DIP Episode 117 - USMLE Step 1 Rapid Review Series 9 (Repro)

Okay, welcome. My name is Devine. I am a PGY2 radiology resident. I guess I better stop saying PGY1, TY resident, going into radiology. So actually I'm now as of yesterday I am now a PGY2 radiology resident. So welcome to episode 117 of the Divine Intervention Podcast. This will be a USML Step 1 rapid review series. This will be series 9 and I'm going to be focusing on repair of today so let's just get right into it. So what is the most common benign breast new plaza? That's a fibroidanoma, right? That's a fibroidanoma. So it will present us like a 30, 30, when something your old lady has this singular mobile breast mass that kind of hurts a little and kind of seems to grow with a menstrual cycle. You're not supposed to do any diagnostic testing and you're not supposed to do any treatment. Now what if you get a bloody report discharging a young female or any female or an MBA me exam? What are you thinking about? That's an introductory Papilloma, right? Okay. Now what if you have a hard mass, a hard breast mass in a woman that previously got into a fight? That's fat necrosis, right? That's fat necrosis. Okay, what if you get a question about fever in a woman with a baby, you know, kind of tugging on her nipple like three days ago? Let's say it's like a postpartum female out. Actually talk about this in a podcast, then we're gonna make right after this.

It will probably be my shortest podcast ever, maybe like a five, six minute podcast, but it's just something that a lot of people get wrong. So I will really, like little bit, I've just said divine can you just make a podcast just for this? It's differentiating between some breast pathologies that people seem to get wrong quite a bit on a USMLE exam. So I'll just make it as a separate like literal like five minute podcast. Now make it right after this. Okay. So this question I was referring to is my status, right? I could my status. Okay. Now what are the three diagnostic criteria for PCOS? Right. So one will be signs of an ovulation, right? So like irregular men's is kind of deal. Right. What's the ultrasound criteria? Policistic ovaries and ultrasound, right? And then they will have signs of hyperangirginism, right? So like the hersotism and all that stuff. Okay. Now what is the most common cause of a breast mass in a female in the US? That's fibrosistic change, right? Okay. Now what if you get a question about a 50 something year female and they tell you that all her lipos, her nipples look like scaly and have like examiners changes. What are you thinking about? I hope you're saying Pajet's disease. Okay. Now what if you get a question about a lady and they this will be a classic thing they'd love to do on the USM in the step one. They talk about a lady, you know, has a small mass that was detected on a mammogram and then they say they took a biopsy and on histology.

They're seeing like new clear with like central clearing and they tell you that oh they did some studies on these cells and they have an e-cat hearing mutation. What are you thinking about? That's Lobelokasinoma inside too, right? So invasive Lobelokasinoma. I remember the Lobelokasinoma is for some reason tend to have those cat hearing mutations. Remember cat hearing is one of those things that holds epithelial cells together. And remember that people that have Lobelokasinoma inside too, they have a high risk of bilateral breast cancer. Okay. Now what is the drug of choice in the treatment of her two positive breast cancer? That's Trostusumab. Remember Trostusumab is a monoclonal antibody against her B2. And remember that it can cause a reversible diethic cardiomyopathy. So a classic USMD question may be prior to beginning Trostusumab therapy. What is the next best step in management? And you answer for that patient who want to be to get an echocardiogram to get a baseline injection fraction, right? And remember that your drugs like a doxoroobicin, donor-obicin. Those are also those drugs can also cause a diethic cardiomyopathy. But remember it's an irreversible diethic cardiomyopathy. It's actually kind of high up to know that for tests. Okay. Now what if the tell you that a person has like a testicular tumor and on histology they tell you that you are seeing like eosynophilic colored rods like pink rods in like testicular cells. What are you thinking about?

What kind of tumor are you thinking about? I hope you're thinking about like the leadic cell tumors, right? Remember those are the ryankey crystals. Okay. Now what do you tell you that you see cells with a with a fried egg appearance on histology and it relates to like a like a ripro malignancy? What are you thinking about? I hope you're thinking about seminomers in in like a testicular seminomers. I hope you're also thinking about those coilo sites, right? That you find with HBV infection and then don't forget the brain tumor ligodendroglyoma can also have a fried egg appearance on histology. Okay. And what's the most common germ cell tumor in guys? That's a seminoma, right? Okay. Now what if a person has like an ovarian mass and they tell you that oh, have beta-HCG is markedly elevated? What are you thinking about? That's a choreocarsinoma. Remember, choreocarsinoma can also happen in guys, right? Okay. Now, if what's the tumor marker that if elevated can basically help you rule off a seminoma? That's an elevated AFP, right? Elevated alpha-phido protein. If you have a little protein is what is elevated on an MBME exam, do not choose seminoma. It cannot be seminoma on an MBME exam. What's the tumor that was the ovarian mass that classically has an elevated AFP? That's a yokesark tumor, right? That's a yokesark tumor sometimes on the MBME decoded and endodermal sinus tumor. Okay. And what are the classic findings on histology in a person that has a yokesark tumor?

They kind of look like small glomeruli. Those are the Schiller-Du-Vol-Buddies, right? These are the Schiller-Du-Vol-Buddies, okay? And for most ovarian cancers, right? So is there like a tumor marker for most ovarian cancers? That's C-A125, right? Okay. Now this thing is, I'm going to focus on epidemiology for a short while, but they love to test this stuff on the USMELIS. What is the most common cause of gynecologic related deaths? What's the most common cause? That's ovarian cancer, right? Okay. What is the second most common cause of gyne malignancy related deaths? That's endometrial cancer, right? Okay. And what is the most commonly diagnosed gynecologic cancer in women? So gynecologic, I don't mean like technically by gynecologic, I don't need include breast, right? But most commonly diagnosed gynecologic cancer in women. That's endometrial cancer, right? Okay. Ovarian cancer is number two on that list. Okay. Now what's the, so let's assume you get a question about a person that, you know, they have a history of, of a con syndrome from like bilateral adrenal hyperplasia. So obviously you cannot do a bilateral adrenalectomy for those people. And then the guy tells you that you start the, let's say you start the guy on a drug and then four weeks later he says, Doc, I cannot take this drug anymore. He's a complaint of like side effects with his breast. What kind of drug are you thinking about? And what side effects am I getting after?

Well, I hope you're thinking about spurnolactone, remember spurnolactone? Can cause gynecomastia, right? Remember it's an outdo syndrome receptor antagonist, right? So it also causes like a metabolic acidosis and it causes like hyperchylemia, right? You remember it's a potassium sparing diuretic. Remember it can cause gynecomastia? Because in addition to blocking outdo syndrome receptors, it also has the ability to block androgen receptors, right? If you want to prevent that gynecomastic side effect, you probably want to go to a plerino. A plerino is an outdo syndrome receptor antagonist, but it has no blockade of androgen receptors. Okay, now what if you get a question on the NBA means about a lady that has a BMI of like 35 and she has a mentees every 45 days. And in time she has a mentees, she has like very heavy mentees and let's assume her self and a husband that have been trying for a while to have kids not working out so well. What kind of drug would you want to give that patient? You don't want to give her clonifin, right? Why is that? Because she has BCOS, right? You want to regularize her menstrual cycles, okay? Because clonifin, right? It's like, it's a, basically it's a serum. If you notice, it sounds eerily similar to like tamoxifen, reloxifen, clonifin, it's a serum. So the thing is it has partial estrogen receptor agonist activity in the brain. So by being a partial agonist, right? It's basically acting as an antagonist.

So it's essentially almost creates like some kind of like a, it kind of like removes negative feedback of estrogen at the level of the brain, right? So that increases the HPG access possibility and that increases the ladies risk of fertility. In fact, I can quote exact numbers, but I know I've read a study where a lot of women that have BCOS, most of them that were placed on clonifin actually got pregnant. Okay. Now, what if you want, what's like the drug of choice in general for pressing SPCOS and let's assume they're not necessarily having plans to have a kid soon or anything like that. They just want to regularize their cycles. What do you give them on MBM Es? You give them OC Ps, right? You give them OC Ps. Okay. Now, what is the drug that can be used to treat hersotism on MBME exams and patients that have BCOS? You can actually use Spironolactone, right? And the reason behind that is that Spironolactone has an ability to inhibit five alpha reducties in the skin. Okay. Remember, five alpha reducties converts testosterone to DHT. Spironolactone in the skin can inhibit five alpha reducties. So you may see it divine. This is super low yield crop.

I promise you, again, obviously I can't say much, but I promise you that it's not super low yield crop to know because one thing your friends on the MBME love to do is they love to test the peripherally-related concept about they can basically give you a question about like a lady that's like in her 30s and she's her suit but you're like, man, this lady's BMI is fine. So she doesn't have PCOS and this lady doesn't have any at Nexomasis. So she doesn't have like like an Androgen secreting to more anything like that and they will show you that oh the FSH is normal, LH is normal, testosterone is normal, everything is normal. If you ever see that, you really want to think about a person that has increased activity or five alpha reducties. That's something that is found in certain populations of people where they just having their completely normal, they have no issues going on but they just have increased activity of five alpha reducties. This is one of those things that I can promise you. If you're a second year med student, you're a student preparing for step one between now and the time you graduate from med school, you're going to see this concept tested at least three times. I can pretty much guarantee that. So it's something you better keep at the back of your mind. Okay, so the reason I'm saying that is right again, increased activity of five alpha reducties can make you her suit, right?

So if a person has her suit, she's in the setting of PCOS, it should make sense that you want to give them a skin five alpha reducties inhibitor like spermolactone. Okay, now what is the, what if you get a question about like a 70 year old guy, he comes in, he says over the last six months, he's been having like urinary dribbling and your occasionally has like urinary urgency. First of what's your diagnosis for this guy? That's BPH, right? B9 prosthetic hyperplegia. And then what's your next step in management of this patient's symptoms? So acutely, like to relieve his symptoms like relatively quickly, what do you want to do? You would want to give an alpha one blocker, right? An alpha one blocker like Prasocene or Doxazocene, right? But remember that those drugs can cause orthostatic hypotension because the alpha one receptor blockers. So on the exam, the drug you probably want to go with is tamsulocene, tamsulocene inhibits the alpha one AD receptor. So by inhibiting the alpha one AD receptor, it only targets the bladder neck, it doesn't target your blood vessels. Okay? And a very nice question that you can actually throw on an NV Me exam is to basically present a question about a person that has a BPH, right? And then let's assume it's a person that maybe has some history of another disease that makes them take a visual dialyther like a nitrate or they are taking like hydrozene or like a dihydropylene calcium channel blocker, right?

Those people have a relative contraindication to an alpha one blocker, right? Because that can cause a profound drop in their block pressures or they can describe a person that has BPH and is already on Prasocene, for example, and then they tell you that oh, this person also has erectile dysfunction, right? You probably want to think twice before putting them on cell DNF, because again, you're in general, I'll just tell you this as a general concept. You don't want to give people two visual dialyters together, especially old people, because they can dialythera block vessels profoundly, they can have very bad hypotension and they can like pass out or something, they can have like a syncopal episode. So that's a very wonderful thing your friends at the NV Me love to do every now and then. Okay, now but for the long term, how can you treat a person's BPH symptoms? How can you shrink the size of the prostate? You can give a five-hour-ferry doctorate inhibitor, right? Like finasteride or dutasteride, okay? And what happens to your levels of sex hormone binding if you take OC Ps or if you're pregnant? It actually goes up, it actually goes up, that's just one of those factors you want to keep at the back of your mind. Okay, now what if they give you a question and they tell you that they see a string of pearls in the ovaries of a, like a 30 something old female or an ultrasound, and this lady has a BMI of 40, that's PCOS, right?

Okay, and what is the gynecologic malignancy that a person with PCOS has an increased risk of? That's endometrial carcinoma, right? Because remember, right, people tend to be hyper-estrogenic when they have PCOS. So if a person has a history of PCOS and they begin to have like very heavy menstrual bleeds and they're like in their late 30s or like early 40s, actually the next best step in the management of those people on NV Me is to actually do something called an endometrial biopsy, one endometrial sampling, to rule out endometrial cancer. Okay, because the classic teaching is, oh, if you see a postman opposite woman, so more than 50 years old and she's having vaginal bleeding, you're doing endometrial biopsies related to endometrial cancer, that is true. But if a person has significant risk factors for hyper-estrogenism, classical your name BMI is that's PCOS, because you want to go ahead and screen them for endometrial cancer as well, even if they are less than 50 years old. Okay, now what if they tell you that on laparoscopy you're seeing like chocolate like cysts in the ovary? What are you thinking about? You're thinking about an endometrial, right? Okay, now what if you get a question about a lady, so let's assume she's 25 years old and she comes in with like, see if you have dominope, nausea, vomiting, in fact the question is almost like screaming hyper-emesis, gravity down to you.

And then they tell you that this lady is 15 weeks pregnant, but then they tell you that the length from the pubic synthesis to the fundus is like 25 centimeters. If you see that, what are you thinking about? I really hope you're thinking about a hydr-tid-form more, right? A hydr-tid-form more. So this is something that's actually kind of high-oat-on-n-n-bMI exams, right? So, hydr-tid-form more can actually, so molar pregnancy, right, pretty much, those things can present as size being greater than beats within like the first trimester of pregnancy, like first or like early second trimester of pregnancy. And it can also present with like significant amounts of like nausea and vomiting, right? So it can kind of look like hyper-emesis, gravity down on an endomete test. And one thing you want to keep in mind, right? Obviously, if you see that, right? You check the beta-hesi-g. The beta-hesi-g will really be some crazy high number, like 100, 200, 300, 400, 1000. And then you get an ultrasound that you will classically see the snowstorm appearance, right? The snowstorm appearance and really the way you treat that, it is is with a suction cure attached. And then, what if they say, oh, after you've treated that with suction cure attached, the lead is that's a complaint of shortness or breath. What's your next step in management? You want to go ahead and get a chest x-ray, right? Because that lead probably has long meds.

Remember, molar pregnancy can turn to a choreocardial carcinoma, right? And if it turns to a choreocardial carcinoma, a choreocardial carcinoma loves to metastasize to the lungs, okay? And how do we treat choreocardial carcinoma on NBM use? That's with methotrexate. Okay, now, what is the placental hormone that increases mom's risk of being diabetic during pregnancy? That's HPL, right? Human placental lactogen, okay? Now, what if you get a question about a man that's been treated for angina? So he's been chronically treated for angina. And then he dies while trying to get an erection. What are you thinking about? I hope you're thinking about the combination of a nitrate and a phosphodistory is 5 inhibitor, like celludena, philtodala, okay? Now, what if they tell you that, oh, on physical exam, let's say you have like a 60-something-year-old guy, and then they tell you that when they palpitate the prostate on a digital rectal exam, they feel a mess in the peripheral zone of the prostate. What are you thinking about? That's prostate cancer, right? Okay, now, what if you get a question about a lady? Let's assume she's 57 years old, she has been on hormone replacement therapy, like estrogen, like therapy, since she was postmenopausal to treat like significant menopausal symptoms. She has been on estrogen for a while, and then they tell you that over the last three months, she has lost like 15 pounds, and she's beginning to have vaginal bleeding a few days every week.

What are you thinking about there? That's endometrial cancer, right? From on oposter estrogen, okay? And then, what if you get a question about a lady, you know, she takes OC Ps, she has only one sexual partner, and then she comes into the EDN, she says that, oh, over the last 30 minutes, I've been having severe assurances of breath, and then they show you like some vital signs, and you see that the oxygen tension is like 80 millimeters of mercury in the blood. What are you thinking about? That's a PE, right? That's a PE, and remember, right? Estrogen containing contraceptives should not be given to a lady that is more than 35 years old, that smokes. That's a high-yield thing you want to keep in mind for the USMLS. Okay, now, what if you get a question about a lady? She says over the past like four weeks, she's been having high fever, let's assume this lady's in at 50s, right? So the last four weeks, she's been having high fever, she's been having like severe, in lateral breast pain, and then when you do like a breast example, notice that a breast is hard, it's kind of like in the rethed, and it has a lot of like little, almost like dots on the breast. What are you thinking about? That's inflammatory breast cancer, right? Remember, basically the cancer is super aggressive, it has involved the dermal lymphatic that run along the breast, so that's why they have that poor, dorengia appearance. Okay, now, what is the germ cell tumor that loves to spread hematogenously?

That's Choreocarsinoma, right? Okay, and let's see, because I don't want this podcast to be too long since it's technically a rapid review. Let's see, what else can I throw in here today? Okay, so what is the drug of choice? What is the preferred treatment regimen for for endometritis on an NV Me exam? That's clindamycin plus gentamycin, right? The isinomonic for that is ECG, endometritis, clindamycin and gentamycin. Okay, now what is the drug of choice in the treatment of Choreocars, off I'm sorry, Choreomionitis on an NV Me exam? That's some pysilin and gentamycin, right? So remember like C-A-G, like the C-A-G repeats in hauntings for Choreo-gift ampanjent, right? So C-A-G and ECG, and that'll help you remember those things. Okay, now what is the drug that classically causes P-I-D on NV Me exams, especially like in a sexually active young female? That'll be like what? Like my ceregonorrhea, right? And chlamydia, right? Okay, and if a person has P-I-D and they have like very bad mucoprolene discharge, what is the bulgur most likely thinking about? That'll be my ceregonorrhea, right? And what if a person has like a watery discharge? Let's assume it's a guy, watery discharge from the penis, or it's a lady watery discharge from her vagina, she has like a mouth fever and stuff like that, and you know, you suspect an STI, and then they say, oh, that you perform, you get some of that fluid sample, you perform a gram stain, and you do not see any bugs.

What is the answer you should go after? That'll be chlamydia, right? That'll be chlamydia. Remember chlamydia doesn't gram stain. Chlamydia only stains well with the with the game's estate. Okay, now what's the most common cause of UT Is in the US? That's equal, right? What's the second most common cause? That is staffs are prophetic us, right? That's staffs are prophetic us. Okay, and what are the three things on MBM is that classically increase a person's risk of recurring candidiasis, recurring vaginal candidiasis? One is smoking, another is diabetes, and another one is some kind of immunodeficiency like HIV, right? And then my final question here, what is the screening guideline for cervical cancer and MBM exams? So from the age of 21, right? So you start at 21, you get a pap smear every three years, right? Till you hit the age of 30. When you hit the age of 30, you can also get a pap smear every three years, or you can get a pap smear plus HPV-co-test in every five years. Okay, but there's this thing you're friends at the MBM love to do. The not everyone has obviously memorized the screening guideline and FYI, you do actually need to know the screening guideline. So the thing is one thing they love to do is to give you a question about a person that has HIV. A person that has HIV actually should get screened a lot more often, almost like every year, pretty much.

So that three year timeline does not apply to a person that has HIV, because again, HIV increases your risk of acquired, like it makes you more susceptible to HPV infection. And if you get HPV infection, that increases your risk of cervical cancer. Remember, the biggest risk factor for cervical cancer is history of HPV infection. Okay, so I'm going to go ahead and stop here. And again, as I always do at the end of every podcast, I do offer one on one tutoring for the USML-E Step 1, Step 2 C, Step 2 C, and Step 3 exams. And then the pre-clinical med school exams, the 30th shelf exams. And also, if you're a college student and you need tutoring for biochemistry, physics, organic chemistry, general chemistry, physiology, histology, all that stuff I offer tutoring for those. And then if you're a resident, I mean, sorry, if you're a med student applying to residency, so like an ERAS application or a college student applying to med school, so I'm a med school student, I do offer one on one like consulting for that. I have been on the admissions committee of top two med school for a year, so I have a lot of experience with those things. So if you need any of those things, feel free to reach out. I wish you a wonderful rest of the day. And I am really looking forward to when free agency opens to more in the MBA. I really, really hope the Lakers can land a Kawaii Leonard, but that's a story for another day. So have a great rest of the weekend. God bless you. Thank you.

Fibroadenoma.

Scaly nipples and exfoliative changes (or periareolar erythema).

Alpha-fetoprotein (AFP).

Oligo-/anovulation, polycystic ovaries on ultrasound, and signs of hyperandrogenism.

5-alpha reductase inhibitors (e.g., Spironolactone).

Chlamydia trachomatis.

Schiller-Du-Volbies bodies (small glomeruli appearance).

E-cat hearing mutation; suggests a high risk of bilateral breast cancer.

Trastuzumab (requires baseline TTE to assess LVEF).

It acts as a partial estrogen receptor agonist in the brain, removing negative feedback on the HPG axis.

Prazosin or Doxazosin; Tamsulosin is preferred because it selectively targets the bladder neck, minimizing systemic vasodilation effects on blood vessels (reducing orthostatic hypotension risk).

Smoking, Diabetes, and Immunodeficiency (e.g., HIV).

Endometrial biopsy/sampling.

E-cat hearing mutation; suggests a high risk of bilateral breast cancer.

Trastuzumab (requires baseline TTE to assess LVEF).

It acts as a partial estrogen receptor agonist in the brain, removing negative feedback on the HPG axis.

Prazosin or Doxazosin; Tamsulosin is preferred because it selectively targets the bladder neck, minimizing systemic vasodilation effects on blood vessels (reducing orthostatic hypotension risk).

Smoking, Diabetes, and Immunodeficiency (e.g., HIV).

Endometrial biopsy/sampling.