DIP Episode 282 - Combo Podcast (Risk Factors/Prognostic Factors) + Step 2CK Rapid Review (Series 46) + Step 2CK Course Reminder

Welcome. Happy New Year. My name is Devine. This is episode 282 of the Divine Intervention Podcast. And in this podcast I'm going to be continuing the Rapid Review Series for the year semilistep 2 CK exam. But to be honest with you, I'm going to maybe call this a risk. Actually you know what? Let's not call this a Rapid Review Series. Let's go ahead and call this another risk factors podcast. Remember I have a bunch of risk factors podcasts that are very high yield for the US semilistep 2 CK exam. Right there's episode 37. There is episode 97. There is episode 184. And then there's episode 239 if I'm recalling correctly. But that's one that focuses primarily on OVGIS risk factors. So let's maybe go ahead and call this. So 3797 or 184 to 39. So let's go. This first factor is number five. Although I'll also be talking about some of the pathologies that just some other high yield things that pop up on MBME exam. So I guess just consider this as a much much. We'll probably be like 80% risk factors and then like 20% of just some other high yield things that you should keep at the back of your mind for MBME exams. And then as a quick reminder, if you're studying or if you're not new one studying for the year semilistep 1 CK exam, I have a very comprehensive course coming up at the end of this month from the 27th to the 30th. It's a 30 hour course, super super high yield, very, very comprehensive. You'll learn a ton of stuff. That's classic literature on the MBM Es.

And a lot of it will be clinical vignettes. And I will present those clinical vignettes in MBME context. Like just like, oh, this is the classic thing the MBME will present on an exam to test this pathology. And then I also have like the MBME test-dicking strategy scores coming up on the on the third of February. That's more for people taking step to see key step three. So MBME test-dicking strategy scores. Again, it's two and a half hours and you'll learn how to in a standardized way how to take MBME exams and how to do well on that. And then I have a comprehensive step to see key course taking place from the fourth to the sixth of February. It's going to be a 16 and a half hour course. This was what was previously the 10 hour course, but I expanded it by six and a half hours because I wanted to, there is a lot of expanded content from like the different disciplines that the MBM Es now testing. But also I cover the vast majority of those new changes that came on, came with the MBM Es starting in November of 2020. So I cover those in those courses. So again, if you're interested in any of those courses and really the the 16 and a half hour course, I will say it's not just something that a person studying for step 2 CK should take. It should be something that a step three person is taking as well. Basically the course covers a lot of cross coverage with what you'll see tested on step three.

So if you're studying for step three exam, that'll be a perfect course to take along with the test-dicking strategy scores. So again, if you're interested in any of these things, just shoot me an email through the website and I'll be happy to point you in the right direction. Okay, so let's go ahead and jump right into this. So what if they give you a question about like a 10 year no? Yeah, let's go ahead. Let's see they give you a question about like a 25 year old guy and detail you that he works as a bartender and that over the last three days he's been having really dry cough, having a little shortness of breath, has a little of exercising tolerance, right? And then the give you like a chest x-ray, I noticed that he has like just complete white out of his lungs, right? And then they tell you that you know he has to be intubated so that he can maintain his oxygenation status and you know even with that intubation, he's 100% FIO2 and let's say he's PIO2 that is like 100, right? You may say oh PIO2 100 is great but that's not right. If you're 100% FIO2 you're PIO2 better being the 100s like 500 something like that, right? So if you see stuff like this what should you be thinking about? I really hope you're thinking about ARDS, right? I hope you're thinking about ARDS. Remember if they give you a COVID-19 question concerning the step to seek exam, it would very likely be an ARDS question, right?

Because that's essentially the common final path of people that are going to die from a COVID-19, right? And then for people that are maybe studying for step one, remember that the vaccine that has been created is an mRNA vaccine. Now what are some classic things you'd find in ARDS? Well ARDS remember those people, they have very low oxygenation, they appear to every issue, right? Like basically like the PIO2 FIO2 ratio will be really low as well, right? And again don't forget the white out longs that you'd see on the image in. And classically whenever it's if they ask you like a risk factor question with ARDS, they're going to ask you for the biggest risk factor, right? So what's the biggest risk factor for ARDS? That's going to be sepsis, right? And remember we treat people with ARDS, we're going to put them on a ventilator, we're going to use a low tidal volumes and high peep, those are long protective strategies and then those people you're going to try to make them prone, right? So you're basically going to lie them on the ability, see the ICU, right? ARDS is not something a person wants to have again, that's why just stay out, stay out of people's ways, rail, wear masks, right? Because again ARDS is bad, right? The mortality rate with ARDS is 40%. That's one of the primary reasons why a ton of people die from COVID-19, right? So I guess my public service announcement there. So again remember the biggest risk factor for ARDS is a sepsis.

And then what if they give you a question about a patient and they tell you that a patient, you know, it's like a 19 year old female and she has that over the last four months, she's lost like 10 pounds and she has all these B symptoms, you know fever and I sweat, sweat loss. And then you tell you that she has like generalized lymph odonopathy around her, like generalized a cervical lymph odonopathy. If you see that, right, what are you thinking about? I would really hope that you're thinking about a Hodgkin's lymphoma, right? Thinking about Hodgkin's lymphoma. And remember Hodgkin's lymphoma, there are some high old things, there's a high old bio statistical thing that they love to test on MBM exams with Hodgkins, right? Remember it has a bi-modal distribution, right? As a bi-modal distribution. And for those that are potentially taking step on listening to this podcast, remember that bi-modal distributions, right? They're not just found with Hodgkin's lymphoma. You can also find them when you're talking about people that are slow versus the fastest and the latest of certain drugs, right? And then also osteosircoma, sometimes on MBM exams, there's a collino osteosircoma, they're called osteogenics or coma. That's another thing that classically has a bi-modal distribution, right? So the thing I will then go ahead and say is what are some, what are some classic MBM questions they can ask? What are some good prognostic factors in a person that has Hodgkin's lymphoma?

Well, it's very high you to know that if a young person has Hodgkin's lymphoma, they have a much better prognosis than an older person with Hodgkin's lymphoma, right? And then if you're looking at the person's, if you're looking at it like if you're doing like a biopsy, the more lymphocyte you find, the better the prognosis, right? The more lymphocyte you find, the better the prognosis. But if another classic one, you may also test with an exam, is if you have fewer reach-term birth cells, that's also a good prognostic thing, right? So are you young? Do you have more lymphocytes in set malignancy? Do you have fewer reach-term birth cells in set malignancy? Then you have a better prognosis again. And that's one of these things, and maybe same, they seem very bizarre to you. But again, I encourage you to know them and know them well, because these are things that classically love to test, love to test on exams, right? So don't forget your prognostic factors in Hodgkin's lymphoma. Remember Hodgkin's lymphoma is CD-15, CD-30 positive, right? And it's very common again in very young people, very common in young people. Okay. And then what is the most common side effect? So they can give you a question about a patient and they tell you that, oh, this patient, you know, is like a 72-year-old guy, and for the last six months he's been having like urinary dribbling, right? And all that stuff, right?

And then they tell you that the physician decides to study on therapy that helps with immediate relief of his symptoms. And then they will ask what's the most likely side effect profile of this medication, right? So this person clearly has BPH, right? Remember when people have BPH, if you want to immediately relieve their symptoms, what you can try to do is you can give them an awful one blocker. And that awful one blocker, remember, by blocking those awful one receptors, well, you're not just going to be opening up the bladder neck, but I don't know the thing unfortunately you do is you don't also be blocking the awful one receptors on those people's blood vessels. So people that have BPH, they could potentially get a visual dilution of their blood vessels, right? So they can get an orthostatic hypotension. So it's actually very high yield. So don't forget me, exams, that's the most common side effect associated with the treatment of initial management of BPH is orthostatic hypotension, right? Again, it's just one of these most common things that they can test. I don't know, like you may notice today that I'm not just really not for risk factors, I'm trying to give a little context by giving like the classic presentations of some of these things. So I guess I can maybe call this a combined rapid review, risk factors, prognosis, whatever. I'll figure out an info for the spot gas, but it's a episode, too, I guess we'll kind of live it, live it of that.

And then what if they give you a question about a woman and they tell you that, oh, she's been having a, you know, she, she had shows hospitalized two weeks ago for the treatment of like really bad pilot arthritis, the required birth spectrum antibiotic therapy. And then now you notice that she's been having a, she tells you that she's been having a lot of like a gumbleed and she's been having a lot of so a lot of gum bleeding, she's been having a lot of epistaxis, right? And the ass like, what's the biggest risk factor for this patient's condition? To be honest with you, what you should be thinking about on your exam is you want to go ahead and make sure you're thinking about like a vitamin K deficiency, right? So remember whenever you take birth spec antibiotics, what are you doing to your GI floor? You're pretty much knocking out your GI floor and your GI floor, they're really helpful in making vitamin K, right? So in fact, they can make this a risk factor question, the biggest risk factor actually for vitamin K deficiency in a hospitalized patient is actually the use of broad spectrum antibiotics, right? Because again, you kill off the person's GI floor, and kill off the GI floor, the person's going to get very likely going to get in trouble, because there's no going to be any vitamin K production.

And one thing they love to do on in-mimim exams is they'll usually tell you that the person has like some weird pass medical history that already involves them taking warfarin, right? So it's like double dip in, right? Because one, you have the vitamin K deficiency to start off with, right? And then for patients already on, I mean like, sorry, the first thing in prison is that's always the taking warfarin. Remember warfarin inhibits vitamin K, box-endory ductase, right? So warfarin almost induces like a functional vitamin K deficiency, and then you go ahead and kill off the person's GI floor to add to that, right? That's a double here, right? Remember if you don't have vitamin K, you're not going to be able to de-moctoboxylate those factors 279 and 10 and 14 CNS. So the person is going to have a lot of clotting factors that don't work, right? So the person's going to get in trouble, right? So again, very high-yout. The biggest risk factor, right? The biggest risk factor for vitamin K deficiency, you know, hospitalized patient is actually the use of blood spectrum antibiotic patient, uh, blood spectrum antibiotics, right? In fact, they can leave this like an ICU question on an in-bimic exam, right? And if you remember earlier, and I said that, the biggest risk factor for ARDS is sepsis, the thing is actually, what if they ask you, what is the biggest risk factor for DIC, right? What's the biggest risk factor for DIC?

The biggest risk factor for DIC is also sepsis, as well, believe it or not, right? So, uh, remember in DIC, right? Like essentially every platelet lab is every hematologic lab just goes out the window, right? That's a classic thing they love to test, right? So obviously your bleeding time is going to be high, right? Your platelet count is going to be low, your PTPPT is going to be elevated, right? And your fiber in-division products is also going to be going to be high as well, right? Your FD Ps are going to be high, your fiber in-division typically is low when you have a DIC, right? When you have DIC, and again, remember there are many things that can cause DIC on in-bimic exams, right? So for example, if a person has an amniotic fluid embelos, right? Again, that's usually in the setting of like some kind of a woman that, you know, is very close to delivering the baby and she gets into some trauma like a motor vehicle accident that can cause an amniotic fluid embelos and cause problems. Other thing that can cause that is, if for example a woman has an abortion, right? You see a woman that, you know, she has an abortion, and then after she has an abortion, maybe she did it at home or something weird. And then, you notice that she's like out of it, she's some malen, she's not responsive, and then she's completely flat, so it's going to be, it's going to be DIC. Maybe even more classically, one with the test, test DIC on exams is with an intruder in phytonomyce.

So basically the baby is dead, right? So let's say the woman has antiphospholubidantibody syndrome. And then she has noticed for the past five days that there's not been any phyton movement. And then they'll give it like some story about the woman, essentially, having become an altered beginning to bleed from her nose, from her ears and all that weird stuff. If you see stuff like that, right? I really, really want you to think about a DIC, right? Because again, when, in fact, sometimes make this an ethics question on exams, believe it or not, right? When a woman loses her baby, right? And the baby is still in utero. You know, the first thing you're supposed to do on an in-bim exam is to let the woman grieve, right? But you can let her grieve forever because you're also putting her at very high risk of getting in trouble, right? So in those circumstances, right? You let the woman grieve, you know, for a couple hours, but after that, you need to take out the baby, right? You need to do like a dilution and an evacuation, right? Because if you don't take out that dead fetus, then that dead fetus is going to start elaborating factors that can trigger the coagulation cascades. And then that woman is going to have a lot more problems than just losing the baby. I don't mean to say some heartless, but you can keep chilling, basically, I think is the big thing I want to mention here. And then, what is the biggest risk factor for renal cell carcinoma?

And I hope you're telling me that it's smoking, right? Really, many of these malignancies that deal with the kidneys and the bladder, they are usually caused by smoking, right? So remember, renal cell carcinoma is the biggest risk factor for, I mean, smoking is the biggest risk factor for renal cell carcinoma is the biggest risk factor for bladder cancer, right? Although usually on exams, they won't see bladder cancer, they can just see transitional cell carcinoma right, of the bladder, right? If you see that again, the biggest risk factor there is going to be smoking. Although, what if they tell you, give you a question about a patient that let's say is like from Egypt, right? And then, they tell you that this patient is found to have over the last three months, he has lost some weight, he has been noticing like blood in his urine, and then they tell you that you're performed by a Psy of the patient's bladder, and you notice a lot of keratin perots, and then they ask what is the biggest risk factor for this patient's presentation? If you see that, right, I really hope you're thinking about a schistosoma hematobium, remember, schistosoma hematobium, right? It's a relatively common cause of squimal cell carcinoma of the bladder, right? Not transitional cells, very high you to know. So, as hematobium, excuse me, doesn't cause transitional cell carcinoma of the bladder, because it's squimal cell carcinoma of the bladder, right?

Because remember, whenever your body is subjected to chronic stress of some sort, it begins to undergo, you know, you may have like metaplegia, right? So, those transitional cells, when they are subjected to the chronic stress of schistosoma hematobium infection, the thing they would usually do on NBM is the underground metaplegia, from the transitional epithelium to squimals epithelium, and when they become squimals epithelium, then you begin to notice that those people have that, you know, that metaplegia epithelium can become this plastic, and then they can have cancer, right? So, the biggest risk factor for squimal cell carcinoma of the bladder, in this particular patient that I'm mentioning, is going to be schistosoma hematobium infection. That's why you're seeing these keratin pearls, right? In fact, remember, in general, when people have squimal cell carcinomas, it can potentially cause hypercalcemia, right? Because menace squimal cell cancers love to make PTHRP, which can, again, ultimately cause problems to the patient with regards to hypercalcemia. So, again, because many times people say, oh, divine, there is some of the risk factors you talk about, I've heard this too many times before, right? Oh, there is factors you talk about, I got a question on my test, and they put like 40 different risk factors for the same disease, and how do I know which one to pick? Again, that's why you need to be careful, right?

That's why, again, doing well on the exams is not just a function of how much do you know. It's also a function of how good are you at testing, right? So, they love to ask these questions on exams about patient specific risk factors, right? To get those patient specific risk factor questions, right? You need to just see the context of exposure, right? The person being from Egypt, maybe they've worked by the now or swam in the now for a while, and all that stuff, right? Again, that will potentially cause problems, right? So, you just want to be careful, right? So, they may give you a question about a person that has a renown cell carcinoma, but the biggest risk factor in that person is not smoking, even if they've been a smoker, right? So, for example, if they give you a question about a person that has smoked for two years, right? And they have a renown cell carcinoma, but then they also tell you that, oh, this person, like 10 years ago, had to have some kind of tumor extracted from the cerebellum, right? That was classified on imaging. Then the biggest risk factor for renown cell carcinoma in that patient, clearly in this case, is going to be one hiphole and down, right? And by the way, the cerebellum I'm talking about is going to be a hemangible astoma, right? So, if you ever see like, calcifications in the cerebellum on an embium exam, that's usually going on, especially in a person that has like a high hematocrit, you want to be thinking about a hemangible astoma, right?

Because remember, those things produce hipo, so they can cause like a, like a polycythemia, right? Well, an embium exam, right? So, again, you need to pick out a risk factor that is specific to the patient. I'm just going to give you an example here, right? Because smoking for two years is very highly unlikely to give you a renown cell cancer when you actually have like a legit genetic disease that's inherited in an autosomal dominant fashion, like V-chell that can cause those kinds of problems, right? So again, just very highly to know these things, know these things for, for exams. And then, what if they give you a question about a patient and they tell you that over the last two days, this patient has been having a lot of like a really bad retoprochordian pain, this patient has like the development of like massive assidies. So you see, I almost, almost think of this as like an acute assidies. If you see stuff like that, then what should you be thinking about? Well, I really hope you're thinking about like some kind of botchiaric syndrome, right? Remember, that's usually happens because the person has some kind of hepatic vein thrombosis, right? So how can they make this a risk factor question? Well, what's the biggest risk factor for botchiaric syndrome on an endemic exam? That's actually going to be polycythemia vera, right? The biggest risk factor is very highly to know the biggest risk factor for botchiaric syndrome is going to be polycythemia vera, right?

But again, look at the patient context. If you don't see any antecedents of polycythemia vera in the question, right? Then it can be something else that's causing the person's botchiaric syndrome. Like people can get botchiaric syndrome on endemic exams from having paroxysmal noxional hemoglobinuria, right? Remember, PNH is where you have that pigage in your t-shirt, right? So you're not able to make those GPI anchors. So like things like CD-55, you know, which we call the KX Alorating Factor or CD-59. They don't hang out on your red blood cell. So the membrane attack complex of complement, C-52 C9 just got to crack open your red blood cells and cause like a hemolytic anemia, right? But all they can give you a question about botchiaric syndrome in a woman that's on OCP. So remember OCP is right? They can definitely cause a person to have like hypercwaulability, right? Especially in a woman that smokes, right? That's why if you're over 35 in smoke, taking estrogen-containing contraceptive options is not the most burden I gained in the world, right? So there are just many different things that can cause botchiaric syndrome. They can even give it to you as a question of a person that has nephrodix syndrome, right? So, because remember in nephrodix syndrome, right, you have like an acquired antithromine, three deficiency. So you're basically peeing out of a tumor protein in your urine. If you do that, one of the proteins you're going to pee out of the antithromine, three.

So you're not going to be able to inhibit factor X and factor II. And then the person can get in trouble on an example, right? So the thing is the MBM is almost like the evolve. The MBM does not necessarily just suddenly decide to start testing concepts that you've never seen before, right? What they love to do is they just like testing things that in just somewhat different formats, right? So they evolve over time, right? So, you know, initially when they knew that, well, risk factors was not a, was not a big thing that people were studying for, you know, they made them just very simple questions. What is the biggest risk factor for this in XYZ patient? But these days, they're not beginning to ask questions on patient specific risk factors, right? So you need to know a little more than that. So they'll give you multiple risk factors, but then you need to look at the patient's pathological history, the chief complaint, the labs, the other antecedents in Sino. Okay, you know what? There's many other factors supporting this risk factor in this patient than the others, right? Just something high to keep in mind. So since this is kind of like a rapid review episode, I'm maybe going to go ahead and stop here. So maybe for the next few episodes, I mean, I actually continue this combo of rapid reviews and risk factors slash prognostic factors, right? And again, as I do at the end of every podcast, I go for one or one tutoring for many exams.

Step one, step two, CK, step three, pretty clean, cool, medical exams, 30-ish-off exams. So if you're interested, feel free to reach out to me again through the website. I have tutor tons of people, I've tutored many people that have failed step one or failed step two CK before. And then I tutor them and then they pass on the next try and they are all by like 40, 50 points. So again, if that's something you're interested in, feel free to shoot me an email. And then if you're a medicine resident, I tutor for the ABIM board exam and the medicine training exams. And then again, don't forget the courses I offer, comprehensive step one course coming up at the end of the month, step two CK course coming up at the beginning of the next month, right? And again, please subscribe to the podcast, I have this on Apple podcasts and Google podcasts, Spotify. And then there's a You Tube channel, Divine Intervention, USMD Podcasts and videos. So please subscribe and Ernie, little bit of support, or spreading the word differently helps. And then the final thing I just want to mention today for a life lesson is just the importance of having a vision. This is my first podcast of the year. This is January, right? And if you notice, this is not just a new year, guess what's a new decade, right? So, you know, if you've been going on the wrong course in life, maybe it's time to get your life straight.

So I think one thing that's very important, this was something actually did in my church because I'm ahead of a young adults and singles group in my church. And one thing we did, actually, literally, this, I think it was the second, the third day of this year. Not actually the second day of this year was on a Saturday. We did something called a vision board, right? So it's very important to have a vision. I mean, like, even there's a part of the Bible that says they should write the vision and make it plain, right? So that you can run with it, right? So I think it's in the book of, I think it's like Habakkuk, or something like that. So I think I'll just encourage you have a vision for this new year, for this new decade, right? As a med student, if you're studying of med school or let's say you kind of blew away your life, like the first six months of med school, ask yourself, okay, what's my vision for step one? What's my vision for step two? What's my vision for research? What's my vision for getting into residency, right? The thing is a person that is visionary is very likely to get to their destination. Or is there a person that has no vision, right? Because if you have no vision, it's almost like you're going on a trip to a place you don't know, and you don't have GPS with you or a compass. Well, guess what? You're very likely not going to end up at the place you're supposed to end up at, or you want to end up at, right?

But if you have like a vision, like it's almost like you have this address you're going to, you have a GPS to take you there and you just make your way there, right? So again, I think very, very key thing, have a vision, I think at the end of the day, that's something that separates people that achieve from people that just kind of count the hours of life. And remember, one's time is going, it doesn't, it doesn't come back, right? Time is probably one of the most valuable commodities on this earth. So thank you for listening. I'll see you next time. God bless you.

Sepsis.

Elevated PT/aPTT, low platelet count, and high Fibrin Degradation Products (FD Ps).

Alpha-1 blockers.

Schistosoma haematobium infection.

Young age and finding more lymphocytes on biopsy.

The combination of broad-spectrum antibiotics (which deplete gut flora) AND taking Warfarin.

Squamous cell carcinoma of the bladder.

CD-15 positive and CD-30 positive.

The antibiotics kill gut flora, preventing Vitamin K synthesis, which impairs the carboxylation of clotting factors II, VII, IX, and X.

Nephrodys syndrome.

Polycythemia vera.

Amniotic fluid embolism or PPHN (Pregnancy-associated thrombophilia/Intra-amniotic infection).

Squamous cell carcinoma of the bladder.

CD-15 positive and CD-30 positive.

The antibiotics kill gut flora, preventing Vitamin K synthesis, which impairs the carboxylation of clotting factors II, VII, IX, and X.

Nephrodys syndrome.

Polycythemia vera.

Amniotic fluid embolism or PPHN (Pregnancy-associated thrombophilia/Intra-amniotic infection).