DIP Episode 238 - USMLE Step 2CK Rapid Review Series 37

Okay, welcome. My name is the Vine-Amar resident. This is episode 238 of the Divine Intervention Podcast. In this podcast, I'll be continuing the Rapid Review series for the Statuesique exam. This will be series number 37 and we'll take things from there. So what if they give you a question about a child? And this child, you know, they tell you he's an immigrant from a, he was just adopted and you know, this child, he tell you that, you know, he just arrived in the US like two days ago and he has been having pretty severe and you know, they tell you that he, physical exam is like they give you some labs and you notice that his album is like one, right? So you know, let's see, he has like really bad protein monotrition and in detail, you know, this person is presenting with like a chief complaint of like, you know, like severe abdominal pain and you know, he has like a mild fever like 100.9 and he tell you that he has like ultra mental status and he tell you that on physical exam of the abdomen, you can see like shifting down us with a fluid wave. If you see that, what are you thinking about? Well, I hope you're thinking about SBP, right? So the thing is, game gaming, you're becoming a little, a little more creative with how they test SBP, right? Because they know that, you know, most people called med student have memorized SBP in the context of, you know, liver disease, you're not making protein, you have auto hypertension, you have nasty assidies, right?

So that acidic fluid becomes infected with SBP. But one of the things that they're beginning to go after, they're beginning to go over like more novel patient populations that may have SBP, right? Like one classic one is like a kid with Quascio core, right? Remember Quascio core, I write this when a person has protein malnutrition. If you have protein malnutrition, that's a problem, right? Because essentially you lack on chronic pressure in your body, right? So your mesenteric vessels will favor filtration into the, like the peritoneal cavity. So you can have like a ton of assidies and that assidies can get infected and you get in trouble. Alternatively, they can make a question about a person that has some kind of nephrodix syndrome, right? Again, nephrodix syndrome, your peanut protein, right? In your glomerulus. And if your hypo-abominemic, again, you're losing on chronic pressure, you can get SBP with that. Alternatively, if a person has many trades disease, remember that's a protein losing gastropathy. I think of it as like nephrodix syndrome of the stomach, right? Those people like essentially again, like hemorrhaging protein in their in their stomachs. So again, that can kill the on chronic pressures and they get in trouble with SBP. Another classic one can be a person that's on peritoneal dialysis, right? Peritoneal dialysis, right?

Like you're kind of like putting plastic in a person's, although this one is a somewhat different mechanism compared to the other like low protein states that I've described. But for persons on dialysis, right? Like, you know, you're putting plastic in a person's GI tract, again, that can potentially be a nightest for infection and the person could get SBP, right? And obviously, I would hope you know at this point that, you know, SBP, you will typically want to go ahead and do like a paracetesis and you're looking for that more than 250 neutrophils. If you find those, you'll treat the person with, even if the gram's thing is negative or whatever it doesn't matter, once you find more than 250 neutrophils, your job is done. You treat the person with a third generation of cephalospor, right? Like except traction or cephotaxe. If you don't see any of those, you can pick a flu or a as your answer choice. Okay. Now, what if they give you a question about a patient? And the patient has, you know, like gets a phybiscane test and is a healthcare worker, gets 10 millimeters of inspiration, right? What's your next step in management? Well, I would hope that you want to choose a chest X-ray. Remember, the next best step on MBM exams after a positive PPD is a chest X-ray, right? If the chest X-ray is negative, they've got a latent TB, right? You give them nine months of isoniasit plus vitamin B6, right?

So that they don't get like cyderoblastic anemia or getting seizures or getting like peripheral neuropathy and all that badness, right? So the thing is, many people that have treated say, divine, I have a hard time remembering the, the codoths for TB. To be honest with you, I look at that, those TB-indirational codoths as a scale. I look at it as a scale of immunodeficiency, right? So like it's like if you're lower on that scale, right? Then we're like, oh, if you have any kind of iteration, we're like, let's go ahead and make sure this person doesn't have TB going on, right? So like it's like a scale like you have like the number five, the number ten, the number fifteen, and these are obviously only millimeters, right? If you're 15 millimeters, iteration positive, then you definitely have TB for sure. Everyone is positive at 15. If you're 10 millimeters, you know, you're thinking of a healthcare worker. When a healthcare worker is not necessarily immunocompromised, but you're pretty close to people that immunocompromised, right? So you're kind of like a surrogate for like a medium immunocompromised, right? And then the people at the lower end of the scale, the five millimeter people, HIV patients, people on chronic corticostero therapy, right? People on, so HIV patients, chronic corticostero therapy, post transplant patients, patients with, um, an immunodeficiency disease, right? Those are people that kind of hit that five millimeter threshold.

And again, remember if you have active TB, they're giving those people the right predium, right? Right? Vampy and I sonyize it, they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, right? So they're not gonna give you a lot of them, and they tell you that the patient is on hydroxychloroquine and they ask for the kind of like preventive measure you're supposed to follow with those people. Well, on MDM Es, you want to think of those people getting regular eye exams. Remember hydroxychloroquine, I mean, classically, in the hospital is known as placuano, right? Placuano. Hydroxychloroquine damages the retina, right? It causes like, it damages the retina, pigmented epithelium, right? So typically those people need like regular like yearly eye exams, actually, they're on hydroxychloroquine. That's a floridly high yield factor to know for the USMD exams.

And then this, there are many people like, you know, that are taking your exams, they're like, ah, define how do I know that this problem is in the spinal cord. If you're listening to my neuro podcasts, I go into like a lot more detail on this stuff. But basically, there are four cardinal signs on an MDME exam that tells you that, you know, this person's got a, this person has a, has a spinal cord pathology going on, right? So the first one is if they have urinary incontinence. Urinary incontinence usually means that the person's problem is a myelopathy. It's a problem at the level of the spinal cord. Another classic one you may see is, ah, if the person has upper motor neuron symptoms in the lower extremities and lower motor neuron symptoms in the upper extremities, right? Because think about it, right? If you translate the spinal cord at that level, you're transacting the lower motor neurons, right? So those lower motor neurons don't work, right? So the person will have like, on a more elevated, like a, like a vertically higher part of the person's body, they'll have mostly lower motor neuron problems, right? But remember that you've also transacted fibers that are going all the way down to lower parts of that person's body. So by transacting those upper motor neuron cortical spinal tract fibers, the person will have upper motor neuron symptoms down low. So low motor neuron symptoms up high and upper motor neuron symptoms down low, right?

Tell you that you have a myelopathy going on. And then the third one that you've probably heard me say at NOSME Many Podcast is a sensory level. The presence of a sensory level, that's very classic and characteristic of myelopathy, right? So what do I mean by sensory level? It just means that below a certain level, a person has lost all of one kind of modality, right? So it may be that they've lost like, oh, pinprick and pain and temperature sensation below their nipple line, right? Below like, it's like, almost like, below this level in the body, they've lost all of a sensory modality. That's a sensory level. That's classic for spinal cord pathology. And then the final one is if you see people having a spinal phalamic tract and dorsal column tract signs on control lateral sides of the body, that's also pretty classic for spinal cord pathology because again, remember, you can see the why those this will work? Well, the reason it works is the dorsal column does not cross until you get to the column of dollar, but the spinal phalamic tract crosses, right? After you have the synapse of the second first, other fibers with the second other fibers, those fibers cross, right? In the anterior white commissure right in front of the central canal. Remember that the syringomile association there, right? So because the spinal phalamic tract fibers cross, basically those people can have, you can essentially deduce that those people could potentially have, you know, like crossing signs.

So you see like, oh, on the level of extremity, the lost pain, temperature and pinprick sensation, the regular extremity, they've lost vibration, fine touch and perperception. You see that? You're dealing with a spinal cord pathology. Now, one of the things that your friends at the MIMI kind of care about that you know is knowing like, you know, they may give you a question about a patient and they tell you that, ooh, this patient was recently, you know, was in a, was found down by the police on the street, persons in alcoholic and the persons body appears cold and the person has like red urine, creatins, like three CPK is like 10 grand and then they're asking for like labs, like they can give you all these, you know, when they will give you these questions and the answers are all like lab values, right? And you're trying to pick out, I mean, the CPK one will be easy. So they'll put that in like many of the answers, you know, your CPK is going to be high when a person has a rabdo, right? But they'll very likely give you a question where you need to figure what's going on with the calcium and the phosphate, right? And also the potassium, right? So don't forget people that have rabdo, right? The emotional cells die. Well, the emotional cells die, they release all that phosphate they have, right? Because remember, emotional cells is a ton of ATP, right? So they release all that phosphate.

And I mean, the phosphate number is variable, so I'm not really going to fist on that right now, but the calcium and potassium are very important to know, right? All that phosphate will bind up those people's calcium. So those people can get high pool calcium. High pool calcium is a hallmark of rabdo myelosis. And then if you remember, your fancy, shmancy sodium potassium ATP is pump, it's job is to pump three sodiums into the cell and no, three sodiums out of the cell and two potassiums in. So potassium is predominantly an intracellular iron, right? It's predominantly an intracellular iron. And if that potassium is, you know, all these muscle cells are dying, they are releasing the acel soup into the surrounding. So you can already begin to imagine that the potassium will be pretty high. And if the potassium is pretty high, you will then notice that in those books, you can have arrhythmias, right? So, I mean, give you a question where you have to integrate like, oh, I got to give this present calcium glucone because they have like a white carus in the setting of rabdo myelosis, right? Because remember, hypercalemia usually on ekegies, you know, you get the white carus first, you get the peak, tall, tall peak stewaves. And then if you don't treat it, the person will like go to a sine wave. And then if you don't treat it from a sine wave, you go to acestely, right? And that's like that, right? So, those are the lab values you should expect in rabdo myelosis.

So Cpk is elevated, calcium is low, and potassium is a, is a increased. And I've explained the mechanisms behind all those things. Now, what if they give you a question about a child, born at 26 weeks, right? And this child, they tell you that this child, you know, has been breastfed for the past like two days. And then now this child has like severe profound abdominal distension, this child has been having like bloody stools, right? And the child is listless and has like significant abdominal pain on parpatient. You want to think about and necrotizing interocleitis, right? And typically, what would you want to do next for those kids in terms of diagnostic testing? I would hope you're thinking of doing like some kind of like, I don't know, like abdominal film, like an abdominal x-ray, right? And what are you trying to find on that x-ray? I would hope you're telling me that you're looking for pneumatosis and intestinalis, right? So, like, in the world of the bowel. And I mean, typically for those kids, that's like a surgical emergency. You need to go on like, resect dead bowel and all that badness. But basically, to be honest with you, some of you may wonder, what's the pathophys behind this necrotizing interocleitis? To be honest with you, the way I think of nec, I think of it as like, obviously it's going to be in a premature kid. So if a kid was born a term or post-term, it's not necrotizing interocleitis. You can pretty much scrub that out of your memory on exams, right?

I think of necrotizing interocleitis as C-DF in primins. C-DF in primins. Because think about it, right? Like as a primi, you don't have much of a GI floor, right? So like all these like bugs that normally are kept in check by the other members of the floral community in your GI tract. They are not kept in check anymore. If you're not kept in check, those bugs can spring forth and cause a lot of problems, right? So that's why again, you want to think twice before breastfeeding a child that is a premature, right? You know, until at least his GI tract is able to take the head. So necrotizing interocleitis, usually those kids are treated with the need surgical therapy. Okay. And then let me take a quick tour through some weird malignancies that revolve around the lymphoma concept that the MBM loves to test, like just in the context of like weird diseases, right? So let's kind of take it from the, let's see where do I want to start. I guess we can take it from the top, right? So they can give you a question about a woman, you know, she has like dental caries, poor dental hygiene, uh, greedy sensation in the eyes, right? Hopefully you're telling me that that person has showgrants.

Well, the thing is in showgrants, one thing that can ultimately happen is they can tell you all those person has a rapidly and large in jaw mass and the person is beginning to, like, you know, it's lost in pounds on intentionally, you know, you see that you want to think about a salivary gland lymphoma, okay? Remember again, whenever you have chronic inflammation in a particular organ, that can predispose the person to get in a lymphomas, right? Chronic inflammation. So salivary gland lymphoma with that. And then if we go from the cheeks to the neck, right? We can give you a question about a person that, you know, has a history of adolescents disease and then they tell you some story about her, like, you know, you know, she has, she has, you know, she had a long history of like fatigue, cold intolerance, they'll give you a heart rate in the 50s, so that's pretty cardio. So you know, this person probably has hashi models, right? Remember hashi models, you can give you a question about a person that has a long history of hashi models and then the person suddenly has like a rapidly and large neck mass. If you see that, you want to think about a thyroid lymphoma, okay? Fyroid lymphomas are very common in people that are, you know, a likely consequence of having a long history of hashi models are thyroiditis. And then if we keep going down, down, down, right? If we get to the small bowel, you know, not small bowel, let's go to the stomach this time. Remember the stomach, right?

H by lorry, right? Again, chronic inflammation, you can form like a mortal informed, right, from H by lorry, right? So that's something you want to watch out for. And then if you kind of keep going, going, going, going, going, like to, like a question about a person that, you know, they tell you that this person has a BMI of 19, has lost, you know, a fair amount of weight has fat malabsorption, person has like microcytic anemia from like iron deficiency, that's ciliac disease, right? And remembering ciliac disease, those people can get a T cell lymphoma. In fact, on exams, you may see referred to as EATL in terrica, so she said T cell lymphoma, right? That's a classic finding in a, in a ciliac disease. And then don't forget that if a person has a lymphoma in the GI tract, especially in the small bowel, you want to think about the terminal ilium as a very likely site, because remember that's where you have pyrospaches, right? Pyrospaches, those are things that, that's essentially the lymphoid tissue of your GI tract, especially your small bowel in your terminal ilium, so you can get lymphomas there. And then the final lymphoma thing I'll talk about, and then our wrap up here is they could give you a question about like a 65-year-old guy, rapidly in large in scrudo mass, it's solid, it's hard, non tender, that's a, that's a, that's a testicular lymphoma, remember?

Testicular lymphomas are the most common testicular cancer in men over the age of 60, and will not be women, right? Because women do not have testicles. So I'm going to go ahead and pause here, as I do at the end of every podcast, I don't for a one-on-one tutoring for a bunch of exams. Step one, step two, see case, step two, see step three, pretty clean and cool medical exams, 30-a-shelf exams. I do these booster courses, one-on-one with people for all the USML exams, it's 20 hours for each of the USML exams, step one, step two, see case step three. Again, if you're a medicine or a PEEDS resident, titular for the infredient exams and the board exams for those specialties, and then if you need tutoring for, let's say, think of it, I guess, more as coaching for like your ERAS application, if you have meds, if you're a med student, to an AMCA's application, if you're a college student, again, I've worked with tons of people, and most of the people have worked with a bunch of their first choices, you know, stuff like personal statements, ERAS application, more kind of interviews, and again, if you have a tricky application, right?

Low scores, no research, graduated from med school 10 years ago, again, I've dealt with people in many of those circumstances, and many of them have much, so that's something you're interested in, I reach out to me, and then I do this longitudinal tutoring where, you know, if you're studying off med school, or studying off third year, I'll tutor you for your block exams, or your shelf exams, and at the same time I'll be tutoring for step two, see case, basically you're upcoming, you're a semi-examined at the same time, again, I've done that with tons of people, very successful with that, and then if you have a buddy that needs tutoring for the AMCA or any of the pre-med subjects, you know, feel free to reach out to me, you can reach out to me either through the website, Divine Intervention Podcasts with an SADN.com, or you can send me an email at Divine Intervention Podcasts with an SADN.Gmail.com, and you know, please subscribe to the You Tube channel, it's called Divine Intervention, US Mly Podcasts and Videos, I also have the podcasts on Apple, podcasts, Spotify, Google Play, and you know, also please subscribe to the actual Word Press website, Divine Intervention Podcasts.com, so thank you for listening, I will have life lesson, most likely my next podcast, and I'll be having my first step two CK Group Review class over Zoom on Saturday, May 30th, if you're interested in signing up, reach out to me, and I will give you some more information, so thank you for listening, God bless you, I'll see you in the next podcast, thank you.

Cirrhosis, ascites/low protein state, and other conditions causing portal hypertension or low oncotic pressure.

Healthcare worker (HCW).

Isoniazid plus Vitamin B6 (Pyridoxine) to prevent peripheral neuropathy and seizures.

Regular, yearly eye exams due to risk of retinal toxicity/maculopathy.

IV Calcium Gluconate administration.

Pneumatosis intestinalis.

Low oncotic pressure/protein malnutrition causes mesenteric vessels to filter into the peritoneal cavity, leading to ascites and subsequent infection.

Urinary incontinence; Sensory level; Mixed UMN/LMN signs (e.g., LMN in upper extremities, UMN in lower extremities).

Chronic inflammation predisposes to malignancy. Example: H. pylori gastritis leading to gastric lymphoma; Celiac disease leading to T-cell lymphoma (EATL) in the terminal ileum.

10 mm suggests a healthcare worker exposure; 5 mm suggests severe immunocompromise (e.g., HIV, chronic steroids, transplant).

Hypocalcemia is caused by phosphate binding calcium; treating the low calcium prevents life-threatening cardiac arrhythmias.

Thyroid lymphoma.

Low oncotic pressure/protein malnutrition causes mesenteric vessels to filter into the peritoneal cavity, leading to ascites and subsequent infection.

Urinary incontinence; Sensory level; Mixed UMN/LMN signs (e.g., LMN in upper extremities, UMN in lower extremities).

Chronic inflammation predisposes to malignancy. Example: H. pylori gastritis leading to gastric lymphoma; Celiac disease leading to T-cell lymphoma (EATL) in the terminal ileum.

10 mm suggests a healthcare worker exposure; 5 mm suggests severe immunocompromise (e.g., HIV, chronic steroids, transplant).

Hypocalcemia is caused by phosphate binding calcium; treating the low calcium prevents life-threatening cardiac arrhythmias.

Thyroid lymphoma.