DIP Episode 103 - ABIM/Medicine ITE/Step 3 Review Series 5 (Cardiology 1)

Okay, welcome. My name is Devine. This is another episode of the Divine Intervention Podcasts. In fact, to be a little more specific, this will be a episode 103. And this episode will be focusing on the internal medicine intruding exam. And also, I guess the medicine board exams. In fact, I will see this episode is focused very heavily on the EBIM exam and the medicine IT exam. And it's also partially focused on step three because many of the things that are invariably tested on those exams, right, they kind of show up on step three as well. So this is something that will be good for medicine residents to listen to. And if you also take in step three, you just want to bifop your internal medicine knowledge for step three, that'll be a good way to go. So today I'm going to be talking about cardiology. And as I've done in the other parts of the series, I'm just going to use a key scenarios. And then basically describe the various ways the concept could be tested on an exam. Okay, and today really I'm just going to focus on cardiology because cardiology is a very high-yup part of these tests, right? I mean, like if you look at the medicine, the medicine board exam, cardiology makes up about almost 15% of the questions that are tested, right? So it's kind of like one of those things you want to know.

Okay, so let's assume you get a question about a patient that is like, you know, 60-year-old guy has like a passie-stove like hypertension, hyperlipidemia diabetes, and it's coming in with like, you know, like severe metastronautchespain, relating to the jaw, and you check the troponins, they're negative, but he has like non-specific T-wave changes on an EKG, right? Now, what would your next step in diagnosis or management be, right? I mean, obviously you want to give like the drugs and what not, but let's assume that they're basically asking about like a next diagnostic step. Would you want to send the patient for a stress test? I would hope not, right? I would hope not under those circumstances. This patient is very high risk, right? So because this patient is very high risk for coronary artery disease, right? Most specifically an MI, even with the negative troponins and what not, he doesn't matter. This patient actually needs cardiac catheterization, right? Because you're, if you were to say, oh, you know what, divine, come on. Why can't I do a, this person has negative tropes? Why can't I do like a regular stress test? The thing is, let me ask you this question, just think about it yourself. If you have this kind of patient, they come in, hypertension, hyperlipidemia, diabetes, past medical history, chest pain, relating to the jaw, everything. And then you get a stress test. If that stress test is negative, would you feel comfortable sending those patients home?

I would hope that you answer to that question is unknown, right? So because you don't feel comfortable sending those patients home, right? That tells you right of the bat, right? That that patient is very high risk. If a patient is very high risk for coronary artery disease, you don't think about getting a stress test and all that crap. No, you just proceed straight to coronary coronary angiography, okay? That's the next step. Because again, for patients with such high risk, if you get the results of a test of a stress test and it's negative in those, like basically this kind of patient, you do not trust the results of that stress test. The result of that stress test, I'll probably say it's one where that's likely a false negative, right? Because remember, if a person has like very high risk for a particular disease, right? If you get a negative test result from a particular test, that negative test result is likely negative, right? It has a high probability of being a false negative, right? That's basically like base theorem. The thing is, it's not like they're going to ask you like super specific like, oh, making tens biostats, whatever calculations on your medicine boards. But the kinds of questions they will go after, like it's basically the kind is it's not necessarily like being able to do the math, it's more being able to understand the mechanism or the path of this, if you may, behind like the application of biostats to clinical concepts, right?

So this kind of patient, right? Where, oh, if the person got a stress test and it was negative, you still won't feel comfortable sending patient home. That'll be like a base theorem example of where like because this person is such high risk for coronary artery disease, a negative stress test, right? It will likely be a false negative, right? So if a patient has like very high risk for disease and you're sending them for, are you sending them for a stress test? That's probably not a good idea because the false negative rate of that test, especially if it comes out as negative is likely high, okay? So that's just basically a base theorem in a nutshell. But compare my initial vignette, right? With a person that, you know, basically presents and they have like, let's say it's like a 50-year-old guy, he says he just has this chest pain that kind of started this morning. And let's say he has like a stroke hypertension. So it has like that risk factor going for him, but he doesn't necessarily have like hyperlipidemia or diabetes. And he says that resting or like exercising doesn't make the pain worse, resting doesn't necessarily make the pain better, right? Then the pain maybe was like a fleeting chest pain, right? You're like, okay, this person is 50 years old. This person has some chest pain. Let's assume it's like mid-sternal, you know, sort of redating. I don't know, so the axel or something, right? So this kind of patient, right?

This is not the, and let's assume you'll get an EKG and it's like unremarkable. You get tropes and they're unremarkable. This patient, yeah, it's, this is not the kind of patient you want to send to the cath lab, right? Because this is low risk from the beginning is, is not low risk. Sorry, this patient is not high risk, right? But this patient is probably so, you'll consider to be like intermediate risk. For a patient like this, a stress test will be an awesome, awesome, awesome thing to do, right? Because again, the patient is intermediate risk. When people are very high risk, like the first thing that I described, you send them to a cardiac cath. But if the patient is intermediate risk, you then send them for stress test, okay? The thing is, this is where base theorem shines really well, right? Because if you're a person at intermediate risk, then by getting a stress test, that can help you either upstage the person's risk. I mean, obviously, see, for example, the stress test is positive, right? Then you proceed with a cardiac cath. But let's assume the stress test was like negative, right? That can help you sort of downstage your risk. So basically, base theorem essentially tells you that if a person is very high risk for a particular condition, go for the diagnostic test. Okay? If a patient is like intermediate risk, right? Like the second veneer I described, you do not necessarily need to, you do not necessarily need to go for like a cardiac cath.

You go for something like a stress test. And I'll talk about those stress tests shortly. But if the patient is like low risk, right from the beginning, chances are, so let's sort of play this game from a second angle, right? So remember, I said that very high risk person. If you send them for a stress test and you get a negative result from that stress test, you're not going to believe those negative results, right? Because chances are in the presence of that negative result, you're like, oh, this is a false negative, right? Now, let's assume you have like a 20 year old guy. He's an athlete, you know, he's pretty healthy. His BMI is like 22. He eats healthy food. Doesn't have any past medical history. And he comes in and says, ah, a dog, I have like this fluid in chest pain, his EKG is clean, his tropes are clean, right? The thing is, those kinds of patients that are low risk, you probably do not want to send them for a stress test. Because think about it from the other angle. If you got a stress test for those people, right? And that stress test ended up being positive in this like 20 something year old guy, that's like super healthy. Chances are that positive test is not something you believe, right? That in the presence of a positive test result, if you're a low risk person, that positive test result is likely, um, is likely a false positive, okay?

So again, you may see divine, why you spend so much time crapping about a best theorem, I promise you, for your medicine board exams and the entry in the exam, the test things around that base theorem concept. Because actually one of those things where it, if you actually understand the concept, which I'm trying to use different analogies and scenarios to explain, it can actually help you quite a bit with, um, with like more like prudent, uh, this clinical decision meeket. So I've been making this false about stress test, stress test, stress test, stress test, right? So what are the different kinds of stress tests? And which ones do you choose? Right? I mean, there's like exercise stress test, there is pharmacological stress test, there's stress echo, there's stress EKG and all that crap, which one do you pick on exams? Right? So the thing is for this, you kind of have to like, uh, make one major decision at the beginning and the major decision is can the patient exercise, okay? If the patient can exercise, you need to send them for an exercise based stress test. If the patient cannot exercise for any reason, then you send them to a non exercise based stress test. So what do I mean? For example, right?

So if, for example, a patient has like, they're severe like peripheral vasculod disease or the patient has like an amputated extremity, or the patient has just basically any like real reason, usually it's peripheral vasculod disease on exams or it may be like some orthopedic, uh, like orthopedic problem. Under those circumstances, you send them for a pharmacological stress test, okay? So whenever you're thinking on it, when you get an exam question and the answer choices are all stress tests and you're trying to decide what to do, the first big decision you want to make is ask yourself, can this person exercise? If they can exercise, send them from send them for an exercise based stress test. And then the next decision you want to make because the thing is these exams, right? In the hero and exam, your panic and I know that crap, you want to have an approach to answering certain questions. So after you ask yourself, can the exercise or not? The next question you want to ask yourself is, do they have any underlying ecagi anomaly, right? So take for example, if they have like a left bando bridge block or they have like STT wave changes already and whatnot, right? That would kind of make like an ecagi based stress test very hard to read. So under those circumstances for those people, you probably, I'm not saying you probably, you should not pick a stress test that involves an ecagi.

If a person has like an underlying like rhythm, like, like a bad arrhythmia or like a left bando bridge block or like live ventricular hypertrophy, stuff like that, you absolutely do not want to pick an ecagi based stress test under those circumstances. You want to go for a stress test that involves an echo, okay? So that's like the next big decision you want to make. So first decision can the exercise or not? If they can exercise, send them for an exercise based stress test. And then the second decision is, do they have an underlying ecagi anomaly? If they have an underlying ecagi anomaly, you should not choose an ecagi based stress test, okay? And then for the people that cannot exercise, right? Obviously, you still need to stress them out in some way, shape or form. The thing is you stress them out with pharmacology, right? And the thing is, in terms of stressing people out with pharmacology, you can use one of two options, right? So you can use a positive anotrop, like like Dubueta mean, remember Dubueta mean is a beta one agonist. And remember, you find those beta one receptors in very high quantity on the surfaces of your cardiac myocytes, right? So the increase like your heart rate and your cardiac output and all that crap, right? So you can use Dubueta mean on those circumstances. And other alternative is you can use an adenosine analog, right? So you can use adenosine, some weird names, you may see on your exam, they kind of sound like adenosine, right?

So there's like this drug known as regadenocene, there's this other drug known as apadenosine, those are all, they all sound like denocene, right? They are all adenosine analogs and you can use them for stress tests. Another thing you can use is you can use diperidomol, right? So diperidomol is an anti-plit lead drug, okay? It's actually a very good viso dileter. It works as a viso dileter by multiple mechanisms, for example, right? It inhibits like foes for diesterase. So that's something that's more like step one, step two, step three, four, if you're interested in that, just let me know. You can send me an email, I can try to explain. But basically, by inhibiting foes for diesterase, it can mix, it can be processed. If that persists, that will mix with muscle relax and you have viso dilation. But other thing is diperidomol also inhibits adenosine diaminase and adenosine diaminase is an enzyme that breaks down adenosine. So if inhibits adenosine diaminase, adenosine will persist for longer and we know that adenosine is a viso dileter, okay? So you can basically use that as your viso dileter for your stress test. So the thing is, what if they write an exam question that involves you, you're like, oh, okay, this person cannot exercise and you need to pick from a collogic source of stress, right? And they give you both as answer choices. Like they put dubidaminase and answer choice, they put, they put a dipereidomol as an answer choice, right?

The thing is, under those circumstances, right? Because again, remember, whenever you're taking an exam, they can only be one right answer, right? Because if they were two right answers to an exam question, everyone will go to the A, B, I, M headquarters or whatever and protest and all that stuff, right? Obviously, they wouldn't want to do that on a test, right? So the thing is, I always, this is just being a good test taker. Whenever you're taking an exam, there's only one correct answer. It just makes sense. So if they give you two things, you're like, man, come on, these two things are right. Like dubidaminase, okay, diperidomol is okay. Then the next thing, basically like, again, all this thing is just test the in strategy. The next thing you need to begin to think about is what kinds of contraindications exist, right? So say, for example, right, if the patient has a history of like asthma, you probably do not want to pick like an adenosine based pharmacological stress option, right? Because remember, adenosine causes very significant a bronchospasm, right? So if a person has a history of like a bronchospastic disease, right? So they have like asthma or they have like real bad COPD, right? One of those circumstances, it is probably not a great idea to go for an adenosine based stress test. And remember, right?

Adenosine, remember it's one of those things you can give if a person has like a really bad like, like, like, tacky arrhythmia and you want to sort of slow down the heart, especially like an like an SVT, you want to slow down the heart and sort of see the rhythm, you can give a denocene. If you know that adenosine can basically slow conduction down the EV node, well, if a person has like EV node conducting disease like, I don't know, like a second degree V block or a third degree V block, it is not a great idea on the medicine board exam to give those people, to give those people adenosine, right? Because again, that can slow, that can maybe turn like a second degree V block, so like a third degree V block, right? And then you have a problem on your hands, right? So on other circumstances, probably not a great idea to give an adenosine based stress test, right? But what if you're like, okay, divine, what are the contraindications to the vitamin? Right? I mean, the vitamin, I just told you it's a beta one agonist, it increases your heart rate, increases your cardiac output. If a person has like a bad tacky arrhythmia, like V tack, for example, right? Or they have like a left bundle branch block or they have like a pacemaker, basically, I'll just tell you this, if a patient has like a notable arrhythmia or they have like bad, bad, bad hypertension, those people should not get a dubious stress option, okay?

If you are choosing a pharmacological stress test, so very high yield to know those things, right? So again, big decisions you want to take in choosing a stress test can be exercised. If they cannot exercise, you go with a pharmacological option. And then the second question you want to ask yourself is, do they have any underlying EKG changes? That's basically the way you approach those problems on these on these abort exams, right? Because again, a person can exercise, you want to exercise them because really the exercise stress test, yeah, you can see blah, blah, blah, but it also gives you like other useful information, right? Like the exercise capacity, it can give you like information that you can tell you that you know what, this person's cardiac disease is real bad versus this person's cardiac disease is real is not that bad, right? So stuff like that, like prognostic information, you can actually get that from from an exercise base, the stress test. So just one of those things you want to keep at the back of your mind, okay? And then, right, so what if they give you a question about a patient and this patient has, maybe they show you like a picture, right, on your test, and they tell you that this patient, maybe it's an immigrant and maybe they've had TB for a long time, and then they show you like a chest x-ray or chest CT, and you see like white stuff all around the heart, what's your diagnosis on that of circumstances?

I hope you're thinking about like a constructive pericarditis, right? Okay, good. And I would encourage you to look up pictures of these things and sort of know how to identify them, what constructive pericarditis, classically on these board exams, they'll put like a lot of white stuff because remember, right? If something is white, that means it's radio-pick, so that means that 10 weeks x-rays very well, right? So something that has like bone density, right? Like calcium, right? So like constructive pericarditis. Okay, now what if they give you a question about an athlete that passes out on the field and dies afterwards, or they tell you that, oh, there's this athlete that's presenting with chest pain, and the person's that died of, I don't know, less than a dead of like a car accident at the age of like 30, right? That's kind of a weird story, right? I really hope with these things, you're thinking about like hypertrophic acardiomyopathy, right? Remember, although those circumstances, those people have like a very thick, like, interventricular septum, right? So those are things that could potentially show you as an image on the exam. Now, what if they give you a question about a patient and the sale? This patient recently, let's assume this patient came in, they show you an EKG, and the patient's heart rate is like in the 30s, right?

So they're like, pretty cardiac, so you start pacing them and whatnot, or they can even present this as a patient that gets like an AICD or like a pacemaker, right? So like for some other cardiovascular problem, and then they tell you that, oh, like a day or 12 to the procedure, this patient is like persistently hypotensive, has like signs of like, right? Ventricular dysfunction potentially on an exam, right? So let's say they tell you that, oh, the patient has like, like really bad JVD, right? And let's assume they show you an EKG, like a new EKG, and you're saying like a low voltage EKG, or they have like variations in the amplitude of the acurus complexity. So let's say they have like a very tall, acurus complex, full of very short, acurus complex, right? Like electrical alternance, so the deal, right? I really hope on that those circumstances, you're thinking of like cardiac tamponat, right? Those people have like a bad, bad, bad, bad, bad, bad, bad, a paracardiophusion that you've basically caused by inadvertently puncturing the ventricles. And for those people, right? Obviously you want to call cardiac surgery, they probably do like a paracardiophondole, like some kind of paracardiophonitis. Those are the answer choices you want to pick out on an exam. Okay, now what if you get a question, and with me talking about like these pacemakers, just I would look up pictures of like a pacemaker and like its leads, right? Those are, that's like another high-alt picture.

Let me show up on these medicine-board exams, right? Because those pacemakers lead wires, right? Like usually you put one like in the ventricle, right? So you can put one like in the right atrium, you can put one in the right ventricle. And usually like the one you put in the ventricle, you put it like close to the septum, right? So just be able to identify, oh, which is which, on an MDMA exam, I think that's I'm sorry, I keep saying MDMA because I do a lot of podcasts for the MDM As. But for the ABAM exam, okay, just look up pictures, like be able to identify, oh, this is, this lead is in the right atrium, this lead is in the right ventricle. Usually on imaging, the right atrial like pacemaker lead, it's usually like right just just about to the right of the spine on the chest right. If it's not on, if it's not to the right, it may be like just a little like it's almost like off center to the right of the spine, okay? It's very close to the spine on the right. That's usually the right atrial lead. Because remember the right atrium constitutes the right heart border on a chest x-ray, right? But another thing that if you're like, oh, define how to identify the right ventricular lead, the right ventricular lead is usually, usually to the left of the spine on like a chest x-ray. If they wanted to trick you and like make your life like a little miserable, they can show you like a lateral x, like a lateral chest x-ray, like a lateral film.

And then they ask you to, oh, like which one is the right atrial lead? The right ventricular lead will be anterior to the right atrial lead because, again, remember, the most anterior cardiac chamber is the right ventricle, okay? So those are things you want to keep at the back of your mind with these tests. Okay, now what if they give you a question about a patient and the patient presents with, let's say it's like a 70 year old guy and he's beginning to have like exercise intolerance and he's been having like chest pain that's worse with exercise and then they tell you that he has like a weak 3 D carotid pulse, right? What kind of murmur are you thinking about? I really hope you're thinking about the o late stenosis, right? Remember, that is your classic, that is your classic, what is it called? It's a OBS systolic murmur, right? A BBS systolic murmur that relates to the carotids, you already know your pulse's privacy status from your USMLE exams. And basically whenever a person is symptomatic, right? From AS, you need to go ahead and you need to consider surgery in those people or pronto, right? You want to go ahead and perform an eiotic valve replacement. Basically for a person is symptomatic from most cardiac diseases, you need to like do something, right? On these A, B, I, M exams. And remember, eiotics stenosis, right? The pathophys involves calcification of the valve, okay?

Believe it or not, for these are valveular problems, they love to occasionally test like pathophys, right? So if a person has eiotics stenosis is like calcification of the valve, if a person has, what is it called? What is this then? Command divine think. If a patient has like mitral valve or prolapse, right? You're thinking about like mix some of those degeneration of the valve, right? That's like the classic thing, they love to test, right? So those things you want to keep them in mind for these exams, right? So eiotics stenosis, obviously you go ahead and replace the valve, another of the doing medical management. Once the person has become symptomatic from eiotics stenosis, their three-year-life expectancy is very low. So in other circumstances you want to go ahead and do a perform an eiotic valve replacement. Okay. And again, remember you need to see calcification of an eiotic valve. Just I would encourage you to just be able to identify this on imaging if you if you quote for an example. And then what if they give you a question about like, I don't know like an immigrant that has the tell you that oh he comes to the doctor's office, he's been having like some chest pain recently and then when you'll scooty this person's chest, you hear like a dastolic murmur like an opening snap of the apex, right? I hope you know that this pretty classically like a mitral stenosis, it's a dastolic murmur because the leventricle is feeling, right?

When the mitral valve is supposed to be open, right? So it's a dastolic murmur opening snap. And if it's an immigrant, right? What what caused this immigrant's mitral stenosis? I really hope you're seeing a rheumatic fever, right? I really, really hope you're seeing a rheumatic fever. That's the thing you want to keep in mind, especially with an immigrant, right? And remember that mitral stenosis is the biggest risk factor for what cardiac condition? It's actually the biggest risk factor for AFEP, okay? It's the biggest risk factor for AFEP. So again, it's risk factors. I promise you, they are floridly high out for these internal medicine abort exams and intruding exams. I will encourage you to listen to the risk factors podcast, I believe it's episode 37. And then there is one of the episodes I made recently, it's like in the 90s on the website, it's called like the most important podcast where it basically talks about like the most common cause of death in this, the biggest risk factor for that blah, blah, blah. I'll encourage you, those are like easy, easy freebie points on exams, but those are things that you either know you don't know, right? I mean, how many people think of mitral stenosis as the biggest risk factor for AFEP? So I'll encourage you to sort of look those up in those podcasts. Okay, so mitral stenosis, right?

So what if they give you a question about a patient that has, I don't know, like, they tell you the description has like bounding pulses, and then they tell you that this patient has like a holosistolic murmur that is heard best at the left strenaal border. What kind of murmur are you thinking about on that circumstances? That'll be a yodic regurgurge, right? That'll be a yodic regurgurge. And remember, classicly on exams, people with a yodic regurgurge, they have like just weird blood pressures, right? Like, blood pressure is like 110 over 40, right? Or like 110 over 50, right? What's unique about that? I hope you're thinking about the pulse pressure, right? The pulse pressure is really white. Basically, I don't want to make this podcast super long, but widened pulse pressures, if you sort of reasoned through the pathophys of yodic regurgurge or like a patent doctor's arteriosus, those kind of half similar pathophys. Those are like the two cardiac like volvular problems that are associated with like the wide pulse pressures. So I'll be able, if you see like white pulse pressures, holosistolic murmur, left strenaal border, that's the yodic regurgurge, take that answer and don't look back, okay? And then the other like key high-yield murmurs, right? So remember, if a person has, so I've talked about mitrosynosis, talked about mitro regurg, talked about diodics, the nosist, talked about diodic regurg, remember if a person has like a holosistolic murmur, right?

Or a patient has like a some kind of murmur that is symptomatic, or a patient has like a dastolic murmur of any kind, or a patient has a systolic murmur that is 3 plus, right? So like a 3 over 6 is stolic murmur, 3, 4, 5 or 6 over 6 or whatever, right? Those patients need some kind of echo, right? Your next step in diagnosis for those patients is to go ahead and get an echo. And usually on the border exams, a TTE is just fine. I mean, there are certain situations where a TEE is a great idea on these border exams. But I'll tell you that there are usually few and far between, so like you could get a TEE if for example a patient has like endocraditis, right? A TEE is actually indicated in the setting of endocraditis, or if you're trying to like, I don't know like, cardiovascular someone for like a 5, a flotter, right? Under those circumstances you want to go ahead and you want to go ahead and get a TEE, that's a great idea, I'm under those circumstances. And something just popped into my mind, I forgot to mention it a few minutes ago. But remember, that person I talked about like the cardiac tamponade or like the pericardial effusion from like a placing like a like a like a lead from like a pacemaker or whatever, like puncture the person's like ventricle and cause like a pericardial effusion, right? Be able to identify a pericardial effusion on a chest x-ray, okay? It'll sort of show up as like a hard, kind of like looks like a water bottle.

It doesn't really, I'll say like water bottle shaped heart in a pediatric question is probably a technology of a low body and an adult and it lets us give you something that develops like acutely. You really want to think more about like a pericardial effusion, slasher, tamponade. Okay, now what if you get a question about a patient that has like high blood pressures in the upper extremities and low blood pressures in the lower extremities and then the, yeah, how about we leave it at that, right? So what are you thinking about on those circumstances? Well, I hope you're thinking about like a courtician of the yoder, right? I remember in adults, a courtician of the yoder usually sort of rises distal to like the left subclavian, right? Because remember if you look at the yoder, right? So you have like your ascending yoder, your arch and your descending yoder for your arch, right? You have your, the first thing that comes off is your bricosephalic artery, right? That gives off the right common corroded and the right subclavian. And then after that, the next vessel that comes off is the left common corroded and then the next vessel that comes off is the left subclavian. Usually the yoder courtician arises distal to the to the left subclavian. So those people have like very big like bricula arteries and all that stuff and they'll have like all these extensive like collateral like intercostal arteries, right? And the thing is I sort of think of it this way, right?

It's like if a person is getting like ripped and ripped and ripped, some people say, oh, those people are shredded, right? So I sort of think of it this way, like if you have, if you have like those collados developing, especially like your intercostal arteries, right? Those those are shredded intercostal arteries will begin to shred the ribs, right? So those people could have like the rib notch in another thing you may see with the audit courtician is something called the three sign. The three sign is just like the yoder that's dilethed before the courtician and the yoder that is dilethed after the courtician, okay? So you want to be able to actually identify those things on a chest x-ray for the ABIM example. The ABIM example, a little bit or not, they've been known to test their pictures. So I'll strongly, strongly, strongly encourage you to be able to identify those things on on imaging. Okay, let's see what else do I want to talk about because I don't want this podcast to go on for too long. Let's see what else I want to talk about. Okay, you know what? Well, we go ahead and talk about, okay, let me give you a kiss in here. So what if you get a question about a person that's like six foot six inches and then they present like tear in chest pain, reading to the back. You already know what I'm talking about, right? That's a that's a erotic dissection, right? An erotic dissection, right? Classically, you'll see a widening media style on a chest x-ray, right?

So let's assume you want that to confirm, confirm on imaging, right? For those people, you can do you can do like a CT of the chest, right? You can do an MRA, you can do a TE, right? This is actually one of those fancy schmancy indications for a TE as well on the ABIM exam, right? So a TE or usually so TE or CT of the chest or an MRA, those are good situations. Those are good things you can do for Yorica dissection, right? And remember, they may give you like a tall person, right? So obviously like Marfan syndrome or like ADPKD, or it was a more dominant polycystic kidney disease. Those people tend to get aortic dissection. And the pathophys actually be like the Bos word pathophysiology mission exams relating to aortic dissection is something called as cystic medial necrosis, okay? That's a Bos phrase you want to remember for tests, believe it or not, we love to test those those are no infants. And then remember for aortic dissection, right? You want to be able to classify them, Stanford A, Stanford B. Basically, aortic dissection involves the A sendin order, right? That's a Stanford A. If it does not involve the A sendin order, that's a Stanford B. Stanford B medical management, okay? Stanford A, medical management, but you also need to proceed to surgery, right? And by medical management on these exams, basically what I mean is to give them a bit of blocker, okay? You need to give them some kind of bit of blocker.

That's basically what you do for for for aortic dissection, but if it's a Stanford type A and involves the A sendin order, right? So you give the bit of blocker and then you send them to surgery, okay? Now, another thing to keep at the back of your mind with the aortic dissection is, right? It's not only people with Marfan's or ADPKD that can get that, right? So people like bicospediotic valve, you can actually get aortic dissection on these ABI and exams, right? And bicospediotic valve, remember, think of it if a person gets aortic stenosis and they're like in your 50s, right? Remember, bicospediotic valve certainly increases your risk of aortic like early onset aortic stenosis. And then don't forget, like if they give you a personal like risky behaviors that has the tear and chest pain, remember syphilis, remember syphilis loves to cause problems at the level of like this and in the order so that can that can be another classic presentation on an exam. And then I guess to go ahead and to go ahead and round up, let me just go ahead and talk about a topic that may show up on a test, right? So it's something called like an introeotic balloon pump, right? So an introeotic balloon pump is something that you basically use when a person has like really depressed cardiac function. You essentially use it when you're trying to like make a bridge to I don't know like a 11-inch of classes device for example or or like a heart transplant, right?

It's something you kind of used to help the person like temporary, right? And basically the balloon pump, you usually place it like super proximal descending thoracic order, right? So like distal to the like your left subclavian artery, right? I mean you know, you're no one a place proximal. So any of your great vessels, right? That I mean you can already see how that could potentially be a bad idea because if you do that, you basically include one of the vessels that feeds the brain and then give your patient a stroke, right? Which is usually not a good outcome, right? But the way the introeotic balloon pump works is that it inflates in inflating in in inflating in in in dastily and the way it inflates the reason it inflates in dastily is remember your coronary vessel sort of come off like the eortical like sinuses, right? So if it inflates in dastily, that sort of like increase like profusion of the coronary vessels, right? But it deflates in dastily and the thing is by deflating in dastily it would basically decrease the it would decrease the afterload on the left ventricle, right? And that will make it easier for the left ventricle to sort of eject a blood. So that's kind of like how the introeotic balloon pump works. So cardiology, again, this would not be my last internal medicine, a cardiology podcast, a cardiology is a super super floridly high yield topic for the medicine boards, right?

Again, like I said, it shows it basically constitutes about 15% of the of the exam. Okay, so I think that's where I'll go ahead and round up and as I always do at the end of every exam, I do offer one or one tutoring for the USML is step one two CK two CS and step three and then preclinical exams in med school 30-ish off exams, the medicine in training exam, the medicine board exams, I do offer tutoring for those and then if you know a person that is taking like basically like most college premed courses, biochem, physiology, histology, physics, gen-chem, whatever, I offer tutoring for those things and then if you're a medicine applying to residency, so an ERS application or or college students applying to med school, so an AMCA application, I do offer consulting for those like application advising, personal sleep main health and whatnot, pretty much everyone I worked with this last cycle matched and I've also been on the admissions committee of a top two med school for a year, so I've shifted through thousands of very high quality applications, so I know things that can basically be for your application, so if you need help with any of those or anyone that needs help with any of those things, please feel free to tell them to reach out to me, so have a wonderful day, it's past 10 pm, so it looks like I'll be going to bed very soon, so I'll see you next time, have a great day and have a good night and God bless you, see you.

Very high risk patients with chest pain and multiple major risk factors (e.g., HTN, DM, hyperlipidemia).

A false negative; therefore, the results are not trusted, and further invasive testing is warranted.

Can the patient exercise? (Yes $\rightarrow$ Exercise-based; No $\rightarrow$ Pharmacological).

Adenosine analogs (e.g., Regadenoson, Adenosine) cause significant bronchospasm.

A holosystolic murmur heard best at the left sternal border, accompanied by wide pulse pressure and bounding pulses.

Mitral stenosis (often due to rheumatic fever).

Marfan syndrome or ADPKD history, and the presence of tearing chest pain.

Electrical alternans (beat-to-beat variation in QRS amplitude).

ECG-based stress tests, as the baseline abnormalities make interpretation difficult.

A diastolic opening snap at the apex.

Stanford Type A (involves the ascending aorta).

Beta-agonists (e.g., Dobutamine) or Adenosine analogs (e.g., Regadenoson). Contraindications include asthma/COPD due to bronchospasm risk.

Thick, calcified, white appearance around the heart (radio-opaque).

Cystic medial necrosis.

Electrical alternans (beat-to-beat variation in QRS amplitude).

ECG-based stress tests, as the baseline abnormalities make interpretation difficult.

A diastolic opening snap at the apex.

Stanford Type A (involves the ascending aorta).

Beta-agonists (e.g., Dobutamine) or Adenosine analogs (e.g., Regadenoson). Contraindications include asthma/COPD due to bronchospasm risk.

Thick, calcified, white appearance around the heart (radio-opaque).

Cystic medial necrosis.