DIP Episode 283 - Combo Podcast (Risk Factors/Prognostic Factors) + Step 2CK Rapid Review (Series 47) + Step 2CK Course Reminder

Okay, welcome. My name is Divine. This is going to be episode 283 of the Divine Intervention Podcast. And again, this is a combo podcast that has been doing in recent times. That's what I did in episode 282. I'm going to be talking about a lot of risk factors and prognostic factors. Well, this is also going to be a rapid review series. So this is going to be series 47 for step 2 CK. And again, I also want to send a reminder again, if you're studying for the USMELIS step 1 exam, I have a super comprehensive course. It's 30 hours long. It's taking place between the 27th to the 30th of this month. Still have some spots available. So if you want to sign up, just shoot me an email through the website and I will give you some more information. And then if you're studying for step 2 CK, the previous 10 hour course I've expanded it. It's now a 16 and a half hour course because I want to, my goal is to include some expanded internal medicine content. And cover many of the new changes that are currently tested on the exam. Like those things with professionalism ethics communications, there's going to be a lot of bio stats. And again, I'm going to expand the medicine content, the pizza content, the ubi dying content. So again, if that's something you're interested in, I have the course from the 4th to the 6th of February. And then I have the MBME test against religious course on the 3rd.

So again, if you're interested, again, just shoot me an email of cutting quite a pretty decent number of sign ups. So there's still some spots available. So if you're interested, just shoot me an email and I'll be happy to point you in the right direction. Okay, so let's go right into it. So what if they give you a question about a patient and they tell you that this patient has been a long term smoker. And then this person has been a long term smoker. And then this person over the last three weeks, they've lost like 10 pounds. They notice like some blood in your urine. Right? And the creatinine has been going up. If you see that, and let's see maybe it's like a guy that also has like this new varicose. But I hope in that circumstance you're thinking about Renau's cell carcinoma. So Renau's cell carcinoma, remember it's kind of a high yield cancer to know for exams. Obviously the biggest risk factor for that, talked about that at NOSM before, is smoking, right? But remember that it can cause a varicose seal, right? Especially like when you have like a left-sided varicose seal. Because if you remember the Renau cell carcinoma can involve the renoving. Right? And once it involves the renoving, that will obstruct flow from the testicle on the left. Remember the gonadol vins on the gonadol, the adrenovine on the left. They have like weird draining drain. So the stuff on the right, remember like the gonadol vins on the right, drains straight up into the IVC.

But the gonadol vins on the left, the adrenovins on the left, the drain into the renoving, the left renoving, which then crosses and then goes on drains into the, goes on drains into the IVC. Right? So if you see a left-sided varicose, long-term smoker, you know, think about reno cell carcinoma. And then please don't forget that reno cell carcinoma, that's really kind of high you to know the primary or plastics, right? You know, it's also really with erythropoetin, where it's a producesipol, so that can cause a polycythemia in the patient. And then another thing you want to keep at the back of your mind with reno cell carcinoma is the fact that, classically, right, if you were to many, many people think that once you get on, once you take step to CK, they don't bother about histologic descriptions anymore. And we show the best, right? People that have reno cell carcinoma, you'll typically find clear cells on histology, right? When you're looking at the malignancy, right? So what are some prognosis things, your friends, that they in-beam, you love to test with this stuff? Well, the big thing you want to know is that these things, they love to, like they can say, oh, they'll give you a question about a person that has reno cell carcinoma, and then they ask, oh, what's the most likely location of metastasis? Right? If you see a question like that, you want to think about met to the lungs. Reno cell carcinoma loves to metastasis on the lungs, right?

And you can even extend that knowledge to, like, well-stunner, right? Well-stunner also, if it metastasis, is going to be to the lungs. Remember, hopefully you can differentiate between one stumer from a neuroblastunner. Remember, well-stunner is going to be a flank mass, it's going to be non-calcified, right? And it does not cross the midlines, very high up to no, right? In comparison with neuroblastunners, right, that are going to cross the midline, right? And then they will, so they love to cross the midline, that's one important thing. And then I think another important thing I should mention is that they also calcified as well, right? And, you know, neuroblastunners love to metastasis to bone, right? So that's a higher thing to know. And one other thing I would say that's also important is that they can ask you like, oh, which of the following is the most important predictor of prognosis for reno cell carcinoma? That's actually going to be extension into the reno vein. Once it goes into the reno vein, right, it's basically taking around towards the systemic circulation, right? So obviously that's like metastasis central at that point, right? But in general for malignancies, what is the most important predictor of prognosis in a person that has a malignancy? So it's going to be, if the person, it will be one of two answers on an exam, right? So it will either be that the malignancy has metastasized. Obviously, if something has met, sorry, it's bad, right?

And the key predictor of prognosis is also like lymph node involvement, right? So if it involves lymph nodes, so the thing I will encourage you is because sometimes your friends at the immun are really smart and they will put two of these things, right? So like they will put like presence of metastasis lymph node involvement. If they put both, pick the presence of metastasis because the fact that something has got into a lymph node, yes, it's metastasized, but that does not necessarily mean that it is already systemic, right? So I think that's a very high yield thing to keep in mind, for example. And then next, one other one we're just going to talk about straight up is they love to ask about obstructive sleep apnea on NV Me exams and ask for the risk factors, right? So the thing is, it's actually high yield to know the risk factors by each, right? So if you're dealing with obstructive sleep apnea in a kid and they ask you for the biggest risk factor, I really hope that you're picking the answer that talks about the person having a denotonsular hypertrophy, right? So they have like just big tonsils, big adenoids, right? So that obstructs airflow, right? And then another thing that can cause obstructive sleep apnea, the biggest risk factor in adults is going to be obesity, right? So obesity is the most important risk factor for obstructive sleep apnea in an adult, right?

But again, as you know, they love to put all these questions where they talk about patient-specific risk factors, right? So if, for example, they give you a question about a person that has a BMI of like 26, and then they tell you that the person has a history of like asthma's best symptoms that are worsened by the administration of an onset, you know, like aspirin exacerbated respiratory disease, then in those circumstances, you want to pick nasal polyposis as the biggest risk factor, as the most important risk factor for obstructive sleep apnea in that patient, right? Because remember, people that have aspirin exacerbated respiratory disease, right? They love to form nasal polyps, and those nasal polyps can obstruct the airway, right? And that can increase the presence risk of having obstructive sleep apnea, okay? So again, you just need to be wise and prudent as you're taking these Mbim exams, I think it's kind of like the big thing I want to mention here, right? And then some of you may wonder, oh, divine, what's the pathophysiology behind aspirin exacerbated respiratory disease? Well, it's pretty straightforward, right? So we know the pharmacology behind our acidonic acid, right? So we know that our acidonic acid loves to do this thing where you can either go down the cycloxygenase pathway where you make prostaglandins, right? Or the lipoxygenase pathway where you make luchotrines, right?

So the thing is, if you give aspirin, aspirin is an irreversible inhibitor of cox 1 and cox 2, right? So if you inhibit cox 1, inhibit cox 2, you're going to have more flux through the lipoxygenase pathway, right? And the lipoxygenase pathway leads to the formation of luchotrines and luchotrines, they can cause bronchoconstriction, they can cause many of those asthma-based symptoms, right? So that's why it's very important. As a person that's trying to treat aspirin exacerbated respiratory disease, they can ask you for the drug of choice and treatment. The answer that you actually want to go after on exams is going to be like a luchotrain inhibitor, right? Remember, you can inhibit luchotrines in one of two ways. You can give a luchotrines receptor antagonist something like Monte-Lucast or Zafri-Lucast, right? Remember, those are the luchotrines receptor. Sometimes the NBME may get cute. Instead of calling it the luchotrines receptor, they may call it the CYSLT1 receptor, right? But alternatively, you can also give something that inhibits lipoxygenase, right? So it's almost like the aspirin of the lipoxygenase pathway in this case, that's going to be Zyluton, ZILUTON, right? Although you kind of want to be careful there because that drug can cause a liver toxicity, right? And then, what if they give you a question about a patient and they tell you that this patient has a newborn, newborn has a white reflexes of a red reflex, right?

And then they ask him for the most likely malignancy this person may develop in the future. Well, I would hope with that, you're thinking about that kid, you know, as a newborn having a retinoblastoma, right? Having a retinoblastoma. Now, the thing with a retinoblastoma though is that he can, you know, it's like arbegin mutation. Those people tend to have osteosarcomas in the future, right? They tend to have osteosarcomas in the future. And sometimes they may even ask you what is the most likely location of osteosarcoma on an in-beaming exam, right? It's going to be the knee. Most times, almost like 90% of in-beaming questions that involve osteosarcomas is going to be a knee problem. And then one thing I kind of want to speak to right now is something that the in-beaming has been doing in recent times that I don't know, I've just seen too many people get questions wrong as a result of some of these things, right? I call these things alternate in-beaming vocabulary, right? So what do I mean by that? Basically, what the in-beaming does is they'll take something that you know and just give it a different name. I mean, that's like a classic, classic, classic thing, right? That they love to do with the more recenter, the newer in-beaming exams, right? So let me just go through some classic things where it has one name that most of us know. But sadly, your friends at the in-beaming have elected to give it another name that many people may not be very familiar with, right?

So for example, what are some key ones, right? Like so like osteosarcoma, instead of calling osteosarcoma an in-beaming call it osteogenics or coma, right? So that's something I want to be aware of. Another classic one they love to do is a neuro tube defect, right? You want to know that another name for neuro tube defect on in-beaming exams is spinal dysraphism, right? They may call it a spinal dysraphism on a test. This other one you've heard me say, you know, I've not seen so you want to keep it in mind, right? Like some of my buddies and laminated calcifications. That's a classic one. Another classic thing they love to do, a nephrodix syndrome, right? So remember, nephrodix syndrome, whenever a person has nephrodix syndrome, you're going to find fatty casts in your urine, right? You're going to find lipid casts. So essentially on in-beaming exams, they may call nephrodix syndrome, lipoid nephrosis, okay? Lipoid nephrosis, lipoid, that's something you want to be aware of. Another classic thing they love to do is they can give you a question about a person with IGN ethyropathy. Remember, IGN ethyropathy typically people have their symptoms like two to six days after the onset of an operation infection, right? So sometimes on in-beaming exams instead of colline IGN ethyropathy, they may call it a sin-fire-ingiotic nephropathy, okay? They may call it a sin-fire-ingiotic nephropathy. And then another classic one they love to do is Kawasaki's disease, right?

So remember Kawasaki's disease, high fever for a couple of days, in a lateral anterior cervical hemphadenopathy, right strawberry tongue, they may have a rash on the palms and soaps. And again, remember the MBM is smart. They will very likely not put a rash on the palms and soaps. They will see that the presi has a dima of the palms and soaps, or they can tell you that the presi has a disclamation of the skin over the palms and soaps. If you see that, you want to think about Kawasaki's disease. Another name for Kawasaki's disease on an in-beaming exam is something called mucocutaneous lymph node syndrome, okay? And you may be like, come on, you've got to be kidding me. Trust me, I'm not kidding. Right? Mucocutaneous lymph node syndrome, right? Mucocutaneous lymph node syndrome, okay? So let's continue. Now what is the biggest, what if they give you a question about a patient and they tell you that this patient will start it on a, you know, like shyness of himself on a fox's arm, right? For, for PCP profile access, you know, in HIV. And then they notice that the person, a few days later, person develops like periuros and osythes, right? And when he shows you that, you know, this person's o2 SAD is completely fine and this person's PO2 is completely fine. If you see that, I'd really hope that in those circumstances, you're thinking about methemoglobinemia, right?

So remember, whenever you take like a drug that's a very powerful oxidizing agent, that can cause methemoglobinemia, right? So for example, what are those drugs? Right? It can be a drug that like TMPSNX, right? It can be a drug like, come on, like a nitrate, right? It can be a drug like DAPSUN. Remember, we use DAPSUN as PCP profile access in people that, you know, for some reason, they cannot take TMPSNX. And we also use DAPSUN to treat leprosy, right? Remember, we can use a combination of DAPSUN, right? Fampian and clufazimid, right? That's another useful DAPSUN. And another one that just came to mind is DAPSUN can also be used to treat, um... Come on, divine. DAPSUN can actually be used to treat... Yes, dermatitis, her performes, right? That's associated with celiac disease, right? That's related to celiac disease. So you have to think about that for a second, right? So that's... Those are all uses for DAPSUN, right? So those are all questions they can frame in the context of repressing getting methemoglobinemia, right? So what's the pathophys behind methemoglobinemia? It's actually pretty easy, right? So all the iron that you have in your hemoglobin is in the ferrous form. It's in the FE2 plus form, right? But if you take a powerful oxidizing agent, right? If you remember from college, oxidation is an increase. Basically, when your oxidation number, when your charge becomes more positive, it means you're becoming oxidized, right?

So if you take a powerful oxidizing agent, essentially the person can go from FE2 plus to FE3 plus. FE3 plus is ferric. Ferric iron cannot carry oxygen, right? So the person becomes cyanotic, right? And obviously, in those circumstances, how do we treat the person? Well, actually, some things we can do, we can give the person a... Come on, divine. What are you thinking about? You can give the person aethylene blue, right? You can give the methylene blue. That's the drug of choice. You can give vitamin C. And then on that thing that you may see on exams, I mean, probably never heard of in any resources, I'm editing. I'm editing is... It's an acid-reducing medication. It's a H2 blocker that we use to bring down people's acid production, essentially, where you're blocking the action of histamine from those enterocromaphyn-like cells that we find in the stomach. So, simulating is actually pretty good at slowly lowering the person's methymoglobin levels. So it's just one of those weird things you may see on a test, they may be like, what? You've ever heard of this before, right? Well, now you've heard of it, right? And the thing is, if the Mbim is really smart, if they wrote this question about a person like with TMPSMX and they put like, oh, the person started for PCP Prophylaxis, because obviously, right, remember, you know, you do that if the person's CD4 is less than 200. And you know, they put methymoglobin in as an answer.

You can almost bet that your friends at the Mbim, one of the answers they will throw down for you is G6 PD deficiency, right? G6 PD deficiency. So you may say, oh, divine. Wow, that's true. How do I differentiate it between G6 PD deficiency and methymoglobinemia? Well, let me give you a few tips here, right? My tips here are first things first. If the question is about a girl, it cannot be G6 PD deficiency, right? Because I would hope that at this point, you know that G6 PD deficiency is excellent, recessive inheritance, right? Excellent, recessive inheritance is going to be in a boy on your test. That's one good thing that will help. And usually people that have G6 PD deficiency on Mbim exams, they're not going to have like physical signs of cyanosis. The ahymoglobin will be low, but they won't have like parloro cyanosis when you have those weird things, right? And then G6 PD deficiency, or it usually they will be some kind of trigger, right? And the trigger can be drugs, but the thing is, other things that can trigger G6 PD deficiency can be an infection, right? It can be like a really bad infection because when you have it, bad infections, right? You're going to really need the oxidative burst pathway, right? But to almost like recycle the oxidative burst pathway, you kind of need, or you know, to deal with all those freridicles and stuff. And oxygen reactive, reactive oxygen species, that glutathione pathway needs to work well, right?

And you need any DPH from the pentose phosphate pathway, right? Remember G6 PD, glucose 6 phosphate dehydrogenics is the retly-mitenium enzyme of the oxidative phase of the pentose phosphate pathway. So they will give you that, right? And they may even give you a blood smear, you may find like those hyens bodies or those bite cells, right? Or they give you like a geographical association, like the persons from like Southeast Asia or like some African country, probably likely going to be G6 PD deficiency, as against, as against the methamoglobinemia, right? So just things you want to keep at the back of your mind. So I think since we're right at mid-17, I'm just going to go ahead and pause here. But maybe let me say one thing, right? So what is the biggest risk factor for methamoglobinemia? It's actually the use of a nitrate, right? So they can give you a methamoglobinemia question easily. And a person that has a history of angina that is being treated with nitrates, right? Or they can give you like methamoglobinemia question, a person that's having chest pain in the setting of an MRI, right? Remember, we'll give nitrates to people that have MR Is to help their chest pain, although obviously, right? You don't want to give it to a person with an RC in fact, right? Because those people are preloaded dependent, right? So you don't want to tank their preload and then cause problems.

And then again, as I said at the beginning, if you're interested in standing up for the step one step two CK courses, feel free to shoot me an email. And I'll be happy to point you in the right direction. And again, I also offer one on one tier and for many exams, step one step two CK, step three, preclinical, medical exams, 30-as-shelf exams, if you're a medicine resident, actually, tutor for the medicine boards and a medicine-entrany exam. And then, you know, please subscribe to the website, diviningrevensionpodcast.com. And then I also have a You Tube channel that has all the videos I post and continue to post, right? It's called Divine Intervention USMD Podcasts and Videos, so please subscribe to that. And then, I also have this podcast on Apple Podcasts and Google Podcasts and on Spotify. So please, you know, any subscription, any bit of encouragement definitely helps. And then my life lesson today is about insecurity. So, I think one thing that's important amongst the people is, or it's like a fairly prevalent problem amongst many people, especially amongst many, many, many students, it's insecurity, right? You always feel that they're lower than what they are. The thing is, it's actually very important in life to have some sense of self-esteem, right? And maybe this may be a series that I may talk about, like, a lot with my life lessons, but I think maybe one thing I want to say about feeling insecure is, stop comparing yourself with other people, right?

When you compare yourself with other people, you're always going to, your mind is naturally going to focus on all the inadequacies you have, and on all the amazing things about other people, right? So, just think about yourself better, right? I think really this insecurity of a thing is something that, you need to be very intentional about it requires, like a very fair amount, like a wee bit of emotional intelligence, right? And I think another thing too, that also maybe is like a related concept, I don't even know if it's maybe even related to what I'm talking about. But it's just the importance of not trying to please everybody, right? That's one thing I used to do a lot in the past, right? I used to try to, you know, just help people out as much as I can. I'm not saying I don't like helping people, don't get me wrong. I mean, to this day, it's one of my primary models in life is to help people, right? Because again, what's the point of you being on this earth if you're not doing any good in people's lives, right? But the thing is, you don't always have to see ES to everything, right? You know, sometimes in life, you should say no, right? The asserting is not everything you're supposed to agree to, because when you're like a yes man or a yes woman, and people know that, oh, they can toy with your emotions, they will just pretty much just walk all over you, right?

Like, there are some people where they're in a relationship with someone, and let's say, oh, they're like, oh, you know what, I'm a Christian. I'm not going to have sex, still marriage, blah, blah, blah, blah. But then someone that he met, that he've fallen for, that, oh, they're like, man, this person is great. I love this person so much. The person kind of precious, precious, precious them, right? And then he didn't, don't set boundaries. And then they do things that they don't want to do, just because they feel insecure, just because they feel that, oh, they could never get someone better than the spouse that they currently have, right? I mean, like, I've heard the story many times for many people doing things that are unsimly, doing things that they just really did not want to do in the first place, right? So I think just, you don't always have to say yes to people, right? It's hard, but the thing is, people may think you're mean initially. What over time they'll begin to respect you because you have boundaries, right? So the thing is, you have to first respect yourself so that other people can respect you, right? So don't always be a yes, man, right? If something is convenient for you, if, if, if, like, do things because you want to do them, not because you want to please people, right? Because again, if your, if your life revolves around wanting to please people, you're going to get in trouble, right?

In fact, like, I mean, as, for me, as a Christian, like, if, if I said, well, I'm always going to please people, then there will be things that I will do that are not consistent with the Bible, right? So again, people are not always going to be happy with you. There's always going to be someone that hits you or hits something about you, right? So you're not always going to be able to please everybody, right? So just do what is comfortable for you. Do what agrees with your values, do what agrees with your principles, and then deal with the consequences, right? And usually you'll be blessed for it in the end, right? Usually come out on top in the end when you, when you do that. So thank you for listening to this podcast. I'll see you in the next episode. Thank you and God bless you. See you next time.

Obesity.

Adenotonsillar hypertrophy (enlarged tonsils and adenoids).

Wilms tumor (Stunner).

Extension into the renal vein.

Leukotriene receptor antagonists (e.g., Montelukast).

Conjunctival injection/petechiae, or mucosal inflammation/desquamation of lips/oral mucosa.

Nitrates (like those used for angina), Dapsone, and TMPSNX.

Neuroblastomas are known to cross the midline; Wilms tumors typically do not.

Osteosarcoma, most commonly at the knee.

Colline IgA nephropathy (a classic alternate vocabulary term).

NADPH from the pentose phosphate pathway.

Oxidation of $\text{Fe}^{2+}$ (ferrous iron) to $\text{Fe}^{3+}$ (ferric iron), which cannot carry oxygen.

Nitrates (like those used for angina), Dapsone, and TMPSNX.

Neuroblastomas are known to cross the midline; Wilms tumors typically do not.

Osteosarcoma, most commonly at the knee.

Colline IgA nephropathy (a classic alternate vocabulary term).

NADPH from the pentose phosphate pathway.

Oxidation of $\text{Fe}^{2+}$ (ferrous iron) to $\text{Fe}^{3+}$ (ferric iron), which cannot carry oxygen.