DIP Episode 366 - USMLE Step 2CK/3 Rapid Review Series 69

All right welcome my name is divine this is episode 366 of the divine intervention podcasts and in through these podcasts we're gonna be talking about we're gonna be doing our update review series for step 2 ck step 3 this is gonna be series 69 first of all yes i will say i'm very good for to god for you know episode 366 i'm just gonna realize it with my with my wife or recently that if you listen to a podcast from the website every single day you can listen to podcast literally for a whole year i'm really grateful for that you know just kind of thinking and reflecting back to where we started and seeing how far god has brought us some really grateful and again i hope in the future to continue to make good podcasts and videos that people can find to be really helpful for these uh usml exams and also just other exams as time permits and again if you're taking the usml step 2 ck step 3 exam so complex level 2 and 3 anytime within the next 12 c six weeks right so like say for example in the month of february or in the first three weeks of March i do have an in-be-me test taking strategy scores taking place on the 21st of february and a 24-year view course taking place between the 22nd to the 25th of february again i've had many people take this process i get emails of wood and i've crushed the exams all the time especially on Wednesdays i definitely get a lot of good reports and also if you check on the website you can see some some of the feedback that some people have given concerning my courses again tons of people have taking these courses i found it to be really helpful and then if you want an extremely in-depth review for the usml step 2 ck step 3 exams i'll be holding a divine intervention step 2 ck school that's going to be held in May of this year it's going to be the first two weeks of it's going to be 75 hours total for that one i am placing a cap because i wa

nt to be able to invest in people very deeply so there's a 40 person cap on the school so if you're interested in any of these things just shipping an email through the website is something if you want to set up you want to set up early because again i know many people take their usml exams in the summer right so if you know when you're taking your exam roughly again there's a 40 person cap once i hit 40 that'll be it for the for the school okay so let's jump right into the rapid review right so what if they give you a question about a newborn and they tell you that this newborn you know was born like seven days ago and his mama's notice that he has these these like just little like just these lesions that had diffused the on the trunk the on the face the on the arms but then they tell you that the child is e-fabral has no lucositis has no symptoms and then they show you like a picture of the baby and you see all these dot like all these little like little pimples on the babies but if you see that what should you be thinking about really hope you're thinking about erythema toxicum right i'll really hope you're thinking about erythema toxicum in those circumstances right you shouldn't do anything just go ahead and reassure the parents the baby is going to be fine now what if they give you a question about a three month old boy his mom tells you that you know he got very angry he was forcing a lot he was crying a lot um and then the mom noticed that he became unconscious for about two seconds and then he came right back whenever you see stuff like that um and they say what's the likely diagnosis i'll really hope you're saying all the vibes this is uh this is a breath uh taking this uh this is a breath uh holding spell my breath taking whoops that'll be weird that's a breath holding spell right and then they will ask what's the next step in management again you're gonna

go ahead and reassure the parents to be honest with you many of the findings in newborns are normal right it's just most times since the parents are new the parents will freak out right to think there's something about going on coming to the hospital and of course our friends at the mbm in the wisdom will decide to put in a question right many times the thing you're gonna do for those parents is you're gonna go ahead and just start reassure them okay now what if they give you a question about uh 34 year old female and they tell you that you know she was eating in a restaurant and you know she was brought in by her friends people 30 minutes ago she's that having shortness of breath they tell you that she starts uh she's been decompensating they give you like an oxygen saturation it's really low and then the ask what's your next step in management i'll really hope that you would see a benefic right this person very likely has an athletic shock the person has an athletic shock remember the drug of choice is a benefic because a benefic is a very powerful bitter to agonist right so because the powerful bitter to agonist it's gonna open up the person's early right but if you notice that one giving this person a benefic and they don't seem to be doing well they need to go ahead and into beats that patient right you need to go ahead and into beat that patient remember there are certain times where you have these acute decompensations and respiratory status for which emergent intuition is the right next step right there are many vineyards that friends at the mbm is gonna write about this thing right that he can use right so for example they can give you the giomberi syndrome patient right it's not every giomberi syndrome patient that gets into beat it but if you notice that the ff 1 starts dropping right that means those people are not long for this world from a respiratory per

spective you need to into beat them or they give you a question about a child who over a few hours is tripod in and grunting right and it's just having like very profound respiratory difficulty right you want to think about a big lotitis remember your first step in management for a big lotitis is emergent and do trick kill intuition right or they give you a question about a person that has a COPD like a let me not see a COPD but let me say like an asmx astrobation of some sort and you notice that this person that has an asmx astrobation the asio 2 is beginning to rise if the asio 2 is beginning to rise you need to into beat those people like yesterday why well the reason behind that is people that have asmx astrobation right they kind of struggling to breathe so they're like right they're blowing off all the CO2 right so they should have a respiratory alkalosis that's very high you know in fact there are friends at the NBA means they've been known to give questions like that where you have to predict the person's acid-beast status right in a certain condition right people that have asmx astrobation they're going to have a respiratory alkalosis because they're blowing off CO2 they're hyperventilating right so that's what's supposed to happen that's the normal thing that's supposed to happen but if you notice that G this person's a PCO to a study rising means the person's respiratory muscles are getting tired right so in those circumstances you need to go ahead and into beat the person as quickly and as rapidly as possible right and remember an aphilaxis is an example of a type 1 hypersensitivity reaction I'll say that again an aphilaxis is an example of a type 1 hypersensitivity reaction okay now what if they give you a question about a patient they tell you that this patient has a history of instigrinal disease well the patient came in with a three hour history of sodiu

m onset you know progressively worsening shutness or breath the give you labs you notice that the chaps persons who to sat or low you know the person is not doing really well right and then they say that you know the there is a very high clinical suspicion for pulmonary embolus right and then be asked for your next best step in in diagnosis again our friends at the NBA means being smart to try to put an answer that says the dimer please don't check the dimer right this person is probably like bed bound or something weird like that the high risk for PE you're gonna be messing around doing a D dimer right but then this person has instigrinal disease it may probably not be ideal to do a CT of the chest with uh with contrast right like CT angiography of the chest with contrast because the presence kidneys just don't work very well right so let's say for example in the question right so they don't make you have to think about this and the question they say oh giving the history of instigrinal disease the decide to perform a vq scan right and then they say that oh the vq scan the results give you uh uh low probability for PE right for pulmonary embolus and then they say oh what is the next best step in management well i was really really hoping you're saying old the next best step in management is to get that CT scan of the chest with contrast right that CT angiography of the chest with contrast right so the thing is this person is a very high risk for PE right so the thing is when you get a person that is high risk for PE and they get a low probability for PE result from a vq scan that's kind of worrisome right in those circumstances you're gonna go ahead and spring for something that will give you a more definitive diagnosis like a CT angiogram of the chest right now how do we treat PE's remember we treat PE's with heparin right we treat PE's with heparin most times you c

an use regular unfraxionated heparin or you can use low molecular with heparin but remember if your kidneys don't work very well they're gonna be using unfraxionated heparin right now the thing is many people are like oh but divine country just you know go ahead and uh do thrombolytromolytromolyt therapy uh we can but again we only do those for people that are hemodynamicly unstable people that are crushing and burning from a respiratory perspective right or people that have like imaging evidence of a right heart straight so let's say for example you get an echocardiogram right and the echocardiogram shows hmm especially has right heart strain in those circumstances you can go ahead and say okay know what we're gonna go ahead and the do a tpa in this person right and remember after let's say they give the person tpa and then the person starts having like very severe headache and they ask for your next best step in diagnosis I would really hope you're saying oh divine let's go ahead and get a non-contrast head CT right like and remember when you give tpa you kind of have this big big big bad risk of hemorrhage in the body right so the person probably has a sub-recognitive you'll get a non-contrast head CT and you'll notice that it's normal I mean you'll notice that you may see blood you know you may see like spider web shaped fins right the person has like a sub-recognitive hemorrhage or hemorrhagic stroke of some sort right and obviously in those circumstances really your treatment so you're just gonna try to keep the person's blood pressure down and they hope for the best right hemorrhagic strokes are quite difficult to treat now what if they give you a question about uh uh 24-year-old male you know he tells you that for the past three weeks he has been having pain in his neck and he also tells you that whenever he comes to the you know that you know he he has been h

aving a lot of anxiety has not been feeling really great right and then the tell you that physical exam is notable for hyper-reflexia and the tell you that he has like lid lag right and the tell you that he's nail folds like he's like he's like he's nails are lifting off the nail bed right whenever you see something like that and you see what's your next best step in management I really hope you're gonna see let's go ahead and check the TSE right this person likely has hyperthyroidism and the thing is there are many signs and symptoms of hyperthyroidism right so we know that first things first this person likely uh you know you see the hyper-reflexia remember hyperthyroidism can cause hyper-reflexia I mean there are many other things hyperthyroidism can cause right they can cause you to be tacky-cardic uh because remember thyroid hormone increases the placement of bit of one receptors on the surfaces of a person's cardiac myocytes where so you can cause that get cardiac cause hypertension that way right those people tend to have hyper-reflexia and remember people that are hyperthyroid we can have a hypercalcemia right because thyroid hormone can have a direct effects on bone and causes to resolve when I'm making a ton of calcium right so many times these people's alkaline phosphatists can also be elevated remember it elevated alkaline phosphatists does not always mean that the person has a structurally very disease it could also be just metabolic bone disease right that's why many times you use GGT gamma glutamol transfer to sort those two things out right GGT is elevated in obstructively very disease GGT is not elevated metabolic bone disease right so we let's say we check this person's TSA right and we notice that it's low right because presence hyperthyroid right and then they say hmm what is the next step in in diagnostic testing I'll really hope you're saying you

know what for this guy let's go ahead and get a ryeo scan right a radioactive iodine optic scan a ryeo scan a radioactive iodine optic scan well why do we get the scan well we get the scan because it can help us show what in the world is happening with this guy's neck right remember our friends at the MBM is they love to use like many alternative names for things that people have memorized right so sometimes instead of calling a ryeo scan right like an R8 IU scan a radioactive iodine optic scan they make polythyroidycentigraphy on the exam remember whenever you see the word centigraphy it means that it's a nucleomedicine study that you're dealing with right and then let's say you get the styrofoam integrity and you notice that you see multiple hot spots right on this ryeo scan well this was a diagnosis you're going to entertain I really hope you're saying oh divine this person likely has a toxic motanodilogoyder right motanodilogoyder right so again you need to make sure you can interpret ryeo scan results on exams right so um if you see the fused up increase in uptake right that's gruse disease right remember you have a thyrus to eliminate immunoglobulin and for gruse disease remember you're treating gonna treat it with i131 therapy right a thyroid dectomy is not really indicated in general for the management of gruse disease on MBM exams gruse disease is gonna be managed with iodine 131 therapy right but if you see a single hot spot that's a toxic adenoma you see multiple hot spots that's a motanodilogoyder if you notice that this person has this neck pain and you do a ryeo scan you don't see any optic then the ver and you notice that g this person's thyroid is like super super tender then probably one of the biggest things you should consider is this person having a dequeous thyroiditis remember dequeous thyroiditis again like many things on MBM exams has multiple

names they can call it dequeous veins they can call it a subacute thyroiditis they can also call it granolomados thyroiditis right granolomados thyroiditis right sometimes you can even ask you that oh if you would buy up say the person's thyroid gland what are you gonna find i'll really hope you're saying oh we're gonna find granolomas with you know epitheliod macrophages right remember whenever you see a granoloma there's gonna be an epitheliod macrophage right around there right so again just things you kind of need to keep at the back of your mind for for exams so if you maybe like what in the why in the world is the person type of thyroid and when I see any increase optical ryeo scan in the quervids well the reason in there is that in the quervids thyroiditis notice is anitis you have inflammation and destruction of the thyroid gland at least let's call it a temporary destruction how's that right a temporary destruction of the thyroid gland so because of that destruction those follicular cells transiently don't work so because they don't work they're not gonna optic thyroid or iodine right in the formation of thyroid hormone so again that's that's very high yield to to to keep in mind now what if they give you a question about uh you know 35-year-old male they tell you that he has a history of a homocystinuria right and he comes in with like you know over the last 24 hours he's having very severe chest pain reading to the jaw right and then they tell you that two hours after he's checked into the hospital he starts completely you know profound shortness of breath they tell you that when you listen to his lungs you hear bilateral crackles right and you also notice that the person has the skull of systolic memory at the apex if you see this what should we be thinking about I'll really hope you're seeing what a vine this is a popular muscle rupture right again remem

ber this will have hyper homocystinemia you know the many times it arises from a deficiency of some enzyme we call CBS um sister thyrinine beta synthase although sometimes you receive this as a deficiency of an enzyme called empty hFR um uh met met met met thyr tetrahydrofolid reductis so basically when you have a deficiency of those things you're going to have high levels of homocystin the thing is homocystinemia is say the viois homocystin is such a big deal well let me explain homocystin is a big deal because um it has a lot of soft hydrial groups and soft hydrial soft hydrial groups those are like sulfur, bontal hydrogen they're pretty reactive right so probably learn this from organic chemistry back in the day um you know very reactive so they love to like begin to torch the walls of blood vessels so people can get all these M Is and all these problems right so now this person got this MI right they be hiding this should probably have coming like you know 24 hours ago end up being started but you know they chose not to forever bizarre reason right but now this person has like this re-bapone regima right and this person's heart is beginning to fail and you hear the systolic memory at the apex or remember the apex is the mitral area so if you hear the holosistolic memory that's going to be the memory of mitral regurg when you see an MI with a temp when you see mitral regurg you see a temporal association with recent MI that's a papillary muscle rupture right there for you and exams although sometimes on exams instead of seeing papillary muscle rupture again the mbme is in the agreed wisdom they'll call it a rupture of the cordy tendony right rupture of the cordy CHOR DEE tendony I believe tendony is spelled as tenddi n-di-n-e-e-e cordy tendony right rupture of the cordy tendony rupture of the cordy tendony right so that can cause a that can cause a that can cause a

problem that can cause the murmur of mitral regurgitation right so remember this person in this case has pulmonary edema right but again it's a pulmonary edema because of a cardiogenic problem right they have pulmonary edema because of a cardiogenic cause okay again remember don't forget your complications of MI's the enough to test those on exams right if you see a person within the first twenty-fourth of an MI they're dying remember the most common cause of death in the first twenty-fourth of trinemi right is is a ventricular arrhythmia right most things are going to be V-fib right I remember when a person has V-fib all you're going to do for those people is unsynchronized cardiivversion right not synchronized unsynchronized cardiivversion if you pick the answer that says synchronized cardiivversion you'd be wrong right you need to do unsynchronized cardiivversion for those people I remember I know the mean for unsynchronized cardiivversion is defibrillation right defibrillation defibrillation right and then again remember if you see this you know acute onset pulmonary edema I hear a whole cystolic moment of the left-low external water right that's kind of like a VSD murmur that tells you that you've ruptured the interventricular septum right and then don't forget you can also get this ventricular free water rupture many times now present with like postless electrical arrest one exam sorry so again those are just all things you need to keep at the back of your mind for for tests right now what if they give you a question about a patient and they tell you that you know it's like a three-year-old boy you know they tell you that he has a Mark or Kid is him where so he has like really big testicles right and they tell you that he's having like learning problems in kindergarten like you see something like that um what's that mostly should you entertain I really hope you'

re saying oh divine this child likely has fragile X syndrome right fragile X syndrome remember people that have fragile X syndrome is one of these trained with every peter the soldiers right if a mom is speaking fragile X has these are CGG trained through that repeats and is actually one of these weird disorders that has X-link dominant inheritance right what's the other disorder that has X-link dominant inheritance I hope you're saying oh divine outboard syndrome right outboard syndrome outboard syndrome also has X-link dominant inheritance right so in fragile X syndrome remember they can get many different problems right many times they have like intellectual disability they can have like ADHD in fact let me tell you this the most common cause of intellectual disability most common genetic cause I'll say that again very high of most common genetic cause of intellectual disability is fragile X syndrome right I remember these kids can get good and get my trova of prolapse right they can get all these problems but for the most why they have a pretty good life expectancy right so those are all things you want to keep at the back of your mind for exams right so I think since this is a rapid review 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 USML exams step one step 2ck step three pre-clean cool med school exams 30th shelf exams offer review courses for step 2ck and step 3 as well I have like the 24-hour review course and the NV Me test taking strategy scores for the month of February those are going to be taking place between the 25th 21st 21st of 25th of February and then the disk school the divine intervention step 2ck school that has a 40% limit that's going to be taking place in the first two weeks of May so if you're interested in any of these things just shoot me an email through the websit

e and I'll be more than happy to give you some more information and then I also have this podcast on Apple podcasts on Google podcasts on Spotify at least the most recent 150 of them if you want anything everything from episode one to episode 366 you need to go to the website divine intervention podcasts with an s.com and then also have a You Tube channel called divine intervention USML podcasts and videos that's why I post the videos that I make I make videos intermittently and I post them on that on that You Tube page and then also if you love the life lessons that I give many people have sent me emails or divine I love the life lessons you occasionally talk about at the end of your podcasts I do have a website it's called divine intervention life lessons.com again divine intervention life lessons.com where you know they're just very short podcasts most of them are around 10 minutes long and it's just Bible based teaching on just common problems that are faced by humanity and if you're interested in that again go to divineinterventionalifelessence.com I even have the podcast on Apple podcasts it's called the divine intervention life lessons podcasts so thank you for listening to me today have a wonderful rest of your day God bless you I'll see you in the next podcast thank you.

Erythema toxicum (a normal finding).

Emergent intubation/mechanical ventilation. This indicates respiratory muscle fatigue and impending failure.

Type I hypersensitivity reaction.

Unfractionated heparin (UFH).

Non-contrast head CT to rule out intracranial hemorrhage.

Fragile X syndrome and Outbred syndrome.

Multinodular goiter (or toxic multinodular goiter).

Increased placement/upregulation of beta-1 adrenergic receptors on cardiac myocytes.

A tender thyroid gland with no increased iodine uptake (low RAIU scan).

Papillary muscle rupture and vascular damage/aneurysms.

Fragile X syndrome.

Thrombolytic therapy (e.g., tPA).

Multinodular goiter (or toxic multinodular goiter).

Increased placement/upregulation of beta-1 adrenergic receptors on cardiac myocytes.

A tender thyroid gland with no increased iodine uptake (low RAIU scan).

Papillary muscle rupture and vascular damage/aneurysms.

Fragile X syndrome.

Thrombolytic therapy (e.g., tPA).