DIP Episode 272 - USMLE Step 2CK Rapid Review Series 44

Okay, welcome. My name is Divine. This is episode 272 of the Divine Intervention Podcasts. And in this podcast, I'll be continuing our rapid review series for the US Emily Step 2 CK exam. This is going to be series 44 and hopefully you find it to be pretty high yield. I essentially want to start this thing where as I'm making audio podcasts, I'll also put them on You Tube because you know some people just are not podcast people. They just rather listen to You Tube. So I imagine they're probably going forward. Most of the content I put on the website I also just upload them to the You Tube channel as well. And if you see me looking down, I'm just trying to make sure that the recording because I'm also trying to record the podcast at the same time. I'm just trying to make sure that the recording is coming through as well nicely so that I can you know again basically just trying to find more ways to put out this material to as many people as possible. And just as an announcement if you're interested in the Step 2 CK Comprehensive Course and the MBA me testing and strategy scores I'm having coming up you know starting on Thursday the testing and strategy scores is on Thursday from 2 to 4 30 pm Mountain Standard Time and then the 10 hour comprehensive step 2 CK course is going to be split into two days. It's going to be on Friday the 13th and Saturday the 14th from 11 a.m. to 4 p.m. Mountain Standard Time on both days again.

We'll cover like the high yields from I am Neuro Surgery Peds Obey Guy and Psych over a 10-up period integrated fashion and again many people have probably more than probably about 500 people have gone through the course at this point and I've got an autonomous very good feedback from it. So if that's something you're interested in just shake me an email through the contact me button on the website and we'll proceed from there. Okay so let's get right into it right so on MBA me exams what is the biggest risk factor for polyhydram news what is the biggest risk factor for polyhydram news on an in-beaming exam I would encourage you to think more along the lines of maternal diabetes the thing is I hear this complaint from many people that oh they gave me a patient and they gave me multiple risk factors and then I have to and all those things are risk factors for the same disease and I have to pick out one the thing I'll just encourage you to do is there are certain patients specific risk factors where they will say something like a particular patient population and what is ordinarily the biggest risk factor for that problem is not going to be the risk factor that is correct for that patient.

So you essentially almost have to evaluate things on a patient by patient basis to being good stead on your exam right so on MBA me exams probably like 80 to 90 percent of the time whenever they give you a question about like oligo I mean polyhydram news right it's usually going to be in a woman that you know has maternal diabetes right maternal diabetes because think about it if a mom has diabetes well she's gonna have a ton of glucose in her blood stream all that glucose is gonna get to the baby's blood stream through the placenta and then again the baby is not like some zombie or something right the baby is metabolically active so the baby's pancreatic beta cells would be like hmm okay well this is way too much glucose right so this time you get a ton of insulin and also all that glucose will also show up in the child's urine so the child is gonna pee more and as the child pee more you're gonna see more urine being me because remember I'm really fluid is essentially for all the intents and purposes baby pests right so essentially the more the baby peas the more you're gonna see fluid in the amniotic sac right again remember there are many things that can cause polyhydram news on an MBA exam right I mean again as long as you understand the cycle that essentially what a baby does is a baby peas and swallow it back and then peas and swallow it back that's gonna like the cycle of amniotic fluid right so the thing is if you understand that cycle you're pretty clear on the causes of polyhydram news for example if a baby does not remember to swallow see for example that baby has an encephaline right when the anterior neuroport feels too close and then the amniotic fluid pretty much wears away the child's brain right that's gonna cause polyhydram news on an MBA exam right because the baby is not swallowed so the baby is peeing but it's not swallowing well there's nowhere f

or that amniotic fluid to go so it's gonna build up and the baby is gonna have polyhydram news another cause of polyhydram news is if the baby has some kind of obstructive lesion right so see for example let's say the baby has like an electricia or some phagyllatricia or the te fistula right things of those of that nature the baby can swallow but again kind of think of it as like heart failure this is like GI tract failure right so you have an obstruction that obstruction will essentially prevent the swallowed amniotic fluid from going through so the baby will not be able to swallow after a while and then it will just build up build up build up build up build up right and then you have polyhydram news on that those circumstances another thing that could potentially cause polyhydram news on an MBA exam is if for some reason they are just many babies right they are just multiple sources of piss right so if for example instead of having one baby you have like twins or triplets or quadruplets well they're just more contributors to that piss pool if you may right so because you're having more contributors to that pool essentially what's gonna happen is you're gonna have a polyhydram news on that those circumstances right and then if you're like oh divine what will cause oligohydram news that's easy whatever will make the baby not pee is gonna cause oligohydram news right the classic one you're probably used to is like potter sequence right like whenever a kid has renaly Genesis if you have renaly Genesis well unfortunately you're not gonna be making any pee if you don't make any pee I don't know where that amniotic fluid is gonna be coming from right so that's just one of those weird bizarre what high yield things you want to know for exams and not that unusual one you may see on the test is like vesicle uretherial reflux or if a kid has like posterior rethral valves the b

aby can pee but the pee has nowhere to go so if the pee has nowhere to go that baby is gonna have oligohydram news on that those are circumstances right so hopefully with that you kind of understand what you know the big thing with oligohydram news and putty hydram news although on mbm exams when a woman is in labor the biggest risk factor for oligohydram news in that patient will just be a rupture of membranes right when you rupture your membranes well that when they see oh woman's water has broken what do you think comes out of that water is broken some meonic fluid right so if your water is broken obviously a meonic fluid index is gonna be low you're gonna have oligohydram news on that those circumstances so again if you notice I'm beginning to go with this bent of like patient specific risk factors so that again you're prepared for those kinds of things on on an exam right so what if they give you a question about a patient and they tell you that oh this is like a 19 year old female and they tell you that she's like a star on the sports team or you know they can make her a supermodel essentially and then they tell you that you know she has a bmi of like 17 you know very slim doesn't have much weight right and they tell you that she has irregular men's ears and they can say which of the fallen is the most likely health hazard that this patient will experience over the next like three to five years or something like that I'll really hope that in those circumstances you're thinking along the lines of osteoporosis right the biggest risk factor for osteoporosis right in a patient that is very young right you should be thinking more along the lines of the person potentially having like some HPG access anomaly usually because they are not even right so that's the thing that's known as athletic immunaria because if you think about it if for example you're not eating then

your body is like hmm okay I don't have enough food to support to you well I'm definitely not gonna be having any amount of food to support some other human being so the thing that's gonna happen is your body is gonna shut down your HPG access you're not gonna have G&RH you're not gonna have FSH LH right so you're not gonna make estrogen remember that estrogen has a bone protective effect I mean think about it why do you think women that be composed men opusal start having all these fractures is because they don't have estrogen anymore right if you remember estrogen because for whatever bizarras and your friends at the mbn 4 step 2ck they study writing these questions where they're beginning to see if you can understand some throwback pathophys from step 1 essentially right why does estrogen protect bone well remember that estrogen it increases the synthesis of a key protein known as osteoportagrin right osteoportagrin the way that thing works is that it pretty much causes you to it's like a dummy receptor for the rank ligand so whenever you know pth is activated and activates an osteoblast remember pth does not directly activate osteoclasts right pth will activate the osteoblast first the osteoplast will express the rank ligand and then the rank ligand will bind to the rank receptor on the osteoclast and then that's gonna cause the osteoclast to be activated and then it then reserves bone right so the thing that happens is osteoportagrin is a dummy receptor for rank ligand so that osteoportagrin will bind of the rank ligand the binds of the rank ligand then rank is not gonna find any receptor so the rank receptor on osteoclasts is not gonna find any rank ligand around to bind with right so your bone is then protected in fact this is essentially how the drug known as the no-sumab works right so remember the no-sumab is a monocloryl antibody against like the rank ligand

that can be used to treat osteoporosis and also maybe like oh divine there's no way they can ever test this on an exam okay well I'll let you think think about that some more what do you think I'm laughing right those are things that your friends at the NV Me routinely test on step 2ck routinely test on step 3 so again it's just one of those high-yield things you want to keep at the back of your mind for exams and let's make sure that this thing is recording right and then what if they give you a question about a patient and they tell you that you know this patient very sick is in the ICU right even they can even make this a COVID question right so they'll give you a question about a patient very sick in the ICU a patient is not doing well at all right the patient has been on a ventilator and they tell you that all this patient is on a hundred percent FiO2 right or the patient's PO2 is like a hundred or something like that maybe like oh divine this person's PO2 is a hundred beyond a hundred percent FiO2 everything is good that is not good I'll tell you that right now the thing is when your FiO2 is a hundred percent your PO2 better be like in the hundreds like 300 400 500 kind of deal if it's very low then you are thinking that okay this person like that hundred percent FiO2 is not really helping that patient out right so this patient in that case obviously has the RDS of some sort right I would not be surprised if your friends at the MBM they make a COVID question because again it's a very popular health issue in this day and age if they make if they make a COVID question an ARDS style question right so again just something to keep on the back of your mind on exams right so this person remember one of the hallmarks of ARDS right is when they have a very low P.A.O.2 to FiO2 issue again that ratio should be much higher than one right because essentially this person's PO

2 is like a hundred and the FiO2 is a hundred percent that's like one right so like a hundred percent a hundred percent that's one right so that PO2 the FiO2 is you it's not good so if a person has the RDS what do you need to do for those folks well usually the smart prudent thing you want to do is you want to you know essentially put them on a ventilator that's like the first thing right we want to use what is known as a long protective strategy right so what in the world why I mean by a long protective strategy I mean that you basically give them you know as much FiO I mean like you want to give them like low tidal volumes and high peak right so your peak can go as high as you can try you know don't be afraid to give them as a peak a peak as high as 20 on an MBM exam there's nothing wrong with that the minimum peak you can ever give to a patient an event is five right so the patient is on five you absolutely have room to go on an MBM exam you can even go beyond 20 especially when the person has a very severe case of ARDS and remember that when people have ARDS right when they have you can hear crackles in the lungs right whenever you hear those crackles remember that's an example of a non-cardiogenic pulmonary edema right remember the path obviously behind the ARDS is they have like a systemic inflammatory state and they're releasing all these nasty things like histamine and bradykining and all that fun stuff and those things right will cause an increase in vascular permeability when you increase that vascular permeability well fluid is going to sip into your lung parankham and that's going to cause hypoxia because the exchange of oxygen right between all that fluid and all that stuff is super inefficient right so because it's a non-cardiogenic cause of pulmonary edema obviously that person is going to have like a normal pulmonary capillary wedge pressure so the pul

monary capillary wedge pressure in those circumstances should be less than 18 that's a magic number you want to make sure you commit to memory on an MBME exam and then what if they give you a question ask what is the biggest risk factor for ARDS again they will give you all these different things they'll put like like malignancy blah blah blah blah trauma drowning blah blah blah again the biggest risk factor for ARDS believe it or not is actually sepsis when a person is septic they have a very high risk of getting ARDS but again remember ARDS the things you want to do for those folks that will help them is you want to essentially again long protective strategies low tidal volume high-peep and you also want to place those patients in a prone position so those patients you want them lying down on their belly right it's gonna help with opening up their earway and increasing the efficiency of their long mechanics right so again it's just one of those great things you want to keep at the back of your mind for example and then one other thing I want to talk about is that ethical scenario that your friends at the MBME will be very happy to throw in on the exam in this day and age right so let's assume they give you a question about a patient you know this patient has to go with the species is in the ICU blah blah blah blah blah and your medical student or some kind of healthcare professional taking care of that patient right let's see you have this patient for 10 days and then in the MBME question they tell you that the patient suddenly goes into cardiac arrest but then they tell you that there's no personal protective equipment available right there are no gowns no N95s nothing again I know some of you may be like divine there's no way they can ever test this I'm telling you they can absolutely test this right if you're those questions that are supposed to start coming from

tomorrow from the 11th of November with those healthcare systems and all those things these are the kinds of questions they love to throw on that these circumstances right so you know the patient goes into cardiac arrest and then you can say what is your next best-tempo management your next best-tempo management should be that you should try to find someone that has PPE that can help the patient right obviously your friends at the MBME they will supply an answer where you're running to the room because you know there's no PPE available you're running to the room to try to help the patient don't do that if you do that I promise you that would be the wrong thing to do on an MBME exam I know it may sound like very colors like oh wow divine you're leaving this patient to die didn't take this oath as physicians to do no harm yes we took that oath as physicians to do no harm but the thing is if you're running to that room to save that patient right and then you get COVID unfortunately you then begin to do harm to other patients that you may see and you may also begin to do harm to your other healthcare co-workers right this is a classic ethics question they can pump into the exam right and also remember God forbid if in getting COVID you die right well guess what they have thousands of patients you would have seen over your career right now you don't get to see because you've got COVID and you've died from COVID and obviously it's going to be a big hit to your family as well right if you look at all the years you've invested to become a physician or that just goes down the drain right so just be mindful of that right obviously before you get into a B on an MBME exam before you run into a patient's room right you always want to make sure that you have a appropriate personal protective equipment again that's very high you to know that for exams so I've been going for like 16

minutes now maybe let me discuss like one or two other scenarios and then we will I guess ultimately ultimately proceed proceed from there and then go ahead and stop so one other thing I want to talk about right so what if they give you a question about a patient and they tell you that this patient is an alcoholic and then they ask for the biggest risk factor for alcoholism in that patient let me tell you this the biggest risk factor for alcoholism in general on MBME exams again I know some people will say that oh divine but I saw in this cuban they said this and that and this and that let me tell you this right now whenever I make podcasts I don't make podcasts for cubanx obviously I'm gonna do really well on cubanx if you know everything I'm covering in this podcast right but the thing is whenever I make podcasts I make them for what the MBME wants you to know right like I know for example many people will be like oh if a person has C-spin injury you're supposed to get like a CT right you're supposed to get a CT scan that's pretty much what people do in many E Ds around the country that's what most clinicians do and that's what many cubans will tell you to do if a person has you know you are worried about C-spincho let's go ahead and do like a like a CT of the head and neck or whatever right but I tell you right now if you do that on an MBME exam I'm promising you you will get the question wrong right when you're worried about like C-spincho on an MBME exam you're supposed to perform a cervical neck x-ray right you hear you heard me say that a cervical neck x-ray right or you can see like a lateral neck x-ray that's another way they can present that right so that's what you do when you're so special or you're worried about some kind of C-spincho on an MBME exam right so in this scenario that I'm discussing right so we're present in alcoholic what is the biggest risk

factor on an MBME exams for alcoholism it's actually having a parent that is an alcoholic in general people that have parents that are alcoholics they have like a forefoot increased risk of becoming alcoholics in the future right we should not be entirely surprising to you now another classic question that your friends at the MBME have started hearing about in this day and age is whenever a person you know like they may ask they may give you a question about a child or they may even show you like a fetal heart rate tracing I noticed that wow you're seeing you're seeing like all these variable decals right you see all these variable decals and then you can ask you about like what is the most likely heart rate response in the fetus right that's like you know responsible for all the stuff basically what you're trying to ask you is whenever you see variable decals obviously you know it's gonna be from court compression right what happens to the fetal heart rate when you have court compression or what is the mechanism behind that right so your friends at the MBME I don't know for whatever reason this is something you started hearing about this year right obviously the answer is gonna be fetal pretty cardian what many people don't understand why is that the case well think about it when you see variable decals right hopefully you still remember the Veil Chop Nomonic that I talked about in my OBGYN video right so the Veil Chop Nomonic right so remember the V is variable D cell right and then the C means court compression when you compress the umbilical cord remember the umbilical cord transmits those fetal blood vessels right remember fetus has two umbilical arteries and one umbilical vein right so two umbilical arteries and one umbilical vein the thing is if you compress the umbilical cord you're gonna compress the umbilical arteries and if you compress the umbilical arter

ies what do you think is gonna happen to the the systemic vascular resistance the systemic vascular resistance is gonna go up right and if that's the systemic vascular resistance goes up guess what the blood pressure in the fetus is gonna go up and if the blood pressure in the fetus goes up you're going to be banging on those barra receptors right that rest around like the carotid right so you bang on those barra receptors when you bang on those barra receptors that's gonna cause a pass in pathetic discharge and when you have the pass in pathetic discharge you're gonna have a decreased speed of conduction down the AV node right so the fetus is gonna be pretty cardiac that is actually what presents on the fetal heart rate tracing as a variable decel a variable decel is you're literally decelerating right if you remember college physics you literally going from an elevated fetal heart rate right to something that is a lower value right so the mechanism behind that deceleration in cord compression is because the increase in systemic vascular resistance and then essentially those barra receptors are giving you a pass in pathetic discharge again I know in this podcast I'm gonna be like I mean it's gonna be some really weird bizarre stuff here but I promise you these things are very high-ears to know especially so for the step two CK exam so I've gone for like 20 minutes now I think maybe I'll go ahead and pause here since this is like a rapid review series again I'm gonna make more really my biggest limitation in some sense that's kind of being time so you know hopefully over the next few days I'll begin to make more and more podcasts and as I do at the end of every podcast please subscribe to the You Tube channel right divine intervention you assembly podcasts and videos gonna be putting this on on there and then this podcast is also available on Apple podcast on Google Pl

ay on Spotify and I'll also encourage you to please subscribe to the website divineinterventionpodcast.com with an S at the end podcasts.com right so if you subscribe if I make a new podcast you're gonna get like an email notification and things like that and then the quick life lesson I just want to share today is the problems with laziness right so problems with laziness.

One thing I've noticed right and don't get me wrong that I won't be seeing this if this is not like many times when I meet podcasts I try to make it on problems that are common to healthcare professionals. The thing is whether you like it or not is not everyone that actually goes into a school that is hardworking. There are just some people that are just to be honest with you just flat out lazy right they're just flat out lazy they don't want to work hard they don't want to do anything right they just want to get a 270 by studying for two hours a day for two weeks right again that's not how life works and to be honest with you I probably you probably on your own will not want that kind of physician.

So again I'll encourage you to work hard again hard work it's called hard work for a reason it's work that is hard but the thing is at the end of the day the benefits of hard work fall out way the amount of effort you're putting in the first place right whenever you see a person that is lazy right yes they may be putting in low effort they may feel good now but the thing is the consequences of that low efforts they've put in over time will begin to show forth in the future right like the thing is you're gonna work hard in some way it's just the point at which you're putting the hard work that will be different right if for example you're putting the hard work with studying well for your exam studying really hard right and then you do it on step one you do it on step 2 ck and then you know you apply for residency you're gonna get a ton of interviews you're gonna match easily is not gonna be a big deal right but the thing is if for example you don't put in as much work as you're supposed to on studying for step one studying for step 2 ck and you get very poor scores they're gonna put a lot of hard work into your application but the thing is you are putting in hard work at a time where that hard work may not pay off because the thing is the fact that you work hard doesn't mean the work is gonna pay off there's a blue that really work hard that get no result from it right the two reasons why people may work hard I mean there are many reasons for this but the two primary reasons why people may work hard especially medicine and not get much from it is they are working hard at the wrong time right like the case of the person that is working hard when applications is in a form instead of working hard when they should have done better on their exams that's one but the second thing that makes people have fruitless hard work right is the work hard in the wrong kind of work right

so the thing is again like I know this thing happens in medical school a lot where you know you study in a new class you're like oh this is the resource I'm gonna use to study for this exam right but then you notice like some classmate of yours has like this big giant almost book that this person is using and you're like wow this big looks way this book looks way bigger right oh wow this person has matured 20,000 XYZ on key deck and I've not done any of those things right and then you start doing those things even if you don't necessarily work for you let me tell you folks that is not prudent at all right so the thing is the fact that something works for one person it does not mean that that is the same thing that worked for you again there's this thing that the amenier road to Jerusal right in fact there's this part of the bible that says that there's a way that seems right to a man but in the end is the structure right so that way you may think he's right may actually be something that lead to your own destruction right so what I'm saying is find your own correct path right find your own correct path is not everyone that's meant to succeed without key is not everyone that's meant to succeed with listening to videos or podcasts is not everyone that's meant to succeed with writing notes would find what works for you and use it to your own benefit I mean many of you can probably start my at this point that from my podcast that not a bigarchy user on key is great but I just don't use it but I've done really well really well on exams thankfully right by using the study approach that works best for my own disposition so I'm gonna go ahead and wrap up here today thank you for listening I'll see in the next podcast have a wonderful rest of your day and God bless you thank you

Maternal diabetes mellitus.

Polyhydramnios.

A low PaO2/FiO2 ratio (ideally > 300-400).

Prone positioning.

Cervical neck X-ray (or lateral neck X-ray), not a CT scan.

Umbilical cord compression leading to increased systemic vascular resistance and subsequent baroreceptor activation/parasympathetic discharge.

Osteoprotegerin (OPG).

Less than 18 mm Hg.

Anencephaly or other neurological deficits affecting swallowing.

Cervical neck X-ray (or lateral view).

Parental history/genetic predisposition.

Systemic inflammatory state (releasing histamine and bradykinin).

Osteoprotegerin (OPG).

Less than 18 mm Hg.

Anencephaly or other neurological deficits affecting swallowing.

Cervical neck X-ray (or lateral view).

Parental history/genetic predisposition.

Systemic inflammatory state (releasing histamine and bradykinin).