DIP Episode 213 - Family Medicine Shelf Review Series 4 (GI)

Okay, welcome. My name is Divine, I am a resident. This is episode 213 of the Divine Intervention Podcasts. And in this podcast I'll be continuing the Family Medicine Show for View Series. This will be Series 4. And I think in this, in this particular episode I'm going to be finishing my GI coverage of what's classically tested on the Family Medicine show of EXA. And again my apologies, I know I haven't made a podcast in about 13 days. That's actually pretty abysmal. And my apologies for that. It's just I've been extremely busy and I also have not been feeling very well for the past couple of days. So my apologies, so but hopefully that should change since things are kind of back on track at this point. So let's just jump right into it, right? So what if you get a question about a patient that, you know, has difficulty swallowing and this person has lost weight, right? What would you recommend next to that person? I really hope that you're thinking about getting an EGD, right? So you may see and you may see the answer EGD or you may see it stated as a sofa go gastro-doide andoscopy on your test or you may see it referred to as operatingoscopy, right? That's what you want to do. The thing is basically you may say, okay, Divine, like when do I do like EG Ds when a person has dysphysia? Well, let me just kind of give you some some big ones, right?

So some big ones you want to keep at the back of your mind if a person, you know, has lost weight, you're obviously kind of worried about cancer at that point. If a person has has like really like painful swallowing, so like a dynophysia, you'd also want to consider getting an EGD at that point. Or if a person, you know, you've tried like almost what I will call maximum medical therapy and did you not appear to be getting better? It's kind of on worrisome sign as well, right? You'd also want to do an EGD under those circumstances, right? So let's say for example, you know, a person has had gourd, you've put them on a PPI, you've optitrated, the dose and all that stuff. You've done it for like many weeks, usually more than six weeks, they're not getting better. You probably want to go ahead and do an EGD under those circumstances, right? But here's one sneaky one that your friends at the MBME have stated, you know, putting a lot more stock in in recent times actually, right? And that's actually this concept of of a bin over the age of 50. If a person has this vision the over the age of 50, basically, bin over the age of 50 is an alarm symptom. Whenever you see that on your exam, you need to very strongly consider getting an EGD under those circumstances. So that's just one of those ones. People don't think too hard about, right? So it's just something you want to keep in mind for your test, right?

And then if they give you a question about a person, you know, that has trouble like initiating swallowing, right? You want to think about that person having more of like an orifice angel dysphysia than an esophageal dysphysia, right? So if, for example, you see a person that you know has like misery, gruditition of food or the person has like trouble like just initiating swallowing, right? I mean, generally, you want to consider thinking more about like an orifice angel cause of dysphysia versus like an esophageal cause of their dysphysia, right? And usually, these people that have like orifice angel dysphysia, like problems, they are almost always people that have like some kind of weird neuromuscular disease like Parkinson's, what do you have like ALS or my esteem your gravis, right? Or like, you know, like they can make it a kid because again, remember your family medicine shelf can include questions on kids, right? So don't think, oh, internal medicine, we don't do anything positive of 18. No, that's not, that's essentially not the case for family medicine. Family medicine, you're going to see kids, right? So kids are going to be on your test, right? So a kid with most of the muscular dystrophy, right? Can certainly have this kind of orifice angel dysphysia on your test. And in general, if a person has orifice angel dysphysia, right? One reason your friends at the MME like this is you do a different kind of test to initially evaluate those people, right?

So you do something called video for our scape, right? Or you essentially like do like a biome swallow, but you take like almost like senior, like that's a radiology term. Just think of it as you're doing like a video recording of them swallowing. Let's leave it at that, okay? The buzz word you're looking for in your test is a is video for our scape, right? And then if they give you a question about like an old guy, you know, has like regurgitation of one digestive food, has like really smelly mouth, like he let's say he's a spouse like complains that honey, mouth smells like a ton in the morning, right? You know, think about Zincar's Diverticulum and the person will also have again a trouble swallowing, right? So think about Zincar's Diverticulum. Basically, if they ask about the pathophysiology for whatever bizarre reason or your family medicine shelf, just be the answer that relates to the crackle firing Joe Mosso, you know, like just crackle firing Joe Mosso crap that's going on is essentially the pathophysiology behind the Zincar's Diverticulum, right? And again, they almost always have halitosis, right? Like just very, very smelly mouth in the morning, right? So just something to keep at the back of your mind, right? And then if a person has this feature for like solids and liquids, right? You want to think more along the lines of again, like a motility disorder, like ecalhesia, right? Ecalhesia is actually an esophageal motility disorder.

People don't really think much about it, but ecalhesia is not because many people think, oh, it's just, you know, increased tone, lower esophageal sphincter. The thing is people that also have ecalhesia, also have like decreased baristosis of the esophagus, right? So that's something I want to commit to memory. And remember ecalhesia, right? Classic appearance, birds big pattern on imaging, right? And people that have ecalhesia, right? You want to think about first getting a barium swallow, right? That's where you see the big sign. And then after they do like esophageal monometry, right? So think about it, right? You want to make sense to get esophageal monometry. If you do not suspect that this person has like a motility thing going on, right? So you get esophageal monometry. And then after that, you do an EGD before you then take those people to surgery, right? And the EGD right is to roll out suboecalhesia because sometimes what may look like ecalhesia on barium swallow is actually a suffigial cancer, right? Because remember ecalhesia is actually a risk factor for scrimocell cancer of the esophagus, right? So you typically want to make sure that, you know, you just kind of make sure this person doesn't have like an actual region malignancy going on before you take them to surgery, right? And remember that ecalhesia can be caused by things like shagas disease, right? So from like a tripano-sumarchruzii. And in general for ecalhesia, right?

You want to do like the, you maybe want to try to avoid like you know like a pneumatic dilution, right? Because we do pneumatic dilution, you can perf the patients esophagus and you know, you have a whole new set of problems on your hands, right? So in general for ecalhesia, like you, you try not to do that. I mean, there are some drugs that you may ask you about on your test, right? On your test, the some things you can do is you can, you can, you can give like, like you can give like a dihydropyridine, consultional blocker that can help with diluting the lures of a geospinter. You can, you can give, you can inject Botox every few months, that also works. But pneumatic dilution, the typically test pneumatic dilution in the context of the complication, which is preferring to the esophagus, right? And the thing is some, remember I said that oh, shagas disease can be a cause of ecalhesia. The thing is basically one way we can introduce that on your test is they can talk about a person that comes into clinic, has been having this feature for a couple of months and the person you know like six months ago, whatever, travel to South America. If you see that, you really want to think about T-Crosi as the potential cause of the ecalhesia, right? And again, ecalhesia do not do EGD first. I promise you if you pick EGD as your first diagnostic test, you're going to get the question wrong, right? For ecalhesia, the first thing you're doing is a biome swallow.

After the biome swallow, you do the manometry, after the manometry then do the EGD, right? Just remember biomedical engineering, BME, right? That's the order. Biome swallow first, one armature second, and in EGD next, right? And again, don't forget your bird's big side, right? And then if a person comes in with like, you know, like, hardburn, and they tell you that, oh, they have like this cough that's worse when they get up in the morning, because you know if you're sleeping, right? You're like in a, kind of like a supine position. So you know that acid can kind of like burn your soft August, burn your larynx, right? Those people may have like hoarseness, they may have like wheezing, they may have like asthma-like symptoms, but it seems to get like, like, really bad at night and when they get up in the morning, you know, think about a girdle under those circumstances, right? And in general, again, if a person has like the classic gird symptoms, but the most part, go ahead and if they don't, again, if they don't have alarm symptoms, go ahead and study them on a PPI, it's not a huge deal, you're going to do EGD or whatever, right? But the thing is if you've, and again, the alarm symptoms like I said, being over the age of 50, right? Losing weight, right? If the person has girded actually with dysphysia, so I'll go ahead and say it again. If a person has girded with dysphysia, right? So notice I talked about dysphysia early as a thing, right?

In general, if a person has dysphysia, like I said, for the most part, so I feel like I may have been spoken a little early. So let me clear this up. Let me talk about dysphysia on its own. Let me talk about gird, right? In general, if a person has dysphysia, the NBMU will almost always give you some kind of alarm symptom or give you some kind of hook that leads you in one direction versus the other. Let me explain what I mean because the thing is the algorithm for dysphysia is not as clear-cut as I would like it to be, right? So, and then I'll talk about gird on its own. So if a person has like the old guy with dysphysia, has hadytosis in the morning and all that badness, you know that zenkers, right? Zenkers causes dysphysia, but you're not going to do an EGD for zenkers, diverticulum, because an EGD is contraindicated in people with zenkers. Why? Because you can prefer, you can per through the diverticulum and then you can have all these problems, right? So the thing you do with zenkers is a barium swallow, that diagnosis made with a barium swallow, right? But if a person has dysphysia and weight loss, right? Or a person has dysphysia and like pinful swallowing, right? Then only those circumstances, you want to consider getting an EGD, right? Now, the area where they get tricky is a person that has gird and again, gird with alarm symptoms. So if a person has gird and they have this any kind of dysphysia with it, like trouble swallowing of any sort, they're getting an EGD.

If a person has gird and they're anemic, right? The animal globin is low, right? They're getting an EGD. If a person has gird and they're vomiting, they're getting an EGD. If a person has gird and they're losing weight, they're getting an EGD. If a person has like gird and again, usually on MDM is this dysphysic scenario, they make it like a prolonged kind of gird, right? And they'll say, oh, they've tried like a PPI or anything and they haven't gotten better, right? If a person is over the age of 50, they are also getting an EGD. That's very, very important to keep at the back of your mind, right? So in general, if a person has a classic gird symptoms, just a classic gird symptoms and nothing else, go ahead and give those people a PPI. That's it. But in general, if you have gird plus some other problem, you almost always will get an EGD for those people, right? So these different scenarios and because the thing is you can't, it's kind of hard to make like one fail full profile, like fail safe algorithm, right? The typically, I will say like these scenarios I've mentioned will probably cover like 95% of what you could potentially see on your test, right? So again, if a person has gird and you're giving them PPI's, right? And the PPI guys don't seem to be caught in it, right? Then that's kind of a problem, right? So for those people, you want to go ahead and again, perform an operating doskopee, right?

And the thing is let's say you perform, I don't see them ever going this far, but the thing is sometimes the family medicine shelf kind of goes too far on things, right? So the thing is let's say you perform an operating doskopee and like the operating doskopee is normal in a prison, the hazard. Then one thing you can do as your next step is actually to do something called like a S of a Joe pH monitoring, right? So you can put a pH monitor is kind of uncomfortable for patients to be honest, but you can put a pH monitor down the prisons and suffer just to kind of like, you know, whenever they have symptoms, the thin wood, I think they will like press a button or something and they will record the pH in their suffer just it's almost like the gold standard actually for making the diagnosis of of dirt. So that's pretty much what I will say, well, pretty much what I will say about that, and again for the most part, if a person has dirt, you treat with a PPI, and one thing I think I get, so if I forgot to say about a calisia, if you're treating a calisia, right? One thing you can do is you can do like a surgical myotomy, right? So you can do like a myotomy and that essentially fixes, that essentially fixes the problem. Although after people actually get the surgical myotomy for a calisia, it doesn't mean that they're not going to be placed on PPI's, right? You know, they are very likely still going to be on PPI's for a while.

So just something to keep in mind there, but that's more clinically relevant than maybe exam relevant. And then again, for dirt, like I said, put those people on PPI's and if dirt continues for long enough, right? Like you're going to go into bites as a suffocates, right? And again, one thing I want to do is I guess let me talk about a testic in strategy here, it's just something that kind of fits nicely with this thing I want to discuss, right? Let's assume your friends at the MIMI give you a question about a person that has a Sovajila no carcinoma, right? And then they see which of the following historic factors is the biggest risk factor for as Sovajila no carcinoma in this patient. And let's see the put an answer that says dirt, and then let's see the put an answer that says baritose suffogos, which answer should you pick on your test? Which answer should you pick on your test? I would really, really hope that you're picking on, I really, really hope that you're picking an answer that says baritose suffogos, right? The thing is dirt, right? Leads to baritose suffogos, but think about it between those two answers, dirt and baritose, which one has the most direct link to Sovajila no carcinoma? That's going to be baritose suffogos, right? So the thing is in general on exams, whenever you have two very close conflicting answers, always pick the one that is the most directly related to the question at hand, okay?

That's a very useful test-taking principle for the NV Me exams, right? So again, just something to keep in mind. And the thing is one screening guideline, you may want to keep on the buck of your mind with baritose suffogos is that basically if a person is like a guy and he's more than 50 years old, and he has had dirt symptoms for like more than five years, and you know, let's say usually you'll make it like a pretty obvious question, right? You'll be like an old person, so be a guy, more than 50, not a woman, a guy, more than 50, has dirt symptoms for like more than five years, and you know, let's say it's kind of like higher risk as well, you know, maybe drinks a ton of alcohol, you know, has all these metabolic syndrome antecedents like like use obese, smokes, you know, like all the bad, all the like the bad, bad, bad symptoms that I kind of think about. Those people actually do need screening with an EGD for a suffogilal adnocarsinoma, right? So that's one of those weird screening guideline questions you may see on your test. And in general, if a person has like baritose suffogos, you typically do like a resection, you do like an endoscopic like resection or like an endoscopic ablation. In some cases, though actually most times those people also get pretty high dose PPI's, right? But the thing is they will also, in general, need like, you know, like routine surveillance, usually every like six to 12 months.

So I'll say like for the most part, like every like, just think of the six to 12 month period for the most part, and you should be fine with that. And in general, right? Again, you don't screen women with dirt for baritose suffogos, right? And then remember the things that can, if for example, they give you a question about a person that has like a dynophasia, right? And let's say this person has like HIV, right? You want to think about like a candidate as a vagina, right? Candidals as a vagina. In fact, the thing is if they give you an as a vagina's question and they don't give you any hints, they don't tell you anything about or the person having throsh on the mouth or anything, right? Because the NVME actually writes some of these questions where they give you like essentially no clues, no hints, nothing, right? And they expect you to just imagine, oh, what's the cause of this person's as a vagina's? Whenever you give those kinds of questions to be perfectly honest with you, go ahead and pick Candida. Candida is the most common infectious cause of asovagitis, right? That's just like epidemiological thinking on the test, right? Just go with Candida. Candida is like the number one infectious cause, number two is CMV, number two is HIV. So just follow enough, a medical order, like CA, as before CM, and then C, as before H in the alphabet, right?

And again, usually people that have Candida, less of asyides, you know, they will have like throsh, but that's not always the case, right? I mean, like the NVME kind of write questions where a person has Candida, less of asyides and they won't give you the classic throsh that you're expecting on your test, right? And also don't forget like peeling uses of asyides, right? Don't forget like your bisfoss fanates. That's a classic one, especially like a lingerie, right? Like that's why if you take bisfoss fanates, you're supposed to like essentially be upright for like 30 minutes, right? So that you don't burn burn yourself because there's some other classic things on NVM Es that tend to cause peel asovagitis. So things like your tetracycline, like your ibuprofen, and other insets, like your potassium tablets, right? Iron tablets, those things can cause all those problems, right? And for the most part, right? If a person has like a so-called gel kind of diocese, you can treat them with like clotrimazolos angis or basically like any of those isles, so you can do like the nastarin, swish and swallow, yada yada yada, that that can work under those circumstances.

And then if they give you a question about like a young person, so this is not going to be an old person's disorder in your test, like you know, like a young person that has, you know, like really bad heartburn, and this person is not necessarily obese, you'll be like, man, this person is pretty healthy, but this person has really bad heartburn, and also has like many episodes where like it's almost like food is stuck in their esophagus, whenever you see that, think about something called eucinophilic esophagitis, okay? Think about eucinophilic esophagitis. For the most part, these people, you give them PPI, so you'll be like, oh, this person has, you know, classic great symptoms, you give them PPI for weeks, like more than two months, they're like, man, this person's symptoms don't seem to get better, and they're like, you know what, let me go ahead and do an EGD, and then you do an EGD, you take a biopsy, and then you notice that there's a crap tone of eucinophiles in that, right? That's eucinophilic esophagitis. For the most part, eucinophilic esophagitis are response to corticosteroid therapy, response pretty well to corticosteroids. And again, for candidates of agitis, again, like I said, prochimusol as angis, you can use floconazole, you can use troconazole, it doesn't matter, you can use my study in swallow.

If a person has herpes esophagitis, obviously you want to use esyclovere, or you can use like fumsyclovere, if it's symv esophagitis, you want to use like gansyclovere, right? And again, remember, if you have like HSV or symv resistentes, like HSV or symv esophagitis that's resistant to, like esyclovere or gansyclovere, you can consider using, you can consider using foscarnate, remember that's like that pyrophosphate analog, penisophagitis, you don't really need to do anything, you know, just tell the patient, you know, drink a ton of water while you're taking your meds, basically so what if they get better? And then, if you get a question about a person that you know has like, like, you know, like, bloating symptoms, like burning, like that's burning, annoying pain in the epigastria, and you know, the kind of feelful early and, you know, they just don't feel great, right? You want to think about like, peptic ulcer disease, right? And for the most part, like the two big causes, you want to think about are your test, H-pylory, NSAI Ds, right? And the thing is, if a person has any peptic ulcer disease symptoms, you need to test them for H-pylory, right? Even if they use NSAI Ds, it doesn't matter, you're still going to test them for H-pylory, right? You're still going to test them for H-pylory. And again, remember that peptic ulcer disease can have problems, right? Like, what are some like, I guess, classic complications, your friends at the NBN equal test, right?

They could test the person that has like a long history of peptic ulcer disease, and then the person presents with like, sodium onset, CV abdominal pain, and then they show you an extra, you see free air under the diaphragm, right? Obviously, those people have proofs that also, they've proofs the abdomen, those people need the exploratory laparotomy like yesterday, right? Another thing that can happen is those people can start having like really bad hemoptysis, especially like if it's like a abdominal ulcer that erodes, and kind of like, you know, kind of like erodes that gastro-adrenal artery, those things can bleed and kill people, right? So for that, again, those people will need like very quick, very quick therapy so that they don't die because that thing is actually pretty deadly, I've actually seen this like personally. And again, for the most part, right? If a person has H-pylory, you know, you test them for H-pylory, and after you test them, you know, you can treat them with like triple therapy, and the pneumonia for triple therapy is like cap, right? So like clarytromycin, amoxicillin, and a PPI, right? Or you can pick quadruple therapy, that's like metronidosol, bismuth, tetracycline, and a PPI, right? So MBTP, that's where I kind of remember that. And again, the thing is, again, if a person has peptic ulcer disease and they have alarm symptoms, you need to perform an EGD, right? Remember an EGD? Literally look at the name, esophagol, gastro-doordinoscopy.

It helps you evaluate the esophagus, the stomach, that's the gastropartathem, and the doggone, right? So just something to keep at the back of your mind, right? And the thing is, in general, for H-pylory, you know, you can do like the hydrogen breath, I mean, sorry, like the urea breath test, or you can do like stool antigen test, right? Essentially, the thing I will tell you is, do not pick like getting like antibodies to test for H-pylory, because it's not going to help you, like, because you have antibodies, whether you have, you've had like a past infection that you've cleared, or you have like a current infection, right? So the antibody test, you know, is usually not, is usually not, usually not useful on NV Me exams, right? And again, if a person has like peptic ulcer disease from like NSAID, you know, stop the NSAID, you know, you can treat them like a H2 blocker, like Rani D'Dene, or whatever, right? You can treat them like a PPI, and that's pretty much all, that's pretty much all I'll say there. And then one other thing I would also say is, there's this thing that just came to my mind, command, if I think about this, if a person is going to be placed as a commanding me in the exam question, if a person is going to be placed on chronic like steroid therapy, right? For like some autoimmune disease or whatever, those people actually require two kinds of perphylaxis while they are on those steroids. They need to be on PPI's, right?

Remember, PPI's can, because steroids can kind of like increase gastric acid production and cause like ulcers, right? Like gastric ulcers and one of ulcers, right? So those people need like chronic PPI's. And also if you're on chronic clinical steroids, remember steroids, right? Can cause ulcer, like ulceronecrosis, they can cause like an evenceclinecrosis of the hip. So typically for those people, they also need to be placed on this phosphatide cell. If you're on chronic clinical steroid therapy, okay? I'll just go ahead and see this right now. If you're on chronic clinical steroid therapy, you need to be placed on profilactic PPI's and profilactic bisphosphonates, okay? That's very high you'll to know for exams. And let's see, is there any other thing I want to say about peptic ulcer disease? To be honest, I think that's all I really want to say. And then what if they give you a question about like a diabetic, you know, having a lot of trouble, the diabetic, having a lot of trouble, like, you know, like feels bloated after a meal and you know, feels marshes after a meal, feels full early, and all that badness, right? You want to think about gastroparesis, right? And remember, diabetes is not the only thing that can cause gastroparesis on an NV Me, right? Because again, remember your friends at the NV Me, they're getting very creative these days, right? So what are some other things that can cause gastroparesis?

So other things that can cause gastroparesis are things like scleroderma, right? Hypofiroidism, believe it or not, can cause gastroparesis. If a person is on like chronic opiotherapy for like chronic pain or whatever, that can also cause gastroparesis, right? If a person is on like a chronic anti-colonial glicy for whatever bizarre reason, a person is taking like daily, like diaphid hydramine, that can also cause gastroparesis, right? And in general, though, the most common gastroparitic thing you'll see in your NV Me exams is from diabetes, right? And in terms of that, what do you do to treat diabetic gastroparesis? Essentially, what you do is you, you know, you can treat it with a motylene receptor agonist, right? Like erythromycin, right? I mean, this is why macrelates cause diarrhea in the first place, right? Because you're essentially like increasing gem motility when you take a take a macrelate, right? So that's why diarrhea is actually one of the side effects. But that's more for step one or step three. And I don't feel like that's something that we necessarily test on step two. So you can use like, you know, like an IV macrelate usually terrythromycin on your test. Or you can also use a dopamine receptor antagonist like metoclopromide, right? But you can already, maybe even begin to imagine what I'm going to see next, right? Your friends at the NV Me, they can write a question about a person that you know will study in a drug for gastroparesis.

And then this person is now having like tardy dyskinesia or having like bradykinesia or like like a positive speech or like a resting tremor. If you see that you want to think about like a drug induced by consentism, right? But the most probably want to go ahead and stop the drug, right? Basically whenever you're having side effects from a drug or an NV Me, always find the answer that involves stopping the drug, right? If you've stopped the drug, then you can start treating or whatever, right? So it's just one of those rare things you want to keep at the back of your mind on tests. And then what if they give you a question about a person that you know has had like weak loss surgery or not even weak loss surgery like some kind of, well usually it's weak, let me make this simple, some kind of weak loss surgery, you know, like a gastric bypass or whatever. And then they tell you that, oh, this person, whenever the person eats, the person says that, you know, I have like this crumpy feeling in my belly, feel nauseous, having all these tools. And then like after that, like you know like an hour each liter, they tell you that they're kind of like sweating, feeling like headed, like all like tachycardic and whatever. If you see that, you want to think about dumping syndrome, right? You don't need to do any specific diagnostic tests for that. It's something that knows clinically, right? You want to think about dumping syndrome.

And for the most part, you may say, oh, what's your best recommendation to the patient again? These are all things that the patients can come in for to family medicine, right? Typically what you recommend for the patient is just say, you know, just take smaller meals more frequently, right? And in general, you want to take like low-carb meals, right? So that you don't take a ton of meals that promote like hyper insulinine, right? So just one of those rare things you want to keep at the back of your mind, right? And then what if they give you a question about a patient? I feel like, because again, I don't want these podcasts to be like super, super long. So I suspect they'll have to be like a final GI podcast, and again, my apologies, because this is just all these things that kind of copied up in my mind that I want to talk about that I kind of high-yout for for the shelf, right? So what if they give you a question about a patient that you know has like studying on set, severe pain in the like a big gastrim going to the back, the presence like vomiting in and you know has a high white count on all that crap. When you see the way you're thinking about, well, hope you're thinking about a pancreatitis under those circumstances, right? And again, remember there are many things that can cause pancreatitis. Alcoholism and ghost ones are the most common, right? But if they tell you that we're pressing those in, consume alcohol, then it's going to be ghost stones, right?

And the ghost don't pancreatitic person on your test will be the person that's like obese, you'll almost certainly be a female, that's like in the 40s, or you know, in reproductive agents, stuff like that, right? So that's like the classic demographic, right? For pancreatitis, or any of these exams, right? Although occasionally, right, they can give you a person that has like, they can make, they can essentially integrate a question with like genetics, right? If a person has like one of those familial hyperlipidemia, especially like familial hyper-traglisidemia, especially when your triglyceride levels are more than a thousand, right? Those things can trigger pancreatitis. And then again, do not forget that HIV drugs, stavidine and didano-syn, those are drugs they love to test on exams, right? And also of our pre-carsid, of our pre-carsid loves to cause pancreatitis. Remember, of our pre-carsid touches the liver and it touches the pancreas, okay? And or they can you give you a question about a person that had like a recent ERCP, right? Or they can give you a question about a kidney pancreatitis, you know, you maybe want to think about like, especially if it's a kid with Down syndrome, maybe unalup pancreas as the cause, or if it's a kid that's like fifth percentile for a week, or a current respiratory infection with pancreatitis, you want to think about cystic fibrosis on those circumstances, right? Or if a person has like a very high calcium, right?

Those things can all cause pancreatitis. And for the most part, pancreatitis, you can actually, basically, there's one of these three criteria. If you meet all of these three criteria, you have your diagnosis, right? Like the classic, like, oh, like severe abdominal pain, like in the epigastrum going to the back, right? That's like the classic abdominal pain pattern for pancreatitis. That's one. If you're lipase, right? It's more than three, four to the upper limit of normal, right? Or you see, you have like imaging features, right? Like on a CT, CT is typically the imaging test you get in a brain that has pancreatitis. But again, you usually do not need to order CT, right? But basically, if you have like two out of these three symptoms positive, right? That person has acute pancreatitis for the most part, right? That person has acute pancreatitis. And for the most part, you make those people MPO, you place them on pain control and you give them copious amounts of IV fluids, usually no most scene, right? And one thing that your friends at the end of the year may have actually started caring about is what are some things that may tell you that, oh, this person may have pretty bad outcomes with your pancreatitis. Basically, you want to memorize the rancings criteria. I'm not going to reel them off here to you.

But basically, right, if those people have like a big drop in the hematocrit or the acosium is super, super low or they have like a very high white count, or the, I think, like the, I know there's like ESD criteria, I think if it's more than 250 or something like that, or the LDH is really high, those are all like bad prognostic factors, right? Or the abuene is like really high and it keeps going up. Again, if you see those kinds of things, you want to think about a, like bad features. So just go ahead and memorize those things. It's something you can look up, right? So just go ahead and look those things up. It'll be really helpful. Trust me, it'll be really helpful to you on a test. And remember that pancreatitis, the most common complication, again, this is one of those prognostic whatever questions you could just get on a test, right? The most likely complication of acute pancreatitis is a pancreatic pseudo-sist, okay? It's a pancreatic pseudo-sist. And the thing is if a person, you know, has had like many episodes of acute pancreatitis and then they're beginning to give you questions about this person like, you know, having like fat malabsorption, stals and thums, or they show you like a CT scan or like an abdominal x-ray. I noticed that you see like white around the pancreatic area, right? So that person essentially has chronic pancreatitis.

Remember those people need a supplementation of pancreatic enzymes and they also need supplementation of our fat soluble vitamins, right? So like vitamin A, D, E, and K, right? And again, in general, people that have pancreatitis do not require CT scans, okay? Because usually they have the epigastric pinguine to the back and they have like elevated lipase. Remember, lipase is more sensitive than amylase. That's all you need, right? They have pancreatitis end of story, right? But if a person has like pancreatitis and you've treated them as you showed, and you're like, man, it's one of two, these persons are not getting better. More than two days not getting better. You can go ahead and get a CT scan under those circumstances. So again, flow aids, NPO, being control, that's pretty much all I'll say about that. So I think I'm going to go ahead and let me maybe say one more thing about pancreatitis and then I think I'll probably go ahead and stop here. The next gypochast should hopefully be pretty, pretty quick and dirty. But basically, you want to think if they give you a question about a person, and you know, this person has like an autoimmune history. So this person has a history of like hypothyroidism, Ikiyashimoso, Hashimoto's, or he's show of celiac disease, or he's show of gravedis disease, or he's show Viniligo, or he's show of Adesine's disease, right? Any autoimmune crap. And then this person has like recurring episodes of epigastric being going to the back.

You want to think about autoimmune pancreatitis under those circumstances. And the thing is autoimmune pancreatitis is one of those things that is one of those IGG4 related disorders. Again, I've said this in many of my rapid review podcasts. Those IGG4 related disorders are very high to low for tests, right? Like autoimmune pancreatitis, autoimmune coluses, stitis, retroperitoneal fibrosis, those are kind of things you want to keep at the back of your mind for tests, right? And I mean, there's like a limitary that, oh, they get like a CT scan of the abdomen and they notice that the presence pancreas is shaped like a sausage. So a sausage shaped pancreas, that's usually pathonomonic when they meet me exams for autoimmune pancreatitis. And for the most part, you give those people critical steroids and they'll be fine. So I'm going to go ahead and stop here. As I do at the end of every podcast, again, I do offer one or one tutoring for many exams. All the shelf exams I tutor for. So like family medicine, emergency medicine, I am peeds, gender surge, obi-guin, neuropsych, ICU shelf, although I've never tutoring anyone for the ICU shelf. Just no one has ever requested it but actually can tutor you for the ICU shelf. And then step one, step two CK, step two CS, step three, pre-cleaned cold med school exams. If you're a medicine resident, I need tutoring for the ABIM board exam, so the intrading exam. I go for tutoring for all those stents.

And then, you know, if you have a college body that needs tutoring in most of the pre-med subjects, so like Gen CAM, O-CAM physics, bio-CAM, histology, physiology, I tutor for all those stents. And then I also do these booster courses. It's 15 hours for step two CK, step three. It's 20 hours for step one. Essentially, in those courses, I review the most nose, like the highest of the high yields in a case-based format. For those exams, I kind of touch on all the different systems and all the different disciplines. And then, starting next month, although I think I'll still make a podcast just on this, starting next month, I am going to, I think probably on a weekly basis, but I'll trail the first one. I'm going to be doing an online, I'm going to be doing like probably weekly online study groups. Basically, it will be like two hours and it will have like a particular focus. So it could be like a cardiology study group or gastroenterology study group. It will just and it will be attuned towards a specific USML exam. Although I'll probably also do this for medicine residents in the future, but essentially, it will be something that will be held over Zoom, okay? And it will be two hours long and each session will cost like a hundred dollars per participant. And what I plan to for sure do the first one, starting the first week of next month. If I get enough interest from people, I mean, if I don't get enough interest, then I won't do it.

I may move it to the second week or whatever. But if you're interested, send me an email and I'll add your name to a list. And then when the time comes, I will probably like, you know, like maybe like a day or two to the end of this month or, you know, latest by the first two days of next month. I'll give you some more details on on like on how payments will be made. And obviously, I'll just send you like a Zoom link, you click and get into the session. I will be very high-yield in general. I'll have like a ton of questions that I bring in that we work on, right? But in general, I will like it will be like nicely, let's say for example, you're struggling with like cardiology, right? Then you know, you just go ahead and attend a study group. Let's see your study with cardiology for step one or cardiology for step two, CK for step three, who essentially fix those problems relatively quickly in that two-hour time-free. I'll probably be able to take a few questions. I won't necessarily be able to take like copious amounts of questions since it's going to be like strictly two hours. But if it's something you're interested in and you want your name to be added to the list because obviously I can't take all limited numbers of people. Just go ahead and reach out to me if there's a topic you're particularly interested in like cardiology for step one or neurology for step one or something like that. Go ahead and indicate that in the email that you sent to me.

Again, you can send these emails out to me either through the website or you can send me an email specifically through and this is probably my preferred method. Divine intervention podcasts with an SIVN. So DIVINE, IN, T-E-R-V-E-N, T-I-O-N-P-O-D, C-A-S-T-S, at gmail.com, right? So you can send me an email that way, right? Just tell me like divine. I mean, I'm interested in your private study group that's going to be through ZO. So just reach out to me through any of those mediums, indicate what you want and I misspoke early. I said the first week of February. I'm studying the second week in February, right? But again, if you're interested, just reach out to me and then I also do like one-on-one coaching, right? So like if you're a med student or a plane to a residency, so like an ERAS application or a college student or a plane to med school, so like an AMCA's application, I'd offer like one-on-one like coaching with like rec letters, personal statement editing, editing applications, marketing reviews, and I do this by specialty, right? Because again, I've worked with tons of people from multiple specialties and again, I also have like one-on-one admissions committee experience at a top-two med school for like a year. So again, I'm pretty good at working with applications and the vast majority of people have worked with have all much that their first shorts, right?

So if that's something you're interested in, feel free to reach out to me and please, like I said, if you could subscribe to the You Tube channel, that'd be really helpful. It's called Divine Intervention Podcasts and Videos. You can subscribe to my Word Press website to I have these podcasts on like Apple podcasts on Google Play on Spotify, so please subscribe to the podcast and any feedback when anything is certainly very helpful. So have a wonderful rest of your day. I'll see you in the next podcast, which hopefully should be coming around very soon. Thank you and God bless you.

Barium swallow study.

Male sex, age >50 years old, and GERD symptoms lasting > 5 years.

A "sausage-shaped" pancreas.

Videofluoroscopy (or biome swallow).

Candida species.

PP Is (for gastric acid) and Bisphosphonates (for preventing osteonecrosis).

Barium swallow diagnoses it, but EGD is contraindicated because perforation risk is high.

Scleroderma, hypothyroidism, or chronic anti-cholinergic drug use (e.g., dihydramine).

Proton Pump Inhibitors (PP Is) and lifestyle modifications (diet/elevating head of bed).

Opiates, anti-cholinergics (e.g., dihydramine), or certain anticholinergic agents.

Candida $\rightarrow$ CMV $\rightarrow$ HIV (CASH/CMH).

1) Severe epigastric pain radiating to the back; 2) Elevated lipase (>3x ULN); 3) Characteristic findings on CT scan.

Barium swallow diagnoses it, but EGD is contraindicated because perforation risk is high.

Scleroderma, hypothyroidism, or chronic anti-cholinergic drug use (e.g., dihydramine).

Proton Pump Inhibitors (PP Is) and lifestyle modifications (diet/elevating head of bed).

Opiates, anti-cholinergics (e.g., dihydramine), or certain anticholinergic agents.

Candida $\rightarrow$ CMV $\rightarrow$ HIV (CASH/CMH).

1) Severe epigastric pain radiating to the back; 2) Elevated lipase (>3x ULN); 3) Characteristic findings on CT scan.