DIP Episode 127 - USMLE Step 2CK Rapid Review Series 8 (OBGYN)

Okay, welcome. My name is Devine, I'm a resident and this is episode 127 of the Divine Intervention Podcasts and in this episode I'll be continuing our rapid review series for the US70 Step 2 CK this will be series 8 and in today's review I'm gonna be focusing on OBGY. OBGY. So of Stetrics and Gynecology, everyone calls it OBGY. Okay so let's just jump right into it. So what if you get a question about like you know any patient or let's say it's a patient that has a CD4 count of 150 okay and they tell you that you know over the last couple of months you been having a lot of each in right in their vagina and like they evolve and all that stuff right and then they tell you that oh you do a kill each prep and you find like a lot of like Sudo-High-Fee. What are you thinking about? So I hope you're thinking about Candida under those circumstances right. Hope you're thinking about Candida with those right. So first things first on MBM Es believe it or not they're actually low to test certain risk factors that increase a person's risk of Candida right. So the things you want to keep at the back of your mind are things like diabetes, diabetes, the like if you I mean if you don't believe me just look through many MBME Candida style questions. You see that for whatever reason most of those people are the abelix right. So diabetes increases your risk of recurring Candida infections.

If you're immunocompromised so say for example you have HIV right that can again be a risk factor for getting Candida on MBM Es. If you take steroids chronically again that can again also be a risk factor for Candida on MBM Es and then another classic two other classic I guess classical tested risk factors are people that recently just completed a course of antibiotics okay that can again increase your risk for Candida infections and then also remember that Candida you can you have a high risk of that if you smoke okay so smoking is an MBME risk factor for recurrent Candida infections so that's a high-o thing you want to keep at the back of your mind. So the big question here is if a person has a Candida UTI or Candida STI or whatever. What is usually true of their vaginal peach? Well I hope you're telling me less than 4.5 right and again obviously the way you trick Candida is you give a like a topical antifongal right you can do like topical fluconazole or topical my conazole or something like that okay and then what are the bugs that are associated with a vaginal peach related on 4.5? I hope you're telling me tricklemonis right to remember with the strawberry cervix, tricklemonisis right and then also Gardnerella vaginalis with bacterial vaginosis and how do we treat those bugs?

Well I hope again you're telling me that we use metronidos or remember the things that are covered by metronidos I mean for those of you listening to this podcast you probably remember this whole business with a get gap on the metron right so like the G's for GRD right to remember GRD you'll be a question about a person that went hiking drunk water from a stream or you'll be a person that has an IG deficiency right those are all classic presentations of a GRD right and then the E is Antamiba right?

Antamiba histolyrica remember Antamiba already tends to cause like liver problems but it can also cause bloody diarrhea okay it's covered very well by metronidosol and then the T's for tricklemonis right so oh you do a kill each prep you find like mortal protozoans in the persons like vaginal secretions that's trick and then the G is Gardnerella vaginalis right so like bacterial vaginosis so obviously you find those classically described a clue cells right and then if the A stands for anaerobes right so anaerobic infections and then the P's for protozoans okay those things are covered with metronidosol and remember backing the D are you give metronidosol like IV metronidosol for for C diff that's not a thing anymore okay metronidosol is no longer first line for the treatment of C diff for C diff these days the first line treatment is vancomycin okay and the MBM is actually updated the knowledge on that so that's something when I keep at the back of your mind right and then if a person has HIV or let me order the question this way how often do you want to obtain pap smears in a regular person right you want to obtain pap smears every three years right and remember that happens when you hit the age of 21 but if a person has HIV or a person has some immunocompromised like they're taking chronic steroids okay their pap smear interval so they're just to like once every year okay that's a very high yield factoid you want to keep at the back of your mind for MBM exams okay now what if you get a question about like an old lady that is itchy itchy itchy right she's each and a ton at the like in her vulva or whatever what's your diagnosis what are you thinking about there well I hope you're thinking about Lycan's Clarosis right and what's your first step in diagnosis do you just want to give in pre-crepan and send the patient on the Ameri Wink well you don't want to do that righ

t because you'll be getting that wrong on an MBM exam right so under those circumstances you certainly want to think about getting like some kind of biopsy usually on MBM is they want you getting like a punch biopsy okay because you want to rule out vulva Casinova okay so you get the punch biopsy and then you treat the Lycan's Clarosis with what with a high potency topical corticosteroid right so like Clobetasol C-L-O-B-E-T-A-S-O-L that's the classically tested one on MBM exams okay and real quick I just talked about bacterial vaginosis, Clous cells, gannerylla vaginalis, p-dreaded and 4.5, chrytumetronidesol what is bacterial vaginosis a risk factor for in a pregnant female this is a floridly high-yote factor you need to know so bacterial vaginosis actually increases your risk of pre-term delivery okay it increases your risk of pre-term delivery and at the end of this podcast I will spend time on like two high-yote I-M concepts that people tend to get around pretty frequently on MBM exams okay now what if you get a question about a patient you know she's like a 35 year old female and let's say she's had multiple sexual partners in her life she uses condoms in consistently and then they tell you that over the last six months she has lost like 30 pounds and then they tell you that her creatinine is massively elevated what do you think the patient has I really hope you're thinking about cervical cancer right so why does this patient have the elevated creatinine what's the most common cause of death in cervical cancer maybe I should work the question that way right remember the most common cause of death in cervical cancer is that the legion express spreads sorry and involves the ureters the ureters right so obstructive nephropathy is the most common cause of death right causing like renal failure in patients with a cervical cancer okay so be able to pull those things to

gether so they may say oh this person has lost with and they have had your nephrosis basically if you see like kidney issues in the setting of suspected like gynecologic malignancy you always want to go with cervical cancer on an ambient right and then one other factor you want to remember is that when a person has like a kidney problem chances are they'll also have molyrian doctor abnormalities okay chances are they'll also have molyrian doctor abnormalities right so that's like a weird thing you want to keep in mind so the person has like kidney problems like oh one kidney did not develop or whatever and then they have like recurring pregnancy losses and all that crap you want to think about some kind of anatomic problem with a derivative of the molyrian doctor right and I would hope that you remember that the molyrian doctor gives rise to your fallopian tubes the ureters and like the upper two thirds of the vagina like the cervix and the upper two thirds of the vagina okay you don't want to make the mistake of thinking that your ovaries come from your molyrian doctor your ovaries and not a derivative of the molyrian doctor so if for example a person has like molyrian egenesis right those people will have ovaries so because they have ovaries they'll be producing estrogen so if they're producing estrogen they're gonna have breasts remember if you're reading any of those if you're reading any of those like genetic style like go eat androgen insensitivity whatever and all that crap on NBN is you always want to ask yourself do they have breasts if they have breasts that means any estrogen is around right so I don't mean like oh Tanner one breast I mean like you know like real breasts like Tanner four like maybe I shouldn't use that term I apologize so I mean like developmentally appropriate breasts for their age right so like a 16 years you probably have like Tanner thr

ee or three or three or four breasts on an NBM exam right so if you see a like developmentally appropriate breasts that means that person has estrogen around right so for person has molyrian egenesis they'll have estrogen around so they'll have breasts and remember ovaries also contain thicker cells right remember the teen thicker for the teen testosterone so they'll be able to make testosterone right so they will have axillary and pubic hair so the presence of axillary or pubic hair on NBM Es tells you that those people have testosterone that's functioning appropriately right and because these people have molyrian egenesis the thing they will lack is they will lack uterus so if you see no uterus you see axillary and pubic hair okay and you see like developmentally appropriate breasts telling you that estrogen is around you really want to think about molyrian egenesis on your exam on the other hand if you get a question about a person that has no uterus no axillary or pubic hair but they have developmentally appropriate breasts what are you thinking about I hope you're thinking about AIS right androgenin sensitivity syndrome so remember people that have AIS they have high levels of testosterone but the testosterone doesn't work they basically don't respond to testosterone so the testosterone effect of helping you with your axillary and pubic hair you're not gonna find that right so those people will not have axillary or pubic hair okay that's the first healthy I'll sign there and then obviously right they will also not have a uterus because remember those people have testes right they're genotype even if they have phenotype is female the genotype is 46xy right so because they have testes right they have sirtoly cells and sirtoly cells make anti molyrian hormone okay so what does anti molyrian hormone what does it do well the term tells you everything it does it kills t

he molyrian dog so if you kill the molyrian dog every derivative the more of the molyrian dog is not gonna be there right so like the uterus the valopian tubes the cervix all that will not be there okay and then they will have estrogen right so the I mean they have developmentally appropriate breasts right the reason they have those ten or three ten or four breasts is because that testosterone they have right the obviously everyone has fat cells right so aromatase can convert their testosterone to estrogen right so they will have breasts for that for that purpose okay now and remember that testosterone also kind of controls your libido that's like one of those weird things you want to keep in mind for example and then one weird I guess too weird presentation maybe give you an idea maybe a person that you know all their life they've been girls right and then they hit puberty and then you're like man over a one year two year period these people almost like metamorphosis and become guys they just pretty much undergo like super rapid virulization if you see that you want to think about this then I think there's a Spanish term for it I think it's called like weaver doches right that's something called a five alpha reductase deficiency right so people that have a five alpha reductase deficiency internally right so genotypically their boys okay what phenotypically for the first couple of years of life until the heat puberty they look like girls okay and the reason they have that is because the testosterone is not converted to DHT remember DHT is the thing that helps you very much external genitalia at birth okay so if you have no five alpha reductase right you will not be able to produce a DHT right and if you don't produce the DHT you will not visualize your external genitalia so you look female on the outside okay so one thing you want to keep at the back of your mind is s

o why do they then metamorphosing two guys if they still retain the deficiency at puberty the thing that happens is I mean think about it at puberty right all your hormones are like just region right so when you hit puberty as a guy you'll make a crop ton of testosterone right and all that testosterone right well forced verilization of the external genitalia so when you hit puberty like the overwhelming amount of testosterone you have will just force you to very large okay so that's why those people when they hit puberty they almost like metamorphose to two guys okay so that's the classic way it will present another way that five alpha reductase related business can present on you MBME is they will talk about like a person that is like relatively normal right so like the testosterone is normal their estrogen is normal they have no they have like their uterus they have everything they don't think to have any like genetic whatever's going on but they tell you that you know they just seem to have like like like almost like a small beard if you see that think about five alpha like reductase over activity right because there are certain populations of people I mean you've probably noticed this there are certain populations of people where they are women have like somewhat of like decent facial hair if you see that those people don't necessarily have anything abnormal with them they just have increased activity of five alpha reductase okay so that's something you want to keep at the back of your mind with exams and then another way of thinking that your friends at the MBME love to test right so remember I said that DHT controls realization of your external genitalia and all that crap right one other thing DHT does is if you have a ton of it it can cause male pattern baldness right and so it should make sense right that if you give a five alpha reductase inhibitor right that

could potentially help you with male pattern baldness like finasteride or deutastorite right so that's one way those are tested and then another way those drugs are tested is if a person has BPH right so remember again the agents that is primarily responsible for the growth of the prostate is DHT okay so for person has BPH you need to read your MBME question correctly to know what they want you to go after they may want you to go after acute relief of BPH symptoms or they may want you to go after long-term management of BPH symptoms if a person has acute urinary retention right so like they have a super pubic mass that's what your friends at the MBME were right they have a super pubic mass and if not PD in a while and the creatinine is high your next step in management for those people is to perform like a urinary catheterization okay that will immediately relieve their symptoms okay but let's assume urinary catheterization is not an answer and the person just has you know just urinary tripling so be an old guy right so people in their 30s 40s don't get BPH on MBM Es right so you'll be an old guy right you have like urinary dribbling and all that crap and it's happened for I don't know like a couple of months right if you see that you know you're dealing with a BPH and another way can present it can actually be as a person that has like renal failure from obstructive nephropathy right so they may tell you that oh this person has like scarring of the renal cortex from like chronic hydrogen froncise from the BPH okay if you see that if you want to again immediately relieve the symptoms of BPH you want to go ahead and give something that would dilate the that would dilate the bladder neck right so you want to give an awful one antagonist right so like tam sullucin right or prazosin doxazosin terazosin those things will all work for that purpose okay so that's something y

ou sort of kind of want to keep at the back of your mind right but remember if for example the person in fact let me attack this in two ways right so if for example you don't want to affect the person's blood pressure much you just want to fix the BPH would you want to choose a drug like terazosin doxazosin or prazosin or would you want to choose an alternative drug like tam sullucin well I hope the answer you're giving me is tam sullucin right because remember tam sullucin specifically blocks the alpha one receptors that you find at the bladder neck right so the alpha one AD receptors AD like Anthony Davis right the alpha one AD receptors that you'll find at the level of the bladder okay but for long-term treatment of BPH symptoms right you want to shrink that prostate right and the way you do that is by giving something that will lower your levels of DHT right like a five-offer adoptees inhibitor like finasterite or deutastorite okay that's a high-yield thing you want to keep at the back of your mind and then one nice way that your friends again at the MDM can integrate this whole concept of alpha one blocker with pretty much any other field of study is they can give you a question about a person that has BPH and then they have a comorbidity and with that comorbidity they will essentially have like a contraindication to them getting the alpha one blocker like doxazosin or prazosin or terazosin or they may tell you that oh this person has this comorbidity they had BPH they were studied on a drug and then whenever they rise up from a seated position or they get out of bed they collapse or something or the film nauseous dizzy whatever right those people have orthostatic hypotension okay so what are the things that can cause orthostatic hypotension basically anything that is a viso-dialeter right so how would your MDM go after that they can go after again a person takin

g an alpha one blocker with any other thing that dilute blood vessels right so hydrozine right can be one that they test on an exam your nitrates right remember your nitrates have a good viso-dialeters right so they can if you combine them with another viso-dialeter right they can cause blood pressure drops right in fact classically on MDM is they love to go after like those nitrates with cell DNF so basically Viagra right because think about it what the people that tend to require nitrates on MDM is people that have like cardiovascular disease right like atherosclerotic cardiovascular disease and what are the people that tend to have erectile dysfunction in the real world people that have atherosclerotic cardiovascular disease right so you've probably watched the Viagra add that says oh taking Viagra with a nitrate make us an unsafe drop in blood pressure right that's essentially what they mean they essentially going after this concept and the MDM has caught on with that right so again remember cell DNF is a phosphodiester is five inhibitors a PD inhibitor right if inhibitors phosphodiester is your levels of cyclic AMP in smooth muscle goes up okay and when your levels of cyclic AMP goes up in smooth muscle that causes relaxation of that smooth muscle so you have viso-dialetion right so you don't want to combine a PD5 inhibitor with like cell DNF with an alpha one blocker okay other again kind of like weird viso-dialetine drugs right so things like again I've talked about hydrozene remember your dihydroperidine calcium channel blockers right so like I'm low-depine fellow-depine plevide pin, nicardepine, my phedepine those can all cause a viso-dialetion right so you want to avoid those they may even make this into a psych question again a person that has BPH and they have a psychomorbidity if a person has BPH you want to think twice about studying an alpha one blocker

if they are taking like a tricyclic anti-depressant right because remember your tricyclics have those anti-hams side effects right so they have anti-hane effects right so they can cause like sedation they have like the anti-alpha one effects so they can cause again orthostatic hypotension and they also have the anti-moschronic effects right so if you see like delirium urinary retention of person that just started at TCA that's basically what happened to them right and since among this whole TCA business right don't forget that the teletyl sign on an MBME of TCA toxicity is a wide QRS on an EKG right and under the circumstances you'll still want to give those people a sodium a white carbonate and then the other drug class that again that is psych-based but can cause these kinds of problems right are your first-generation anti-psychotics that have low potency right so like your clopromazine for example right those drugs your low potency first-generation anti-psychotics they also have these same anti-hams side effects that you observe with your tricyclic anti-depressants and then two things that just literally just dropped in my mind as I was discussing this because again the high-yod MBME concepts but let me kind of talk about them right so one is this concept of myocarditis okay is this concept of myocarditis the thing is myocarditis on MBM Es will always present as dilithid cardiomyopathy okay your friends at the MBME for myocarditis they want you knowing bugs that can cause myocarditis and they want you knowing drugs that can cause myocarditis right so for example if a person has a recent or respiratory infection and then you're now hearing like an S3 heart sound the EF is in the toilet and all that crap what happened what bug when I hope you're thinking about coxacab virus right so remember coxacab virus can cause a viral myocarditis and again myocarditis always on

MBM Es presents as a systolic dysfunction right so like a dilithic cardiomyopathy sort of picture so usually they'll slot in that oh the person has a new S3 heart sound to tell you that they're going into a systolic or heart failure okay so that's a high-yod bug cause of dilithic cardiomyopathy remember another weird high-yod bug right so if they describe an immigrant or whatever you want to think about a tripanosomacruzii okay remember tripanosomacruzii loves to cause big problems right so it can cause a big heart it can cause a dilithic cardiomyopathy it can cause a big esophagus it can cause a collision and it can also cause a big GI tract right from like herchproms right so you can get remember those are t-cruzii bugs they can destroy your your nerve plexus in your distal GI tract right so they can cause like a colonic egg anglionosis okay so that's when we those can present and then in terms of drugs right that can cause a myocarditis right you want to think about like your anthrocyclics right so like your doxodonorubicin right remember those drugs can cause an irreversible dilithic cardiomyopathy right because they're those drugs right they tend to involve a lot of iron in their mechanisms right so they can use that fentin reaction and basically destroy your heart okay so that's why for person is on doxodonorubicin you can actually prevent the toxicity the cardiotoxicity by giving this drug known as dexrozoxin dexrozoxin so DEX R A dexrozoxin Z O X A N E dexrozoxin is it's an ion chelid or you can use it to prevent the cardiac toxicity or reduce the incidence of the cardiac toxicity in patients that have been treated with an anthrocycling like doxodonorubicin and then what if you get a question about a patient that has breast cancer right and they have a myocarditis after this that therapy what drug are you thinking about I hope you're telling me about trastuzuma

p okay trastuzumap perceptive right trastuzumap it's a her two monoclonal antibody against like the her two receptor whatever right so remember it can cause a reversible dilated cardiomyopathy contrast that with doxodonorubicin that cause an irreversible dilated cardiomyopathy on NV Me's although again that anthrocycling cardiotoxicity there are actually some people that have had that thin reversed but on your NV Me's it's irreversible and then also remember there's a side drug that causes myocarditis it's a side drug that can cause a granuloseitis what drug do you think I'm talking about it's also one of two drugs lithium is the other one that has been shown to decrease the risk of suicide in psych I hope you're thinking about clasoping right so clasoping clasoping clasoping clasoping can cause a myocarditis which can present again as a dilated cardiomyopathy on an NV Me exam okay so those are kind of again high-yield drugs you want to file away at the back of your mind with myocarditis dilated cardiomyopathy esterihard sound systolic heart failure on that crap okay good now the last thing I want to talk about I sort of made this big fact about cell dena field being a phosphodiestriase inhibitor right so there's kind of weird thing you want to keep in mind with these phosphodiestriase inhibitors and that's in the setting of a person that has like cardiogenic shock or like bad heart failure right one drug you can use is myorino okay the thing is the drug meorino on NV Me is they love to test it in the context of like cardiac physiology right so they may give you like a step to seek a question where you see all these arrows and then they tell you that the person was started on meorino right or they can give you arrows that relate to different drugs and then you need to match the arrow to the appropriate drug right so the thing is meorino is a phosphodiestriase inhibitor ri

ght and by inhibiting phosphodiestriase it raises your levels of cyclic AMP okay it so happens that meorino can inhibit phosphodiestriase in cardiac muscle and it can also inhibit phosphodiestriase in smooth muscle so in cardiac muscle when you inhibit phosphodiestriase the levels of cyclic AMP go up what does that do to your cardiac contractility it increases it okay so elevated levels of cyclic AMP in cardiac muscle increases contraction on the other hand if you inhibit PDE in smooth muscle elevated levels of cyclic AMP in smooth muscle do something totally different okay they actually cause smooth muscle relaxation and you have blood vessel dilation okay so meorino is a positive I know troop it increases cardiac contractility by raising cyclic AMP in cardiac muscle but meorino is a vasodiliter okay so it actually cuts down on your after load okay because it raises levels of cyclic AMP in smooth muscle okay raises levels of cyclic AMP in smooth muscle so meorino will increase your cardiac output so it will increase your systolic blood pressure meorino will decrease your after load so it's decreasing your systemic vascular resistance right so your systolic blood pressure will go down so for person is tired of meorino the pulse pressure will get wider okay again these are weird high-yale things you sort of kind of want to keep at the back of your mind for MBM Es right I mean like if you've ever wondered oh why do we use cellostresolute peripheral arterial disease well guess what cellostresolute is a phosphodiestrize inhibitor right so by being a phosphodiestrize inhibitor it raises cyclic AMP levels in smooth muscle so that dilates blood vessels so that can help you with peripheral arterial disease so that you can produce those ischemic extremities better okay so I think I'm gonna go ahead and stop here I want to again try hard to keep this on the 30 minutes and as I d

o at the end of every podcast right so I do offer one on one tutoring for many exams step one two CK two C.S.

step three right the med school preclinical exams 30-ish-elf exams I offer tutoring for those and then if you're a medicine resident right and you're studying for the intranin exam I offer one on one tutoring for that if you're studying for the medicine board exam so the EBA exam I do offer one on one tutoring for that and then if you're a college student and you need to learn for general chemistry organic chemistry physics biochemistry physiology I do offer tutoring for all those things okay and then if you're a medicine applying to residency so like an ERAS app or a college student applying to med school so an AMP CAS app I do offer like one on one consulting and advising for that so like personal statement writing application prep on all those things okay so if you need help with any of those things reach out to me through the website or you can send me an email at divine intervention podcasts with an S.S.V.N. gmail.com so have a wonderful rest of your day I will see you in the next podcast I really hope you get something from this God bless you and good night thank you

Diabetes mellitus, immunocompromised state (e.g., HIV), chronic steroid use, and recent antibiotic exposure/smoking.

Clue cells, which are vaginal epithelial cells coated in bacteria (specifically Gardnerella vaginalis).

Punch biopsy, as a simple swab or culture will be insufficient for diagnosis.

G-R-D-E-T-G-A-P (Gardnerella, Trichomonas, Amoeba/Antamibia, Protozoa, etc.).

Alpha-1 blockers (e.g., Tamsulosin) for acute relief; 5-alpha reductase inhibitors (e.g., Finasteride) for long-term reduction.

Irreversible (Doxorubicin/Anthracyclines); Reversible (Trastuzumab).

Diabetes mellitus, chronic steroid use, or HIV infection.

Obstructive nephropathy due to spread into the ureters.

Dexrazoxamine (an iron chelator).

Molygonegenesis has estrogen evidence (breasts) AND androgen evidence (pubic/axillary hair); AIS lacks pubic/axillary hair because testosterone cannot act on receptors.

PDE-5 inhibitors (e.g., Sildenafil); they cause smooth muscle relaxation and vasodilation.

1) Increases cardiac contractility by raising cAMP in cardiac muscle; 2) Causes systemic vasodilation by raising cAMP in smooth muscle.

Diabetes mellitus, chronic steroid use, or HIV infection.

Obstructive nephropathy due to spread into the ureters.

Dexrazoxamine (an iron chelator).

Molygonegenesis has estrogen evidence (breasts) AND androgen evidence (pubic/axillary hair); AIS lacks pubic/axillary hair because testosterone cannot act on receptors.

PDE-5 inhibitors (e.g., Sildenafil); they cause smooth muscle relaxation and vasodilation.

1) Increases cardiac contractility by raising cAMP in cardiac muscle; 2) Causes systemic vasodilation by raising cAMP in smooth muscle.