DIP Episode 369 - USMLE Step 2CK/3 Rapid Review Series 70

Okay, welcome. My name is Divine. This is episode 369 of the Divine Intervention Podcasts. And in this podcast we're going to be continuing our Rapid Review series for the USMLE Step 2 CK and Step 3 exams. This is actually going to be series 70. This is episode 369 series 70. Again it's going to be a short podcast. We're going to focus on some really high-yield things that tend to be tested on these exams. Again, if you're taking the USMLE Step 2 CK or Step 3 or complex level 2 or 3 exams, any time within the next one month I do have an NV Me Test Ticking Strategies course taking place on the 21st of this month from you know 2 to 4 30 PM Mountain Standard Time. And if you also want a pretty good thorough review, I have a 24 hour review course taking place between the 22nd to the 25th of February. And if you're taking your USMLE exams in the summer, I do have Divine Intervention Step 2 CK School. Obviously, it also applies to Step 3 and complex level 2 and 3. It's going to be 75 hours. It's going to be taking place between the first two weeks of May. If you're interested, that actually one has a 40% cap on the number of people that can attend. So I can you know very deeply invest in everyone that attends. If you're interested in any of those courses, just shoot me an email through the website and I'll give you some more information. All the courses are going to be held through Zoom. Okay, so let's begin. So what did they give you a question about a patient?

And they tell you that this patient, you know, she's a 24-year-old female. She's a gravitor-one parallel, you know, you know, this is maybe a first. Or let's say she's this our first pregnancy. Let's make it easy, right? This is our first pregnancy. She's never had a kid before. And they tell you that, you know, she was diagnosed with high premises, gravitorum, four days ago. And they taught her to take, you know, vitamin B6 and doxylamine and it's more frequent meals for her high premises gravidare. Right? And then they tell you that over the last two hours, she's been having very severe, very significant chest pain, right? And then they say what's the most likely diagnosis, right? If you ask me for the most likely diagnosis, I would really hope you're saying, hmm, divine. Looks like this one has ruptured her esophagus, right? So the thing is obviously this person has ruptured their esophagus. That's bad, right? Now the thing is most times for these people on exams, they're just going to ask you what are you going to do in terms of treatment? Well, remember, whenever you rupture something in the body, your next best step is pretty much always going to be to go to surgery, right? Pretty much always going to be to go to surgery, you know, depending on the part of the body that has been junked up, right? So if for example, it's your abdomen that has been messed up, you'll be like some kind of laparotomy.

If it's your thoracic cavity that has been messed up, I mean, remember your esophagus is predominantly your thoracic cavity, you're going to do a thoracotomy, right? You're going to do the army procedure like the OMY, thoracotomy, laparotomy, whatever, right? Remember, since it's the chest, it's going to be a thoracotomy. You use cartonies, right? Or, you know, otomies, whatever, whenever you're trying to incise into a specific cavity in the body, right? So since this is the chest, you're going to be doing a thoracotomy, right? But if for whatever reason on the offhand they say, huh, they want you to pick a diagnostic test for the patient. Well, whenever you suspect that a person has ruptured their esophagus, what are we going to be doing for those people? Well, typically what are you going to be doing in general? Is you're going to do a gastro-graphy in anema, right? You're going to do esophagography, where you're going to use water soluble contrast, right? Water soluble contrast. Again, remember, another name for water soluble contrast is gastro-graphy. In general, if you suspect that a person has ruptured their esophagus, using barium is a terrible idea on MBM exams, because barium can cause a very powerful media stenitis, and that will obviously not be a very good thing for the patient. It's almost like you're creating a freshness set of problems for the patient, which is probably not the smartest thing in the world to do, right? So there is that.

So this person, you're going to do water soluble contrast enema or gastro-graphy enema. And you're going to see extravastation into the thoracic cavity, right? That tells you that again, they've ruptured some kind of viscous, and obviously your next step again is going to be exploratory thoracotomy, right? So again, just as a quick reminder, what are the indications for X-lap, right? So let's go to the abdomen. What are the indications for repressing getting exploratory laparotomy on MBM exams? Again, there are many classic reasons, right? The classic ones they love to test on exams. First things first, if a person has like a signs of periodtonitis, right? So what does signs of periodtonitis? If a person has like rebound, ready for pressing has like guardian, ready for pressing has like severe abdominal tenderness, exquisite abdominal tenderness, right? Those are situations where you need to go ahead and proceed to X-lap. Now, some people say, oh, divine, if a person has absent bowel sounds, that's periodtonitis. No, that is not periodtonitis. Let me tell you this. A person can have periodtonitis and have absent bowel sounds, but it's not every person that has absent bowel sounds that has periodtonitis. Let me explain. If so, how, I guess maybe how do you differentiate between those two things? Let me be a better question here. The way you're going to differentiate between those two things on exams is ask yourself this.

Does this person have absent bowel sounds in the context of other signs of periodtonitis, like rebound tenderness? Guardian? Yes, they do have periodtonitis, but if they just have absent bowel sounds and you don't see any of those other classic signs and symptoms of periodtonitis, you cannot say that the person has periodtonitis with any kind of definitiveness on endemic exams. Now, what are some other indications for X-lap? Well, some other indications for X-lap, I'm going to be things like penetrating trauma to the abdomen. Penetrating trauma to the abdomen. What are some things that can cause penetrating trauma? Well, if for example, you have a stab wound to the abdomen or you have a gunshot, things that are physically penetrating, foreign bodies, they're literally penetrating through your skin and into your abdominal cavity. That's going to be an indication for exploratory laparotomy. Then another thing that may also buy you this X-lap is if you have free air under the diaphragm. Free air under the diaphragm. So, if for example, you get a chest x-ray notice that, wow, I'm seeing this loose and C under the diaphragm. That tells you that, and many times it's going to be linear, that tells you OG, this is free air. Well, that air did not just show up out of thin air. No, it's not air you swallowed. No, it came because you ruptured a viscous. So, because you ruptured that viscous, that tells you that, oh no, this person has perforated something. So, those people need X-lap.

Another classic one is if you see like blood, like blood, like blood just pulling somewhere in the presence of abdominal cavity. Well, blood does not just pull in the abdominal cavity for fonzies. No, the blood pulled because a vessel ruptured or an organ ruptured. Many times it's the organ rupturing that then messes up the vessel and then you start bleeding out. In those circumstances, that person also needs X-lap. And again, if you ruptured something, if you ruptured something, and the thing is sometimes, because the endgame is they know that most people these days have got to cut onto, oh, you ruptured something so you get X-lap. So, they are beginning to use more creative surrogates of rupture to see if you can still catch onto the fact that this person ruptured something. So, for example, they love to give these questions where a person has shortness of breath. And then you're doing, you know, you think that, you know, maybe you put a chest tube of some sort or whatever, right? And you place a chest tube and you start getting bile out of the chest tube. I don't know, chest tubes are not supposed to be returning bile, right? Bile is an intra abdominal fluid, right? It's something you get from the doodinum and later, right? So, if you're pulling out bile, right, from a person's thoracic cavity, I don't know, this person is there from as probably ruptured, right? So, again, that would be an indication for exploratory laparotomy.

And another classic one they also love to do on exams is they'll give you some person that has had some kind of surgery, right? And most times the surgery is going to be intra-dominally mature, right? And then you notice that the person is having signs of periodonitis after they've had surgery, right? So, it can be like, for example, a person that has like Crohn's disease or a person that has all three of colitis where you know you caught out some part of the abdomen, many times it's going to be the colonel's small bowel and then you do like an end to end an asthmosis. Well, the thing is, if you're connecting something together, then there is the potential complication that you did not connect those things as well as they should, right? So, the person has like an asthmotic leak, right? This is many times something that you get again from, from, you know, like colon or small bowel surgery or like biliary surgery, right? Like biliary surgery, right? When you see those things, you see a person having periodonitis after abdominal surgery, you really want to think of them either bleeding into their abdomen or they have like an asthmotic leak of some sort, right? Even bowel, bowel can cause peritonitis, right? Those are all situations where you're going to go ahead and do an exploratory laparotomy. And again, remember, exploratory laparotomy can have many different means, right? Especially based on the branches of the, the branches of the yoder that supply the gods, right?

Probably like the common one I think I've seen that you love to test on exams, right? It's like a ciliotomy, right? Sometimes these have colinith and exploratory laparotomy, they'll call it an exploratory ciliotomy. Well, the word ciliotomy comes from, I don't know, maybe because the key blood supply of the foregot is the ciliocardery, right? Remember, the blood supply of the foregot is the ciliocardery of the mid-got is the supermissing terricardery of the hind-got is the inferior-missing terric artery, right? So those are all situations where you're like, okay, we're going to go ahead and do an exploratory laparotomy. Again, I just really wanted you to have a solid basis. Basically, if you know these scenarios I just discussed, I'll be really surprised if you somehow feel to get those things right on your test. Okay, now, next thing I want to talk about are what if they give you a question about a patient? And they tell you that this patient, you know, for the last five days, she has been having like worst-necked abdominal pain, right? And the pain is kind of diffused and she has not had any bowel movements and she has been having a lot of vomiting and a lot of nausea. If you see something like that, what should you be thinking about on MBM exams? Well, I'll really hope you're saying, huh, divine, this person has a small bowel obstruction, right? This person has a small bowel obstruction, right?

Remember, small bowel obstructions, most times, it will present with a person having nausea, vomiting, right? No bowel movements, right? For a while, right? And they'll feel bloated, right? Those are our classic signs and symptoms. Now, what are the things that typically cause these small bowel obstructions? Well, there's a bunch of stuff that can cause these small bowel obstructions, right? The most common one, right? The biggest risk factor for small bowel obstruction is going to be an adhesion from prior surgery, right? From prior abdominal surgery. Again, sometimes, they may even give you like a prior surgery, like a hysterectomy, right? As the thing that was the tipping point that years later, then caused their problems, right? So, if you have any kind of surgery below the diaphragm, those things can increase your risk for having, in fact, they have the most common causes, they're the biggest risk factor for small bowel obstruction, right? Well, well, as some other things that can cause this problem, well, hernia, remember, hernia is actually the second most common cause of a small bowel obstruction. Remember, hernia can become incarcerated, right? Because most times, hernia is not a big deal because, you know, they can pop out and then you can pop them back in, right? You can reduce the hernia. When a hernia is reducible, not a big deal, right? But hernia starts becoming a big deal when it's no longer reducible, right? Where it's no longer reducible, right?

In that case, you have an incarcerated hernia, right? But then when a hernia becomes irreducible, right? You can reduce it anymore, and then you could have blood supply to the parts of bowel that have herniaed, right? Then you have a strungly hernia, a strungly hernia, and incarcerated hernia. Those are both surgical emergencies, right? Those are both surgical emergencies. Those things can cause small bowel obstructions, right? Obviously, if you have necrosis, right, then you need to, because most mobile obstructions, all you need to do is just do like a nasogastric tube, but sometimes nasogastric tubes don't work because the person has had like bowel necrosis, right? In those circumstances, you're going to go ahead and do exploratory laparotomy so you can call out that dead bowel, right? And remember, it just has an extra tip dead. Before I keep on talking about the causes of a small bowel obstruction, remember femoral hernias, and not, because most hernias, you can be like, you know what? Let's go ahead and do what for waiting. Well, not all the time. For femoral hernias, which will look like in a female, right? Remember, female or in females, right? Femoral hernias, you're not going to do what for waiting, right? Those things, you're going to go ahead and schedule the surgery so that you can fix it. Most times, just remember hernias, they're going to be in females, and they're going to be under the inguinal ligament, right?

Those things can, they have a very high risk of incarceration and strangulation, so you don't wait on those on those hernias, right? Now, remember cancers at the third most common cause, right? So I said, the most common cause of an FBO is going to be an adhesions from prior abdominal surgery, right? The second most common cause is going to be hernia, third most common cause is going to be cancer, right? Third most common cause is going to be cancer, cancer, cancer, cancer, right? Colon cancer, small bowel cancers, gastric cancers, these things can all cause a person to have a small bowel obstruction, right? But again, our friends at the MBM Es, they know that most people that have the job description, medical student, have memorized that, L, the most common cause of small bowel obstructions is adhesions. Second most common cause, hernias, third most common cause cancers, right? So what are they doing these days again? They be coming more and more creative, right? Again, sometimes they try to see your understanding of pharmacology and they throw it as a small bowel obstruction question, right? So you want to make sure for MBM Es exams that you know the drugs that love to cause SB Os, right? Basically, these are drugs that grind your GI tract to a halt. For example, if you're taking a drug that has anti-colonergic properties because again, you know, they know that everybody knows that opioids, right? They grind your GI tract to a halt, right?

Because you have reduced like contraction, but you can have all those problems. But the MBM Es, they know that many people, unfortunately, don't know the specific drugs that have anti-colonergic properties, right? So anti-colonergic drugs are things on MBM Es exams that can cause two major problems. One, they can cause a small bowel obstruction. Two, right? So basically the small, it's not more than obstruction, it's more than ilius. Let me put it that way. It's more than ilius, right? So the whole bowel usually will be involved, right? And then the second major problem caused by anti-colonergic drugs is delirium, right? Delirium, delirium, delirium, delirium, right? So what are these drugs? Well, the classic ones, they can give you like cold medicine questions that's going to be diphenhydramine, for example, right? Diphenhydramine is cold medicine. It can absolutely positively cause a small bowel obstruction. I mean, it can cause ilius, right? Because it has anti-colonergic properties, right? Another thing that can also cause a similar problem on exams, right? You know, things like, like those first generation low-potency anti-psychotics, right? Those things have anti-colonergic properties, right? So things like clopromazine, CHLOR, PRO, MA, ZIN, clopromazine can absolutely, absolutely, absolutely cause a small bowel obstruction, right? It can cause an ilius. And also another drug that can cause it an ilius on exams, right? Think about your tricyclic antidepressants.

Remember your tricyclic antidepressants? They have these things I love to call anti-harm side effects, right? That H stands for anti-histamine, so they can cause sedation. The A stands for anti-alpho-1 effects, right? So they can cause orthostatic hypotension. And then the M stands for anti-moscorinic, right? So they have these anti-moscorinic effects. Again, these drugs can certainly cause ilius on NVME exams, right? So again, those drugs, right? You want to keep these drugs at the back of your mind for, for exams. And also the calcium channel blocking medications, right? Those calcium channel blockers, they love, love, love, love to cause small bowel obstructions on exams, right? Like your amloaded pain, for example, because remember, your GI tract is lined with smooth muscle, is lined with all these muscle cells. You need calcium, even those neurons for them to work, the neurons that you find in your my anterior nerve flexile, right? You need calcium for those things to work properly. Remember many times before you squared out neurotransmitter at a synapse, right? Most times you're going to need calcium coming in through those voltage-gated calcium channels at the synapse, right? So that you can then squared out neurotransmitter. Well, if that doesn't happen, right? Those neurons don't work, right? You have like impaired GI motility, right? So calcium channel blockers can absolutely on exams cause a small bowel obstruction, right?

Now, the last classic thing that can cause small bowel obstructions on exams are people that have like chronic ulcers of some sort. These like a classic one, many people are actually not really aware of these days, right? So they have like a chronic ulcer of some sort, right? So what's this chronic ulcer? You can have it like from chronic gird, right? You can have it from like, if you have like peptic ulcer disease from like H by lorry, like even in your dwoad numb or your stomach, right? Or you can even have a chronic ulcer because you have like an ulcerative disease, like ulcerative colitis or Crohn's disease, right? Whenever you see small bowel obstructive symptoms in people that have a history of UC or Crohn's, it's from an ulcer, right? Many times on in some unfortunate cases ulcers can heal with strictures, they can heal with fibrosis, and those strictures that fibrosis can cause a small bowel obstruction, right? And when you get that small bowel obstruction, you're absolutely going to have symptoms. So again, if you kind of keep these things at the back of your mind, I think you should be very good with answering small bowel obstruction questions on your exam, right? So if you know these things I just talked about, you should be very good from the perspective of answering small bowel obstruction questions on your exams, right? And again, in general, small bowel obstructions, you don't have to do anything down the busters, right?

What are the things you generally need to do for these people on exams? So the very first thing you should do is just do nasogastric, you're placing an angitube, right? An nasogastric tube, look at the name, nasogastric, right? They would decompress the bowel, right? But if those, and many times you also want to fix the electrolyte of the malities, right? Just give them potassium. Many times by giving those people potassium that can help. Hypochegemia has a very strong association with many of these small bowel obstructions, right? Has that very, very stronger association, right? But again, obviously, if all those things don't work or they start, but, and actually let me say one thing. Remember, you're going to see air fluid levels, right? On an abdominal x-ray. Most times for small bowel obstructions, just get an abdominal film, and you'll see those air fluid levels, right? You'll see those air fluid levels, right? Most times in those circumstances, right? That's what you're going to see on imaging, right? But again, if you notice that the person starts getting really bad, let's say they start developing like a really bad lactic acidosis, they start crashing and burning from a hypodynamic stability perspective. And in those circumstances, we're all developing signs of like peritonitis, that you need to go ahead and consider surgery in those people.

Okay, so I think what I'm going to do since this is a rapid review podcast, again, I really have this goal of trying to keep these things 20 minutes or less. I think I'm going to go ahead and stop here. Again, as I do at the end of every podcast, I do offer one on one tutoring for all the USMLA exams, step one, step two, CKAN, step three, you know, pre-clinical medical exams, 30-ish-off exams, I also offer these review courses, right? For I have the MBME test-taking strategy scores, I have the 24-hour review course, I have those taking place this month. And then in the summer, I have the 75-hour step two, CKAN, step three, school that's going to be taking place. That one has a 40% cut. And then I have this podcast on all the major podcasts apps, right? Apple podcasts, Google podcasts and Spotify. So if you want to subscribe, you see the most recent 150 podcasts. If you want everything for episode one, up to this episode, episode three, 69, then you want to go on the website, divineinterventionpodcast.com. If you actually have a Word Press account and you subscribe to my website, whenever I make a new podcast, you get an email notification. And then I also have a website, a new website called divineinterventionlifelessons.com. Many people have told me, oh, divine, I really love the life lessons you put at the end of your podcast. So I decided to make a like a new podcast website, divineinterventionlifelessons.com, where it's just Bible-based teaching.

So it's based on the Bible. Most of these things are like 10 to 15 minutes long. And they just address like a particular problem that's, you know, common to humanity. And I use a biblical perspective to describe the problem and explain how to counter those problems. I add like two podcasts roughly every week. Right? And I think I'm almost at episode 60 for those. And actually, I also have the podcasts on Apple podcasts. It's called the divineintervention life lessons podcast. So I also have, you know, You Tube channel called the divineintervention, US Mly podcast and videos. That's why I post the videos that I make and I make quite a few every now and then. So thank you for listening to this podcast. I will show the very best on your exams and congratulations to those that go via scores today, the passing scores. And for those that are participating in the match, I will encourage you, you know, if you're telling programs that they are your number one program, you want to go ahead and throw out that send that information to them sometime soon. Right? You don't want to be sending it like at the very end of this month when the committee has already met or already made their decisions, right? They're not going to be adjusting their rank list because of your email. No, right? So if you want to send that information across, it's usually a good idea to do it like two weeks or thereabouts ahead of the, ahead of the, ahead of the, the, the match deadline.

So thank you for listening to me. Have a wonderful day. I will see you in the next podcast and God bless you. Thank you.

Water soluble contrast enema (Esophagography), because barium can cause mediastinitis.

Rebound tenderness, guarding, and abdominal pain (signs of peritonitis).

1. Adhesions (most common); 2. Hernia; 3. Cancer.

Reducible means it can be manually pushed back into place; incarcerated means it cannot be reduced, posing a surgical emergency.

First-generation antihistamines, tricyclic antidepressants, and calcium channel blockers.

Nasogastric tube placement to decompress the bowel.

Water soluble contrast enema (Esophagography).

Perforation of a viscus (e.g., perforated bowel), requiring exploratory laparotomy.

Adhesions from prior abdominal surgery.

First-generation antihistamines (e.g., Diphenhydramine) and Calcium Channel Blockers (CC Bs).

Foregut: Celiac artery; Midgut: Superior mesenteric artery; Hindgut: Inferior mesenteric artery.

Proceed to exploratory laparotomy (surgery).

Water soluble contrast enema (Esophagography).

Perforation of a viscus (e.g., perforated bowel), requiring exploratory laparotomy.

Adhesions from prior abdominal surgery.

First-generation antihistamines (e.g., Diphenhydramine) and Calcium Channel Blockers (CC Bs).

Foregut: Celiac artery; Midgut: Superior mesenteric artery; Hindgut: Inferior mesenteric artery.

Proceed to exploratory laparotomy (surgery).