DIP Episode 285 - USMLE Step 2CK Rapid Review Series 49

Okay, welcome. My name is Divine. Welcome to the podcast. It's a beautiful morning here. It's like 30-90 degrees or something like that. Well, thank you for joining me. This is a piece of 285. I'm going to be continuing the USMLSTF2 CKRAPI review. It's going to be series 49. Again, I'm going to be doing a talking about a lot of risk factors, a lot of prognostic factors. Again, I think that's something that's always helpful on exams. So, this will be Rapid Review Series 49. Again, this will be episode 285. Let's just jump right into it. So, what if they give you a question about a patient and they tell you that, oh, this patient, you know, over the last two days has been having like low back pain, right? And then the person has been having like low extremly weakness, urinary tension and all that stuff. In a way, you see that. I really hope you're thinking about, you know, like spinal cord compression, right? And remember that that is classically caused by like, met from a person that has like, a some kind of primary malignancy. Now, if they ask you, they can give the, they can say, well, the patient like most likely has, and again, you may see me see some things here. It's something really weird. But again, just trust me on this, I've been tutoring for the staturecy exam for a while, right? And again, I keep very close tabs on what the NV Me cares about. So, they ask you like, what's the most likely pass medical history in this patient?

I hope you're thinking about like a history of breast cancer, right? I very see a person on NV Me exams that has some kind of malignancy damage as the size is to the bone. You want to think about breast cancer. Many people think it's prostate, but it's actually not the most common cancer to metastasize to bone, at least in adults, is breast cancer, right? So, that's very high. You'll remember breast cancer can cause both plastic and lyric metastasis, right? And again, you can, if you want to look for bone meds of malignancy, the best test to use on NV Me exams is a bone scan, right? These bone scans, these meds just light up beautifully, right? And if they give you a question about a patient that is in this particular situation, right? Persia has like a history of breast cancer and they have altered mental status. What should we be thinking about? If we're thinking about those people potentially having hypercalcemia, right? Of malignancy. That's like a classic thing they love to test. Basically, whenever they see hypercalc- whenever they see a person that has like altered mental status in the setting of malignancy, they're thinking of hypercalcemia or hyponychromia, right? Hyponychromia is usually a small cell lung cancer, but hypercalcemia, typically for the most part, you know, it can be breast cancer, it can be prostate cancer, but obviously that'll be a guy, right? And remember, whenever a person comes in with simulomatic hypercalcemia, what are you supposed to do first?

Well, that's pretty easy, right? You're supposed to go ahead and give them a, you're supposed to go ahead and give them a, what is it called? Fluids, right? Give them normal cells. And, you know, hopefully in the very near future, I'll make a podcast on fluids because that's a question of being getting from many people in, they've been getting a lot of questions from people that way in a recent time. So, I'll make a podcast on that very soon. God willing. So, again, hypercalcemia malignancy, for bracing symptomatic, right? You're going to give them, you're going to go ahead and give them a normal salient. Remember, there are other malignancies that can cause hypercalcemia, right? Squamous cell lung cancer with a PT-HRP, PT-HRP literally works like PT-H, right? So, it's going to cause a release of calcium, right? And then the person can have, can have problems. Multiple malignancies can also cause hypercalcemia, right? But again, remember, the mechanism there is you're releasing trillukin-1. Remember, those plasma cells, they make a interleukin-1, which is also called osteoclast activating factor. And then that osteoclast activating factor, is going to literally activate osteoclast for them to reserve bone, right? And remember, the way osteoclast activated for the most part, right, is when rank ligand from the osteoblast, pretty much binds to the rank receptor on osteoclasts.

And then the osteoclasts, they have like carbonic anhydrase, and that carbonic anhydrase is somewhat used to make acid, right? That they then used to pretty much reach away a presence bone, right? Remember, from, you know, if you study for step one, you probably remember those, those things where the osteoclasts will kind of form like a, like a border right next to the bone. And then, you know, then just dump a ton of acid into it through carbonic anhydrase, and then that bone will be resorbed. And it's actually maybe high-youture, remember that, osteoclasts, they almost like the macrophage of bone. If you ever look at a histology specimen, right? You see osteoclasts, you see like they almost look like giant cells in a sense, right? So, and if you have a mutation in that carbonic anhydrase that we find with osteoclasts, what disease would that be? I would hope you're thinking around the lines of osteopetrosis actually. Osteopetrosis is one of these classic things that again, people don't really think about, those insure opinionary sources, but again, they love, they love to test that stuff. Okay, and remember, a person with acute spinal cord compression from some kind of malignancy. Obviously, the first thing you're going to do for those people is you're going to go ahead and down, give them steroids, right, to relieve the swelling. And then this is actually one of those radonc emergencies, right? You're calling radonc overnight.

And then the thing they'll pretty much do is they'll go ahead and read it's the presence back, radiation is the high-youthing you do for spinal cord compression. That's like the good treatment, right? In those circumstances. Again, just high-youthings to keep out the back of your mind, for example. And then what if the give you a question about a patient and they tell you that all this patient presents with like severe, like, right low cordron pain and they started like two hours ago and you know, standing around the omelicas and then starting going more towards the right low cordron. If you see that, right? Obviously, that's up in the side. That's not a nothing big there, right? So the person has been decided in those circumstances. Now, what are some high-youthings to keep out the back of your mind with with up in the side as well? The first one is, I want to remember that a person that has a person that has been decided is, you know, it can arise from many different reasons, right? So we know that if a person, how do I put this? We know that if a person has a pain decided and it's an adult, right? It's usually a fickle that's causing the problem, right? So you've had like a fickle that obstructs like a dots or, you know, preventing drainage of the appendix. So because you have a fickle that's preventing drainage of the appendix, then guess what?

You know, remember whenever there's an obstruction, bacteria, they laugh to build up behind it and when the bacteria build up behind it, they can cause inflammation and that can cause a lot of problems, right? Well, if it's a kid, it's usually going to be hyperplegia actually. So those kids, they'll have like a lot of like lymphoid hyperplegia because they have some kind of viral infection. And then that lymphoid hyperplegia is going to cause an obstruction of the gallbladder. Of the appendix, like the appendix, the cell movement, again, bacteria can bacteria can build up behind it and that can most certainly, sorry about the sneeze there, that can most certainly cause cause problems in the patient, right? So remember, in terms of appendicitis, don't forget your physical exam findings, right? Remember there's going to be the Bernice point if you press on that, the person is going to have a lot of tenderness and other classics sign is so assigned, right? So if you extend those people's thighs, the regular quadrant is going to hurt a lot more. Another classic one is a rough syncing right where you press on the left lower quadrant and that's going to like inside regular quadrant pain. So if you see all those things where you want to think about appendicitis, now what's the most likely cause of infection, bogwise in the presence that has appendicitis? I really hope you're saying that it's equalized, right?

Remember equalized is probably like the most common cause of meningi infections, right? That's why many times when people have gen infections, given a third generation, cell flow spory, like cell triaxone or cell photoxym is not always the worst idea in the world. I mean life was spontaneous, but your period tonight is for example, right? Which will be like a like a person that has like a side is for any reason, again the a side is doesn't always have to be from n-stitial or a disease. It can be from many different things, right? Like it can be like a question or question, right? In a shock or you know, either love protein, right? So the oncotic pressures in your bloodstream, you know, like your mesenteric vessels is going to be diminished, right? And if it's diminished, then you're going to have a lot of fluidic transition into the peritoneal cavity, right? And you're going to get a side is as a result of that. And if you get that aside, as well, guess what's going to happen? It can be coming infected and that can cause that can cause a SBP, right? And remember, SBP, you're going to go past and thesis to try to look for those more than 250 neutrophils and then give a third gen cell flow spory, right? Like cell triaxone or cell photoxym, right? On NV Me's for treatment. So back to having decided, right? So the thing is, many times on exams, they like to ask, what is the most likely, what's the most likely complication, right?

Of pressing having a pain, that's actually the development of an abscess, right? So development of a peri-a-pain-de-cell abscess is actually the most common complication of a pain-de-sitis. And the thing is, many times when a pressing gets a surgery of some sort, right? Like some kind of abdominal surgery, it's usually going to be for a pain-de-sitis actually. It's actually the most common abdominal need for any kind of surgery, right? It's the most common abdominal need for any kind of surgery, right? And then, what are some pathologies I think especially important to know with the regular quadrant? The regular quadrant is like a classic hot spot for NV Me questions, right? So let's kind of run through a few things here. The first one, right? If you see a person that, you know, has like, is a young person, has like chronic diarrhea, you know, you know, you not always be blood, right? But just young person, chronic diarrhea, a lot of my absorption, right? And, you know, they tell you that you're seeing lesions, the person has like some oral mucosal lesions and all that stuff on exams. I hope you're thinking about Crohn's disease, right? And but Crohn's disease, it's the thing that, you know, it does all these skip lesions and it can involve pretty much every part of the GI tract. Mucrones, loves, loves, loves, loves, loves, loves, the terminal ilia, right? On NV Me exams, it loves the terminal ilia, right?

That's why people that have Crohn's disease, they tend to have my absorption, right? Because again, they are not reabsorbing those possible vitamins, they may have trouble reabsorbing bile, right? They may have a B12 deficiency, remember B12, right? Is reabsorbing intrinsic factor in the terminal ilia, right? And if they won't give you a question about a person that has a history of Crohn's and they have nephrolithiasis, I would hope you're thinking about some kind of oxalite stones, right? Remember again, whenever your terminal ilium doesn't work right, that's going to cause increased reabsorption of oxalite, right? Because that oxalite normally is tied up with other things, but Wendy is a lot of inflammation or problems with the terminal ilium. The oxalite kind of breaks free, it gets reabsorbed and then it causes problems in the presence of eerie, causes a hypooxyloriate, so the person can get a nephrolithiasis from that. Again, by the way, stop, this stuff I'm talking about very high yochino. Right? And then remember the regular quadrant is also where you should think of with, you know, they can give you a question out like a six-year-old male and you know, he has been having bloody bowel movements that are painless, right? Bloody bowel movements that are painless for like a couple of weeks or a couple of months and all those fun things, right? And then they tell you that you know, he's otherwise normal and this is going to be a guy on your exam.

If you see this, what should you think about? Well, I would really, really hope that you're thinking about a mechols diverticulum, right? I hope you're thinking about mechols diverticulum. Again, mechols diverticulum, almost always on imbiming exams. Can you have it being the other parts of the GI tract? Absolutely, but almost always on imbiming exams, he goes after the terminal ilium, right? So, and how do you make the diagnosis? Right? Again, don't forget, you make the diagnosis by getting a mechols scan, but again, your friends at the imbiming, they are smart. Sometimes you just don't put a mechols scan, right? You'll put the Technicium 99 M scan, right? So, Technicium 99 M per technetic, right? Per technetic, I believe he spelled as P-E-R-T-E-C-H-N-E-T-E-T-E per technetic, right? P-E-R-T-E-C-H-N-E-T-E-T-E-E. Yeah, that's the right spelling. Technicium, right? It's like T-C 99 M. It's a nuclear medicine study. Right? So, that's how you make the diagnosis. Again, just how you'll know this stuff, the stuff for exams. And then, another thing I want to see, right, with mechols, right? Obviously, you're going to go ahead and excise that portion of the GI tract, and then the pressing should largely be fine. Although, don't forget, let's see. So, you know, someone will say, yes, so why do they bleed, right? So, why do these people bleed? Again, remember, those are diverticular, right? Containectopic gastric amyocosa, right?

So, that gastric amyocosa obviously contains parietal cells, right? So, those parietal cells, right? It would make sense that, you know, this is a ton of acid, and then that's basically going to leach away the amyocosa, surrounding amyocosa, and then the pressing is going to have GI bleeds, right? So, again, just how you'll know that. And then, if you're like, there's one more regular cordium pathology I want to talk about. Yes. What if they give you a question about some person, right? And, you know, the daily of the person, you know, consume pork. And then the person now has really bad bloodied diarrhea, and, yeah, consume pork has really bad bloodied diarrhea, and severe regular cordium pain. But I really hope you think about your senior, right? The person has infection with your senior, interacallic, remember that thing loves to consume up in the side is on an amyocosa, right? And since we're also in the regular cordium, remember that's where people usually get problems with what's the name of this thing? That's where people usually get problems with, you know, that's around the appendix area, that's where people can get carcinoid issues, right? Remember carcinoid usually raises from the genumine or helium, but many times on amyocosa, you can also raise from the appendix, right? And usually if you have the lesion just in the abdomen, it's not going to cause any problems, right? It's not going to cause any problems.

Essentially what's going to happen is first pass metabolism in the liver, just pretty much keeps everything, you know, keeps everything in check, right? The liver is able to just deal with the problem, so you don't really run into issues, right? But to remember that once you have met to the liver, then the presence that's having problems, why? Because especially right-sided heart problems, right? Because when you get to the right side of the heart, the carcinoid and all that stuff will cause like, you know, it can cause some inflammation, cause like, fibrene deposition and all those things, right? So those people will have like, try to cause pid in sufficiency and pomonic stenosis, there's like a classic tips, TIP, is somonic that goes along with that. So you may see okay, divine. When the left heart also have problems? Well, no, the left heart from no-half problems, because the pulmonary capillaries kind of help, right? Remember, the lungs are very powerful in the bolognics organ, many people don't give the lungs a lot of credit, right? But remember that the lungs contain angiotensin, convertin enzyme, right? That's really where ACE is, right? So the angiotensin two, that's where angiotensin one gets converted to angiotensin two, like literally in the pulmonary capillaries.

In fact, I can totally see your friends at the MBM, giving like some, some head scratching question where they will give you someone, they'll give you all these questions that involve hours and then they'll talk about like some experiment that some bizarre scientists did, you know, just for fun. And then the scientist sees, the scientist sees, what do I want to say? The scientist sees is measuring angiotensin one and angiotensin two levels, right? Obviously angiotensin two levels will be lowest in the pulmonary arteries and they'll be highest in the pulmonary veins, right? Because if that angiotensin one is on that gunt transformation, across those pulmonary capillaries in you going from angiotensin one to angiotensin two. So the concentrations of angiotensin one will be lowest in the pulmonary arteries, I mean, sorry, in the pulmonary veins, but the concentrations of angiotensin two will be highest in the pulmonary veins. And then on the flip side, the concentrations of angiotensin one will be highest in the pulmonary arteries and the concentrations of angiotensin two will be lowest in the pulmonary arteries. Again, remember, pulmonary arteries lead to the right ventricle, I mean, lead to the pulmonary capillaries, reaching lead to the pulmonary veins, right? So back to the carcinolid story, remember the pulmonary capillaries, they actually express, what is it called? They actually express monoaminoxidys, right? So that monoaminoxidys breaks down serotonin, right?

It breaks down serotonin. So that's why they don't have left-sided heart problems, right? And again, remember, your friends at the MBME, right? They love to do these things where they will give you like alternative names for certain pathologies. I mean, that's a classic thing they're doing on the newer MBM Es, like the newer exams. Pretty much what they will just do is they will take what you know and just give you different words. It's not like they just magically start testing, you know, new pathologies that, oh no, no one has ever heard of. No, no, no, right? They test the same pathologies that people are used to. They're just using like, you know, some more different names, right? So the some more different names, instead of calling it a carcinolid syndrome, they can call it, they can put an answer to it that says neuroendocrine tumor, right? So that's something I want to be aware of on exams. And again, just some classic other names for things, right? I believe I've maybe mentioned this on the podcast, but I know, you know, people may be listening to podcasts here and there. So I think sometimes these things need repetition, right? But remember, on MBM Es exams, they can call IGN Fropathy. A sin, right? SYN, a sinfire-ingiotic nephropathy, because again, remember, people that have IGN Fropathy, they tend to get problems two to six days after an upper respiratory infection. So it's almost like the nephropathy happens happening synonymously, right?

With the with the upper respiratory infection, that's why it's called a sinfire-ingiotic nephropathy. That's one. And then the second one is a neuro tube defect, right? Again, neuro tube defect, they know it's in every Anki, they're known to them. Right? So what do they call it these days? Sometimes on MBM Es exams, especially the neuroendemices, they love to call it a spinoid dysraphism, right? They love to call it spinoid dysraphism. Another classic one would be like an euphrodic syndrome, right? Nephrodic syndrome, again, they know that it's a term many people recognize, right? So these days, what do they do? They choose to call it like a lipoid nephropses, right? They love to call it a lipoid nephropses, right? And they feel like divine, why does this need make sense? Well, think about it if a person has nephrodics syndrome, right? What kind of caste do they pump into the urine, right? The pump, the pump, you know, fatty castes into the urine, right? That's why it's called a lipoid or lipid-beast nephropses, right? So those are just all things that they can put in you. If you've heard me serious, I've not seen many podcasts, some of my body's being laminated calcifications. And if I think of any ones, you know, I'll keep bringing them, bringing them to the, I'll keep bringing them to the limelight as we go along or, you know, in future podcasts. So, carcinolite syndrome, again, how do you make the diagnosis, right?

Remember, you check the levels of 5-heat chai in the urine or in the serum, right? And then, you know, you can excise the tumor, you can give a true tight for treatment and all that stuff. And since I guess we're talking about meds of stuff to the liver, remember, colon cancer, right? The most common, the most common sight of metastasis of colon cancer itself is the liver, right? Which obviously makes sense just because of the drainage through the porno vein. And then also don't forget, if they are giving you, because I know I cannot talk about some of these inflammatory bowel diseases today, if they are giving you like a person having an ulcerative colitis, person having, another person having Crohn's, and they see, which of the four lanes is the most likely to progress to having a colonic malignancy, then you want to think about ulcerative colitis, right? Ulcerative colitis, like the big, big, big one that loves to progress to colon cancer. It has a much higher risk than Crohn's, right? That's why many times when people have ulcerative colitis, you typically want to pursue doing like some kind of a surgical, some kind of a surgical therapy. Okay, so let's go ahead and pause here. I have an engagement coming up soon. So, thank you for listening. I hope you have a wonderful day.

Please, if you're interested in the Step 2 CK course, again, for those of you who think Step 2 CK like, you know, early next month or something like that, it's a very good high level, very, very thorough review, right? We're going to be reviewing Peds, surgery, site neuro, OB-GYN, IM, and we're going to be doing a little bio stats and ethics. Basically, right? The course is the 10 hour course, but it's been expanded by six and a half hours. To cover all those November 2020 changes and also to include bio stats, to include ethics, professionalism, errors, quality, and safety, and all those things. And then there's the MBME Testicking Strategy course, right? That's two and a half hours. It's on the third of February, but then the 16 hour and a half hour course is, you know, five and a half hours each on the fourth, the fifth and the sixth of February, right? And it's over Zoom. Again, I've heard tons of people participating in the course, many of these people are now, you know, sending their rank lists and their, I love you, you know, my number one letters to residency programs. And please subscribe to the website. And if you need any information on these courses, there's still some spots available. Just shoot me an email through the website, divineinterventionpodcast.com, and I'll send you some more information. And then don't forget, please subscribe to the website, you know, divineinterventionpodcast.com, the podcasts, and Apple podcasts as well, on Google podcasts on Spotify.

So please subscribe. And then I have a You Tube channel, divineintervention, use heavenly podcast and videos. So have a wonderful day. I will see you all next time. God bless you. Thank you.

Breast cancer, not prostate cancer.

Steroids (to reduce swelling) and Radiation (the definitive treatment).

Tenderness at McBurney's point, Rovsing's sign, or Psoas sign.

E. coli (or other Gram-negative enteric organisms).

Hepatic metabolism, leading to deposition and fibrosis in the pulmonary circulation/right side of the heart.

Ulcerative Colitis (UC).

Periappendiceal abscess formation.

B12 deficiency (due to terminal ileum involvement) and Oxalate stones/Nephrolithiasis.

The pulmonary capillaries express Monoaminoxidase (MAO), which breaks down serotonin, preventing severe left-sided cardiac issues.

Upper respiratory infection (URI); symptoms appear 2–6 days post-infection.

Technetium-99 M ($\text{Tc-}99\text{M}$) scan.

Diverticula containing gastric mucosa (e.g., ectopic gastric mucosa).

Periappendiceal abscess formation.

B12 deficiency (due to terminal ileum involvement) and Oxalate stones/Nephrolithiasis.

The pulmonary capillaries express Monoaminoxidase (MAO), which breaks down serotonin, preventing severe left-sided cardiac issues.

Upper respiratory infection (URI); symptoms appear 2–6 days post-infection.

Technetium-99 M ($\text{Tc-}99\text{M}$) scan.

Diverticula containing gastric mucosa (e.g., ectopic gastric mucosa).