of the loam. These things are all common in people that have a de-George syndrome. So just something you want to keep in mind. So please don't neglect these things. Don't neglect these things. Where they will give you a pathology and then ask what else should you screen the person for? Or whatever, right? It's just like for example, if a person you know presents with like muscle weakness that is worse by the end of the day, you know that all your de-Leon-mystine aggraves.

And then they ask you which of the following is the which of the following additional diagnostic tests should be done. They want to get like a chest x-ray or some kind of chest ct, right? Because we know that my stin aggraves is associated with thymomas, right? My stin aggraves is a sort of thymomas, right? In fact, some people when you resex those thymic masses, then you notice that they are myestinia symptoms improved tremendously. So please be mindful of these things where you're asked about one thing and you're supposed to check for something else, right? Or sometimes instead of using the word thymoma, they may actually say which of the following is strongly associated with the patients on the line condition, right? They may put thymomas and answer, or they may put an anterior miestinomas. Remember a thymoma? It's an anterior miestinomas, right? So again, just to summarize, the George syndrome, don't forget that they can have this congenital cardiac problems like truncose arteriosus, tetrology of the low. Don't forget that they can have clef lip and clef palate. Don't forget that they can have hypocalcymic seizures because they basically is a congenital cause of primary hypoparathionism. Like literally, don't be surprised if our friends at the NBM Es, they give you the George syndrome question. And then the one of the the right answer ends up being something like congenital primary hypoparathionism.

The thing is, as I'm saying it now, it's something that seems pretty obvious to people that are listening to the spot cast. But in the heat of an exam, congenital primary hypoparathionism you like. What? To find that doesn't make any sense, but no, it does make sense because that's literally what they have, right? That's literally what they have. Again, the C, and this is something I share a lot in my test against strategies class. I tell people this that C, be comfortable with hearing the NBM Es talk about things in other terms that you're not used to. Get comfortable with that because that's the reality of your exams, right? Your exam is not going to be a buzzword heavy, buzzword, buzz phrase field exam. No, that's not how your exam is going to be. They're going to take what you know and just put it in other terms. And honestly, that's a good way to see if people really understand what's going on. So please just be careful about that. Just be careful about that. Right? And then we've talked about my senior gravies and how it may be associated with thymomas, right? He may be associated with thymomas. All right. And we've talked about how thymomas and ture media's tino masses. Now, what if they give you a question about a person that is diagnosed with polymyocytes or dermatomyocytes, especially dermatomyocytes, right? And then you are asked, well, which of the following additional screenings need to be done?

Well, the thing is that person is going to need some kind of age appropriate cancer screening, some kind of age appropriate cancer screening, right? If a person gets it because remember, polymyocytes and dermatomyocytes have very strong associations with people having like malignancies, like lung cancer or breast cancer or colorectal cancer or things of that nature. So based on the age of that patient, that should guide you as to, okay, these are other things we need to screen you for. Because many people think that just by memorizing the screening guidelines, they are home free on the exam. No, no, that's not all that's going to save you on your test. You need to know those screening guidelines for you need to know them in what in context, context really, really matters on the USMELIS. I'm going to say that again, context really, really matters on the USMELIS. So it's just something I want to keep at the back of your mind as you're prepping for your exams, right? They can literally make a screening guideline question out of dermatomyocytes, for example, right? Or what if they give you a question about a patient and they tell you that, oh, for the past four weeks, this patient has been having like very significant pain in his hands, very significant pain in his knees, right? And you know, they tell you that, oh, they get an extra of one of these joints and you see like a lot of reactive bone formation.

And then you're told that this person has a two-pack per day smoking history for the past 35 years. And then they ask which of the following is the most appropriate next best step in diagnosis or screening or whatever? You should go ahead and get a chest CT for this person. Why? This person has lung cancer. You're like, what? Divine, how did you get there? Well, I got there because this person has a perennial plastic syndrome. The person has hypertrophic osteoarthro, you know, pulmonary osteoarthropathy, right? You see this, you know, basically a thropathy that develops over a few weeks or whatever. It's a common perennial plastic syndrome we see associated with lung cancer. So for those people, they're going to need some kind of pulmonary imaging in the form of some kind of chest CT so you can see exactly what is going on, right? You can see exactly what is going on. All right. Now, what if they give you a question about a patient? And you're told that this patient, you know, was recently started on, you know, this patient has a lung history of diabetes. And you're told that this patient, you know, has been on metformin, but he's a once he did not decrease. And then two weeks ago, he was started on a new drug. And that for the past two days, the patient has been having trouble sleeping. And you're told that when you listen to the person's chest, you can hear, you know, by basilar crackles in the person's lungs, what should you be thinking about on that those circumstances?

What kind of drug was this person placed on? I would really hope you're saying divine. It sounds like this person was placed on a TZD. It sounds like this person was placed on a fire solid in diet. So what's a fire solid in diet? Well, a thousand, the fire solid in diet, fire solid in diet. Let me spell that.

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ndins, prostaglandins are visual dilators, you have less visual dilation, and you have more visual constriction.

That visual constriction will cause you problems, because if you constrict the afrin arterial, then there's going to be less perfusion of the person's glomerular capillaries. That's going to reduce the hydrostatic pressure within that person's glomerular capillaries, and if that happens, that's going to lower GFR and risk creatin. If you then add another problem on top of that, like taking an AC Hibiter and ARB, that may tip a person over the edge. I'm not coming out here to say that, oh, never take AC inhibitors or AR Bs if you're in an NSAID or aspirin. No, that's not the point of this. But if a person has already impaired renal function, and they're already on an NSAID or aspirin, and then you throw an AC Hibiter and ARB, that may tip those people over the edge. Let's go ahead and continue here. Now, we've talked about cleft lip and I said that, hey, it's a zero D George syndrome. Is that the only disorder that is associated with cleft lip? No. They actually other disorders that are a little cleft lip. And one big one that is very high yield to know for you exam is Trisomy 18, right? What is Trisomy 18? That's Edward syndrome. Remember, there are certain very classic features that we find in Edward syndrome that are very, very high yield to know for you exams, right? Like, for example, what can they have? They can have micrognathia, right? They can have the George syndrome. I mean, sorry, Edward syndrome. They tend to have very small jaws.

They tend to have very small jaws, right? And the thing is, these people tend to have abnormal developments of their wrists of their digits. So they may have issues like clenched hands, right? You may notice that they have like clenched hands, they may have like overlapping digits, right? Sometimes on your exam, they may even use the term that they have a rounded profile to the bottom of the foot around their profile. What do I mean by this rounded profile to the bottom of the foot? This rounded profile is rocker bottom feet. But again, our friends at the MBM is they know that everybody that has at least many people that have the job description medical student have memorized rocker bottom feet, rocker bottom feet, rocker bottom feet, right? So why use the term rocker bottom feet when you can just describe it and say, Hey, this person has a rounded profile to the bottom of the foot. And then as you're reading the exam question, you're sweating, you're rounded profile to the bottom of the foot. What is that? Well, that's literally a description of a rocker bottom foot, right? These are things we find in people that have Edwards syndrome, right? So round their profile to the bottom of the foot, that's rocker bottom feet, right? And these people also tend to have a permanent calcinius. The calcinius is one of the bones of your of the foot, right? All those things can be found in Trisomy 18. Most of these keys, they don't really make it very long.

You know, many of them die in utero. If they're born, they'll probably die within the first few days, max within the first year of life, they're gone. Unfortunately, right? Now, what if they give you a question about a child, and they show you a picture, the thing is for some of these congenital diseases, they know that many people have memorized the findings, but they don't actually know what those findings mean, right? Like, for example, many people have memorized people that have down syndrome, they have a transverse Palmer crease. Many people have memorized that, but you know that there's a lot of people that literally have no idea what that transverse Palmer crease looks like. I will encourage you, pause this podcast right now. Well, if you're driving, don't do that, but pause this podcast right now and literally just look up what a transverse Palmer crease looks like, because instead of giving you those words, they may substitute that with pictures. See, the NBM is they find creative ways to put things in other terms, right? Instead of using the words transverse Palmer crease, a very easy creative way to put it in another term is to just substitute that with a picture, right? They will show you a child and you notice that there's just this straight horizontal line running from one end to the other across the palm. Look at your palm.

I can almost promise you that you don't see a straight horizontal line running from one end to the next is kind of interrupted in most people, right? When you see that transverse Palmer crease, you really want to think about a child having Down Syndrome, right? And you know, many times people that also have Down Syndrome, they may have like this flexion crease on the fifth digit, this flexion crease on the fifth digit of the hand, right? So like they're pinky, right? So you should again, try to look that up, try to look that up, make sure you can recognize for your test. All right. Now, what if they give you a picture of a child? They tell you that, oh, that this is a newborn and this newborn, you notice that the extremities of this newborn are fused, they're fused, right? They have like fused extremities, you know, they almost look like mermaids. What should you be thinking about on your exams? I really hope you're saying, oh, the viney sounds like this child has something known as sary no milia, sary no milia, right? Sary no milia is when you basically have fusion of your lower extremities, right? And sometimes on the exam, they can ask, what's the underlying path of physiology behind the observed physical exam findings? Well, the path of is there is that basically you, you have a failure to establish vascular supply. You don't have good blood flow to your lower extremities in utero. So because you don't have good blood flow, it does not develop properly, right?

So those extremities stay fused, right? So again, they may talk about like a vascular normally in utero as the pathophase behind sary no milia was another high yield congenital issue that arises from vascular normalizing utero. I hope you're saying, ooh, divine, that's gejonal atrija, gejonal atrija. Remember, do other latrija is a failure of recolonization, but gejonal atrija is from vascular issue in utero, right? It's from vascular issue in utero. So sary no milia, where you have fusion of the lower extremities, it arises because you don't establish good vascular supply from the lower yoder to your lower extremities, right? So that causes you problems, right? And what is sary no milia heavily associated with on the USMELIS? Well, I hope you're saying divine is very heavily associated with maternal diabetes, right? With maternal diabetes. The thing is, maternal diabetes can cause so many problems for for a fetus, right? It can cause this fusion of the lower extremities, it can cause sary no milia, but what else can it cause? Well, it can cause something called cotto regression syndrome, right? Sometimes they call this cichlal age and SS, where basically your secret fails to develop, your secret fails to develop, right? It can cause a myriad of problems for for a fetus. They want to make sure that you can recognize for your exams, right? And remember, maternal diabetes is also associated with a child having a VSD. It's also associated with a child having a VSD.

What else can maternal diabetes cause? It can also cause seizures in the newborn. Hey, we've talked about seizures in the newborn already today with the George syndrome because they have congenital primary hypoprothyroidism, but you can also see hypoglycemic seizures in an infant of a diabetic mother. What's the pathophysiology? It's pretty straightforward. Think about it. Your fetus in the womb, you're exposed to high sugar mom, high sugar mom, high sugar mom. Well, all those high sugars are going to cross the placenta and come into the fetus. So the fetus is like, hey, I don't like having these high levels of glucose around. So the fetus bittersales are going to be like, okay, okay, let's undergo some degree of hyperplasia, right? So you undergo that hyperplasia, right? You undergo beta, I let cell hyperplasia. So you can make enough insulin to deal with that problem. You make all that insulin. It helps you deal with the problem. And that's amazing, right? It helps the fetus control their blood glucose. Their blood glucose. But after the fetus is born, this fetus has been disconnected from the source of high glucose, aka mom. But hyperplasia is a genetic process. It's not something that just reverses quickly. So this child is now in a state where the source of high glucose mom is out of the picture because the child has been born. But the source of the high insulin, the hyperplasia, if there's a, that's wrong English, but just work with me here.

Those hyperplastic, okay, let's be more accurate, right? Those hyperplastic beta, let's say, it's not immediately that the hyperplasia will just resolve out of the blue. No, it's not just going to resolve out of the blue like that. It's going to take some time. So that child is still going to be producing very steep amounts of insulin. And those steep amounts of insulin going to drive down the child's blood glucose. If you have low blood glucose, that can cause hypoglycemia and that can cause what? Seasures. That can cause hypoglycemia and that can cause seizures. And let me ask you this, besides the hypoglycemia, what other electrolyte abnormality will you expect? You know, within the first few minutes, first few hours of birth in an infant of a diabetic mom. I hope you're seeing, define this child may have hypokillemia. Again, that may be a question you see on your exams. Why? Because remember insulin increases the activity of the sodium potassium ATP spot. That's literally one of the reasons why you can do insulin plus glucose to manage hypercalibrate. Remember, the first thing you're going to do obviously is to give calcium glucose and to stabilize the myocardium. But insulin plus glucose, they increase the activity of the sodium potassium ATP is pump. And what does this pump do? It takes three sodiums out of the cell and puts two potassiums into the cell.

So if you activate it, you're going to redistribute potassium from the serum into the person's cells to try to control those blood potassium levels. So this child is in a state of hyperinsulinemia. That can tank the child's potassium. And you can already begin to see that that may potentially cause arrhythmias and things like that. So being an infant of a diabetic mom is not great. It's associated with many, many, many, many different problems. Like, for example, they can give you a shorter, distusier question. Because think about it, if you're an infant of a diabetic mom, insulin, many people forget this, but insulin is literally a growth factor. Insulin literally makes people grow. Have you noticed that many type two diabetics are pretty big? Especially people on a lot of insulin. Insulin is a growth factor. I mean, have you ever heard of IGF one? What do you think IGF means? It means insulin like growth factor, right? So insulin is a growth factor. So you can cause phidomaicrosumia. Phidomaicrosumia can cause a lot of problems. It can cause shoulder distusia, right? Where the child's anterior shoulder is stuck under the pubic synthesis, right? It can cause an increased rate of cesarean sections, right? Like literally, they can give you a bio-statistics question and talk about a cohort study, right? So it's almost like a bio-stats and peeds and OB-GYN question or rooting to one.

They can talk about some kind of cohort study involving moms that have like a BMI of 30 something or whatever. And then they also talk about their A1 Cs. They'll say, well, they got a cohort of 200 moms. And then they then say, oh, which of the following outcomes will be observed in this cohort, right? And they can say, oh, increase, and the right answer will be something like increased relative risk of a cesarean of cesarean deliveries or increased relative risk of congenital abnormalities, right? They know that these are all things you know. They know that you know that or being an infant of a diabetic mom or being a diabetic mom increases your risk of your child having VS Ds or you having C-sections or your labor being prolonged or you having a shoulder disorder, you know, having labor where shoulder distortion is a problem, right? But again, why ask it as a direct question where you can just reframe it? It's all about reframing and make it like a cohort study question where you ask about the most likely outcomes of this cohort study over like five years or 10 years or whatever, right? Again, these are just all forms of what? Of reframing of reframing. So please just be conversant with these methods of questioning on your exams. Please, I'm doing, I'm saying this not because I like to hear myself speak, but because I'm trying to help you see how the USMEL is love to test information. So since this is our rapid review series, I'm going to go ahead and stop here.

I mean, if you're interested in any of my classes, if you like the way I teach, you like the way I meet integrations, you like the way I show people how the USMEL is test information, you're going to be very interested in the classes I offer. I have a class starting tomorrow, right? I have a test taking class starting tomorrow. It's for step one to step three. On Wednesday, I have a bio-stats class, four hour class, also for step one to step three. And third, they have a social sciences quality improvement healthcare systems class. Also for step one to step three, right? And then on Friday, I have a last minute review just for step two and step three. And then next week, I have a 20 hour step two step three review. And then first week in May, I have a step one class that's for people taking step one on level one. Or if you a taking step two or step three, or level two and three, you have like a poor basic science foundation, I think you'd find that that class to be extremely helpful. And then I have this one of a kind class, 50 hours step two step three review, taking place in the first two weeks of June. If you're interested in many of these classes, just shoot me an email and I can give you some more information. And I've also made podcasts where I talk about these classes. And again, these classes, many people have attended them and done extremely well on their exams. And then I also offer one on one to learn for all the USME Ls, all the complex exams.

I also help with like era's applications, personal statements, more interviews and things of that nature. And then I have these podcasts on Apple Google and Spotify, have a You Tube channel, you can check out. And then also have another website called divineinterventionlifelessons.com, divineinterventionlifelessons.com. Many of you that listen to this podcast, you know, I'm a Christian. So every week, I post like two or three podcasts where from a biblical perspective, I address a life lesson. There's actually an Apple podcast associated with that called the divine intervention life lesson spot. So just listening to those, I have like more than 310 podcasts on there. Again, many people have found those to be really, really helpful. So thank you for listening to me today. Please, quick summary, pay attention to the pathologies I discussed here. That's number one. Number two, pay attention to the methods of questioning I talked about here. And the test taking principles I talked about here, it can be very, very helpful for your success on the exam. So I will see you in episode 583. Have a wonderful rest of your day. God bless you and bye for now. Thank you.

The third and fourth pharyngeal pouches (leading to absent thymus and parathyroid glands).

Cleft lip/palate, T-cell deficiency (immunodeficiency), and hypocalcemia.

Thymoma or anterior mediastinal masses.

The apex/top region (for the thymus sign).

Hypokalemia.

Saethre-Straus Syndrome (Synechia).

Clenched hands, overlapping digits, rocker bottom feet, and permanent calcaneus.

Thymoma/Anterior mediastinal mass.

Transverse palmar crease (single deep horizontal crease).

DiGeorge syndrome.

Hyperinsulinemia drives potassium from the serum into the cells via the Na+/K+-AT Pase pump.

Increased risk of malignancy (e.g., lung, ovarian, colorectal), requiring age-appropriate screening.

Clenched hands, overlapping digits, rocker bottom feet, and permanent calcaneus.

Thymoma/Anterior mediastinal mass.

Transverse palmar crease (single deep horizontal crease).

DiGeorge syndrome.

Hyperinsulinemia drives potassium from the serum into the cells via the Na+/K+-AT Pase pump.

Increased risk of malignancy (e.g., lung, ovarian, colorectal), requiring age-appropriate screening.