DIP Episode 318 - NBME Gastroenterology Series 5 (for all USMLEs)

Okay, welcome. My name is Divine. This is episode 318 of the Divine Intervention podcasts and in this podcast I'm going to be continuing the Gastro and Roger review. By the end of this this will be like a thorough complete GI review. I've done for in the series the most recent one was episode 298 and that was series 4. It was going to be series 5. Okay, so let's just jump right into it and again my guess for people that are taking step 2. See case step 3 anytime soon. I have an MBA me testing strategy scores for that on the 17th of this month via zoom and then I have a comprehensive 20 hour review course for both of those exams on the 18th and the 19th of this month also via zoom it's 10 hours each day. If you're interested again feel free to ship me an email via the website and I'll give you more information again there's tons of people that are taking these courses that I've done really well on the exams. In fact I've got in a lot of emails in recent times from people like oh wow, Divine, it took your course last month and I've passed my exam. I took your course last month oh I got like 30, 40 points higher than I did on step one. So again it's a pretty I feel like the the course is pretty well put together and again most people have got in a lot of benefit from it. So again if it's something you're interested in feel free to ship me an email through the website and I'll give you some more information.

Okay so what did they give you a question about like a 44-year-old female and they tell you that she presents with signs of anasaka right and then they tell you that her serum albumin is 1.5 then they tell you that oh they perform an EGD right so like operating nostril remember EGD means a so-called gastroid and anoscopy and then you notice that this person has like hypertrophied gastric folds and they tell you that these gastric folds have a cerebriform appearance a cerebriform C-E-R-E B-I-B-R-I-F-O-R-M appearance if you see that what should you be thinking about? I really hope you're saying oh wow Divine sounds like this person has a minute Rears disease right? Minotrares disease so let's explain some of these findings on what are the things your friends have the MBME expect you to know about a minute Rears disease right so minute Rears is spelled M-E-M-E-T-R-I-E-R right? Minotrares disease right so sometimes you may see on the examinations even call this a protein losing gastropathy to be honest with you one of the easier ways I think about these diseases I think of it as like an euphrodic syndrome of the stomach pretty much right?

In this case instead of losing protein through your urine you're gonna be using losing protein through your stomach so obviously it's gonna be going to your poop so the thing is if you're losing protein right if you think about it obviously it's the primary protein in a human in a human's body right so the serum albumin is like 1.5 so it's really low so because this person has a low serum albumin you can already begin to deduce the many things your friends at the MBME test right like for example this person why does this person have an acycric remember an acycric is like a generalized form of severe dima right?

Well that low albumin is contributing to those people having low plasma on cortic pressures if you have low plasma on cortic pressures then fluid is not gonna sting your vascular tree right and if fluid doesn't sting your vascular tree then it's going to extravacite right into the interstitial and caulge generalized a dima right they can even give you a question about this person having a plural effusion right and ask you what kind of effusion this person can have I would really hope you're seeing oh divine this person will likely have some kind of trans-udidiva fusion remember trans-udidiva fusion's refusions that meet you know certain key parts of light criteria right we know that the light criteria right I hope you remember that oh one part of it says your peripherally protein to serum protein ratio should be less than point five your peripherally LDH to your serum LDH ratio should be less than point six and then the plural fluid LDH should be less than to thirds the upper limit of normal of serum LDH as long as you meet you need to meet literally all three criteria to be classified as a trans-udidiva fusion and unfortunately for trans-udidiva fusion's unfortunately for trans-udidiva fusion's you see people memorizing long lists of stuff right the truth is you don't really need to memorize like long lists of stuff to memorize these are the causes of trans-udidiva fusion's these are the causes of exudidiva fusion's no you literally don't have to do any of that all you need to do is to just understand the mechanism trans-udidiva fusion will be caused by pretty much anything that increases your hydrostatic pressures in the lungs or I mean in the body or decreases your oncotic pressure right because again the reason you form those effusions in a trans-udidive format is that fluid is literally extravaceted from the pulmonary capillaries into the pulmonary interstition r

ight so the thing that will cause fluid to extravaceted is either if you have long collic pressures right because some collic pressures are kind of a smaller pressure they keep fluid within the walls of blood vessels so if a person's plasma protein is low because they have an euphrodite syndrome peanut protein in your urine or miniature disease peanut I mean pulmonary protein in your stool right or they have liver disease right because remember the liver is the primary side of production of proteins in your body right all those things all those things can literally all give rise to a person having a trans-udidive fusion right but another thing that can do the same thing is if you have an increase in hydrostatic pressures in your lungs right so say for example a person has like congestive heart failure right the heart is not working fluid will back up from the left ventricle to the left determ to the pulmonary veins to the pulmonary capillaries because of those increasing pressures right you have fluid extravacetion right for pressing has to wash your core right for pressing has to wash your core you're literally not eating protein if you're not eating protein well guess what you're gonna have very low plasma oncotic pressures right that's why many times when you see pictures of these babies that have to wash your core they should have these really have like pretty big big big bellies I'm sure you've probably seen the classic picture on many of these are study resources right there is if you have those big bellies it's literally a demon right that a demon is from the air superma's enteric vessels right because there's long colic pressures in those abdominal wall vessels right those people just I mean those abdominal vessels they just have fluid extravacetion and then they get they get into trouble right so again that's why this person in this question has an acirca rig

ht and then exudative effusions are just basically like pneumonia and cancer and pulmonary embolite pulmonary embolite they're one of those unique causes of transudative and exudative effusions okay now what if they give you a question so again and many of these questions I'm talking about relate to gastric diagnosis so what if they give you a question about a patient and detail it that you know this patient has been having GI problems and then they decide to perform a gastric biopsy and they notice that there's hyperplegia of the person's g cells and then they also tell you that oh this patient falls over when you try to do some kind of test of proprioceptive ability and the person's CBC you know the person's hemoglobin is eat so they have an anemia I notice that their MCB is like 115 if you see this I would really hope that you're thinking of an answer that says autoimmune metaplastic atrophic gastritis or amag right autoimmune metaplastic atrophic gastritis so remember when people have like this autoimmune gastritis it is actually a type A and a type B the type B is the one that involves the antrom of the stomach and it's actually associated with a H by Laurie what type A which is the one I want to talk about now because you see like this person seems to have like a prelicious anemia right but it's just anemia is an autoimmune pathology right the type A involves the body of the stomach so the easy way to remember this is the type A involves the B structure in the stomach the type B involves the A structure in the stomach right so the type B auto the type B gastritis involves the antrom that's an A structure the type A with gastritis involves the B structure which is the body right so in autoimmune metaplastic atrophic gastritis right it involves the body of the stomach so because it involves the body of the stomach unfortunately you're gonna nuke your parietal cell

s if you nuke your parietal cells if you destroy them then you're not gonna be able to make intrinsic factor so if you're not able to make intrinsic factor then B12 is not going to be reabsorbed because remember B12 is too afraid to walk through the terminal ilium on its own into your bloodstream but I mean B12 needs intrinsic factor as a married partner to make it make it across so the thing that will happen in those circumstances is these people can develop a B12 deficiency as a result of that right so that explains many of the findings because remember in B12 deficiency it's one of those causes of megaloblastic anemia because the cell because remember whenever a cell wants to divide it gets bigger first as it's you know doubling its DNA content and all that fun stuff right but as the cell is getting bigger and sizable you notice is that I don't have B12 to make this DNA synthesis happen the cell is just bigger right so that's why these people have megaloblastic anemia and to be honest with you when people have B12 of fully deficiency it's not just their red blood cells that get bigger it's just the red blood cells are a very common cell in the body so we notice it a lot but pretty much many of the cells in their bodies get big because guess what many of the cells in the body also have DNA and they also have to divide right so just something to keep in mind there so they just have almost like a generalized cellular megaloblastic doses right when people have I mean you know like let me say megalocyte doses right the cells get bigger because they have these B12 of fully problems right so why is it that when we did a test of a perceptive ability this person fell over well I was basically describing the rhomburg test right remember the rhomburg test there are three there are three maybe let me explain the pathophase because again I don't really want people memorizing th

ings here so remember that for you to know where your joints are in space there are three things that help you do that one is your drossal columns two is your vision and then three is cranial nerve eight your vestibular cochlear nerve of those three things you need at least two working at every point in time so that you can know where your joints are in space if let's down two out of those three things are working you're gonna topple over and fall right so for example this person has a B12 deficiency we know that B12 deficiency is associated with a subacute combined degeneration of the spinal cord so the drossal columns and the lateral corticospinal tracts are gone pretty much so if those are not working well you still have cranial each you still have your vision but if you tell them come into my office put your feet to close your eyes right with the close your eyes if taken away a second thing out of that triad so now they are left with one out of three vestibular cochlear nerve fall over right remember this test will also be positive in person that has like t-beast or salis from tertiary syphilis or a person that has like anterior spinal artery syndrome right because the anterior to third of the spinal cord with the exception of your drossal columns is pretty much a go okay now there is in these people have g-cell hyperplegia right again if you think about it g-cells are the cells that make gastric so gastric job right is to work on it to work on many different mechanisms to cause you to produce acid right I'll probably talk about those later although I believe I've talked about those in the GI from our college podcast I'm gonna skip that for sake for the sake of time but basically act on your release a gastric and then that gastric act on receptors on enterochromophilic cells so you can make histamine right but it also has some things that just act directly on the

parietal cells when if your parietal cells are not producing they are not making acid and there is no negative feedback so you're gonna keep making gastric gastric well for you to make those increased levels of gastric you don't make gastric out of thin air right if you're making more gastric than you normally do make then it would make sense that those g-cells have to get bigger than is normal for them right so the person will have a g-cell hyperplegia okay now let's describe some more operandostopyr results right so what if they tell you that oh you perform operandostopyrinopation again that's basically fancy terminology for an easy and then they tell you that you see what looks like a water melon appearance to the person stomach right a water melon appearance to the person stomach and then you notice that all this person has the has an anemia and the MCV is like 70 right so the person has a micrositic anemia if you see this what should you think about well I want you to think of a condition that I call give gastric antro vascular ethesia right gastric antro vascular ethesia right so look at the term ethesia it means that you have blood vessels almost like seeping through the walls of the antrom of the stomach right the thing is unfortunately some of these blood vessels can bleed right and if you have that chronic slow bleeding that can cause an iron deficiency anemia that's why this person has the micrositic anemia so I really hope you're saying oh divine because this person has an iron deficiency anemia the iron stores will be low right so the affinity will be low since the affinity is low the body is like scouring up you know for a ton of iron everywhere so the TIBC goes up and the transference saturation is going to be low right again and the RGW the RET cell distribution with is going to be increased as well and also the a free rethrocyte protoproferin right be

cause remember for you to form him you need iron and protoproferin right but again if you have an iron deficiency protoproferin like is like left standing at the altar there's no husband or wife around for basically there's no partner for for protoproferin so it keeps accumulating right so the persons free rethrocyte protoproferin will will go up right again you can just see how they can make that's why I like making podcasts like this you can see how your friends at the NV Me they just love this thing of making integrations right so again you need to be able to see tell people this you need to be able to see concepts in like a multi-dimensional fashion and then let me ask you this what there is this particular vessel I don't know I don't know this thing is gonna see in my mind there's this particular vessel that loves to thrombose when you see people that have gastric varicence right what's that vessel that loves to thrombose in people that have gastric varicence I hope you're saying oh divine these people have a splitting vein thrombosis I mean splitting vein thrombosis you can also find in people that have acute pancreatitis right so why is it that when people have gastric varicence they can have a splitting vein thrombosis well the one thing I wanted to remember is remember that the left gastric veins be draining to the splinic vein right so if a person has gastric varicence right that's almost like introducing because the blood has nowhere to go because of the increase the pressures right so the thing is because the blood has nowhere to go is just kind of collecting so the person has a lot of blood steases and if you remember vehicles triad of thrombosis right remember steases hyper coagulability and ophilial dysfunctionally have that steases any thing that is like a tributary I don't know if it's pronounced as tributary but I know in major back in the day when I

was learning geography we pronounced this as tributary right so it's like TRI BU TRI right so the thing is the left gastric veins actually draining to the splinic vein so the thing is if a person has a left gastric vein issue I hope potentially it costs some blood steases in the splinic vein and I will increase the risk of the person thrombosing the splinic vein right so that's one of the reasons why gastric varicence associated with a person having splinic vein thrombosis and then what if they tell you that on egd you notice that oh this person has like you see some sub neocosal arterials that I eroding into the stomach and bleeding right you see like all these arterials bleeding that I want you to think of a of a doula for is lesion right so I think it's doula for or something like that but anyway I'll just tell it for you it's like di EU LAFY right doula for the lesion or doula for is lesion whatever right I'm sure it's a French sounds a lot like a French term okay now what if they give you a question about a 52 year old female they tell you that she has a 10 year he's strong gastric ulcers and then over the last 10 months she has had like a 15 pound weight loss if you see this what should you think about well I hope you're thinking that oh this person potentially has a stomach cancer right this person has like an adenocarcinoma right and remember when people have adenocarcinomas of the stomach again many times especially this person that has had like gastric ulcers for a long period of time is probably associated with heaps of lower infection right so that means this person likely has some kind of intestinal type adenocarcinoma remember there are many kinds of gastric adenocarcinomas the intestinal type gastric adenocarcinoma has a very strong association with heaps of lower infection okay now what if they give you a question about a 52 year old female and they te

ll you that you know she presents with complaints of like early so tiny for the last 10 months and she has lost like 45 pounds and then they tell you that she also has like some kind of adenocarcinoma ass right if you see this I really want you to think of again another kind of gastric adenocarcinoma but in this case it's gonna be the diffuse type adenocarcinoma right this one is super super super aggressive right and the thing is unfortunately you see this adenocarcinoma I'm describing is that gastric adenocarcinoma this diffuse type gastric adenocarcinoma metastasizing to the person's ovaries right when you metastasizing to the ovaries that's when it's called a crooked bird so K-R-U-K-E-N-B-E-R-G it's called a crooked bird tumor right and again the classic exam question will be a person that has endoscopy revealing like a you know like a robbery immovable stomach the hotel you that the stomach the person stomach has a pair of stances it's not moving right that's what's called like night is plastic that's a pretty classic finding in people that have these a crooked burger tumors now what if they give you a question about like a 19 year old male so you're like huh the thing is kind of weird right so you say like a 19 year old male pretty young they tell you that oh he presented like early satiety on intended week loss for the last three months and they tell you that you know they don't really know much about his family history but they are many many family members that have died of gastric cancer right if you see this this person has a familial condition that is associated with gastric cancer right and the thing is many times on mbim exams yet they're not trying to get you to make any specific diagnosis of a condition they're trying to make get you to make the specific diagnosis of a mutation right so what's this big-time mutation that tends to have this very solid as

sociation with gastric cancer I want you to think of cah hearing mutations right cah hearing CAD HERIN right cah hearing mutations remember cah hearing is one of these things that keeps epithelial cells together right so whenever a person is about to have like metastatic disease right there's usually a loss or a downregulation of cah hearing so essentially those cells break apart and then they start flying off to different places right so these cah hearing mutations are usually inherited in an orzomodominant fashion and they can be associated with gastric cancer right in a in a patient especially like again familial gastric cancer very high you to know that for for purposes of exams right so now let's just really quickly in the last few minutes here begin to depart tools into like some small some small intestine epithologies right that again our friends at the mbim you love to test right so again one big small intestine epithology right again they can give you a question about a person and they tell you that oh this person you know has abdominal pain and they tell you that this abdominal pain gets better when this person eats right and it's kind of like in the epigastric area sometimes it can be non-specific but if the best person fasts for a while the abdominal pain gets worse if you see that you want to think about peptic ulcer disease right member in peptic ulcer disease is the most common cause especially when you have like a doodonal ulcer again where we're now in the small bowel whenever I do a doodonal ulcer classically those people tend to be obese right because whenever they eat then their symptoms get better so why do the symptoms get better when they eat well the reason the symptoms get better when the eat is because their burner glands right the subucusal glands in the bottom of the of the small intestine when a person eats those glands produced by carb an

d that by carb can sue the ulcer right so those people that have doodonal ulcers the classically the ulcers just feel better when the when the eat right so that's peptic ulcer disease and again the most common cause of doodonal ulcers on mbim exams is hitch by lorry right and then again if you're seeing ulcers in our usual places in the in the small intestine like in the jijunum for example I would really want you to think about Solinger-Elysene syndrome which we've again talked about in a in a prior podcast I believe this was episode 298 which was series four by the way this is this is series five right and then there are these malabsorptive disorders that the mbim is love to go after right for the small intestine and many times people tend to screw this up on on exams so I'll encourage you to not screw this up in fact I'm gonna try my very best to try to parse these things apart right so like like ciliate disease right so obviously we all know that ciliate disease arises from a person having a some kind of gluten sensitivity right now there's some key facts about ciliate disease that your friends at the mbim want you to know one is that if you were to perform like an eGD on these people right upper endoscopy you're gonna notice bluntin of the microv-line right you're gonna notice villas bluntin right and then it's also high you to know that oh if you were to take a biopsy of a tissue section and a person that has ciliate disease you're going to notice a lot of lymphocytes within the epithelial tissue right so the buzzword you want to remember for exams believe it or not they do this on step one step two CK step three right is epithelial lymphocyteosis right and in fact you'll see like my like a lot of my totic figures in the in the crept of the intestine right again just because of all this inflammation and you have to regenerate the person's intestinal amicosa righ

t and many times when a person has ciliate disease it usually involves the doodnam and the jajunum ciliate disease many times on mbim exams spares the terminal in them that's very high you'll know many times he spares the terminal in him right and really the way you're gonna make the diagnosis is you're gonna do all these are serologies right and either do like the serologies like you're gonna find antibodies against gliadin or antibodies against tissue transgotaminis or anti endomacial antibodies so EMD or MY S I E L right and no many times these people symptoms will improve when you withdraw gluten from from their diet right but again the key thing I think I want to emphasize with ciliate diseases these people are gonna have lots of laba abnormalities right so they can have like a vitamin D deficiency they can have rickets they can have iron deficiency anemia they can have things of that nature right and usually these people they they have trouble gaining weight that's that's a pretty classic picture for ciliate disease sometimes they call it ciliac spur on exams so how do you differentiate ciliate disease from tropical spur on mbim exams again tropical spur look at the name tropical spur they will give you a question about a person that has some kind of travel history right either to like the Caribbean's or to South America right and then this person they will get some kind of non-specific GI infection it's a problem that usually happens after the fact after the GI infection right and one key thing to keep in mind with tropical spur is that it tends to destroy a person's terminal elium it's very high autonome it tends to destroy a person's terminal elium and for the most part it improves with antibiotic therapy right on like ciliate disease that improves with gluten withdrawal from the diet right and then contrast this with lactase deficiency right remember in lact

ase deficiency this is something usually for like in Asians on mbim exams right or in people that they didn't have my absorption before but then instead of having my absorption later in life you know like young adults Italians right lactase deficiency is a pretty common in Italians on mbim exams right and many times they'll tell you that they perform an HD and you have like normal histological findings and usually you'll notice that this person's symptoms tend to be as it as temporarily associated right remember temporal associations matter for USML exams right so their symptoms tend to be temporarily associated with food and many times these people they will not have any lab abnormalities right literally they will have no lab abnormalities that's very high you know so they won't have signs of like iron deficiency andemia of vitamin D deficiency or anything of that sort right if you see that I want you to think of lactase deficiency many times you can you can make the diagnosis with like a hydrogen breath breath test but for the most part again these people you can give them like supplemental lactase right or you know they can take milk that does not contain lactose those things are very commonly sold in many many grocery stores right and then one of the set of small bowel disorders I think I want to discuss I like static small bowel disorders right because again these things whenever you have stasis remember whenever you literally have any kind of stasis you're gonna have bacterial overgrowth in the GI tract especially like anaerobic bacteria right and when you have like overgrowth of these anaerobic bacteria they do a bunch of things one is they can decontrigate your bile acids and when they decontrigate your bile acids that's gonna have cause a diarrhea right and again these things they can eat up your vitamin B12 they can cause a B12 deficiency as a result of that

right and also in some cases right these people can also begin to have like fat soluble vitamin deficiencies right like a vitamin A or vitamin D or vitamin E or vitamin K deficiency remember vitamin A is gonna be night blindness right but I mean D is gonna be rickets osteomal lesion right is actually they will essentially have like a secondary hyperparaphrathirides in vitamin E right remember those people have a lot of ataxia remember typically these people if you look at the array of blood cells you're gonna find a canthosytosis and then by the mean K remember it's your these people are gonna have a lot of a lot of bleeding right because remember you're required by the mean K for the gamma co-oxylation of factors 279 and 10 and 14 C and S right so what is like the key stasis causing the solder that you see on the immune exams think of scleroderma right think of scleroderma remember and scleroderma your muscularis appropriate essentially becomes non-functional because you've replaced a lot of it with fibrosthesia right so whenever you see people in that situation right again it can cause a small intestinal bacterial overgrowth right it can cause a small intestinal bacterial overgrowth and many times for these people just give them antibiotics to help but again unfortunately it's not necessarily the best the best measure right so again just something to keep in mind for example remember another notable part of a GI tract that can be fibroast and people that have scleroderma is the esophagus right so they can have esophageal dysmortality remember that's the E in crest syndrome for oscleroderma and then in terms of infections right there are two classic actually three classic infections your friends actually I take that back four classic infections your friends have the immune you love to test right so the first one right again if they give you a question about a person

that has a small bowel disorder and you're not even they have iron deficiency andemia and yet your synophils are elevated I'll really hope you're saying oh divine this person potentially has some kind of hookworm infection right so you can be like an infection with like Nikita americanas right or ancelostoma buodenami right so ancelostoma or Nikita those things they literally suck blood from your small intestine and it can cause a cause an iron deficiency andemia this person will have like non-physic symptoms but the key thing to remember is you notice that you have elevations in the your synophils because it's a parasitic infection right and they'll tell you something about maybe like have the person having like beach exposure or the person always walks around bare footed because that's usually how people get getting to trouble with this stuff another classic one you may see on exams maybe a person that again just has a non-specific abdominal pain right but you notice that you have a B12 deficiency right B12 deficiency and again yet your synophils are all jacked up if you see that I want you to think about di-filobothriomalato right di-filobothriomalato remember that's the fish tape one the fish tape one literally just like you love B12 it also loves B12 so that can cause a megaloplastic andemia so keep your mind these two parasitic infections that are very classic for causing either micro-synchemia in the case of hookworms like ancylostoma doguadenali on the keramiricanas and then the fish tape one that causes a megaloplastic andemia right di-filobothriomalato and then don't forget if they give you a question about like a person that you know when campaign and then the person has this false million diarrhea after they return back from a campaign I want you to think of giardia lambella right they can also make this a hiker problem on an embankment exam right so this

person you have drunk water from a stream or something like that this is giardia lambella remember it has like fecal oral transmission right you're pretty much put it from the water so if your hiking don't just like put your hands in the stream and like oh let me drink water from there it's only if it's absolutely necessary because you're kind of setting yourself up for for giardia and remember giardia giardias has an association with i.g.

deficiency as well right because again i.g.

is the thing that protects your mucosal surfaces and you're not able to protect your mucosal surfaces if you have that deficiency right so and how do you treat giardia lambella we're gonna give metronidousol right we're gonna give metronidousol to treat these people now what if they give you a question about like some old guy and this old guy has like chronic diarrhea and has all these cardiac problems and then they tell you that oh they decide to perform a eGD with biopsy and then they notice that oh wow on on histology they see like rounded v-lye in the small intestine and they notice a ps positive micro-figures that's very high you know ps positive micro-figures or the tell you that they see foamy micro-figures if you see this you want to think about we pose disease right want to think about we pose disease remember we pose disease it's caused by a bug known as a troferema we apply right it's caused by a bug known as troferema we apply right troferema we apply and this is actually one of those bugs that stands positive with silver remember each binary is also silver steam positive till we apply is also silver steam positive and then there's one more bug come on divine Legionella is also silver steam positive right Legionella is also silver steam positive and you must see this is your vetsis is also silver steam positive just again something to keep in mind right so again we pose disease these people usually have like endocraditis right they can have like cardiac symptoms like endocraditis myocarditis perioditis it also tends to cause like joint problems or so these people have a lot of astrologers many times in further early in disease that's where they have this problem and then they also tend to have like neurologic problems right they can have like seizures they can have dementia right they can have all these like visual things where where they have like these s

pasms of the ocular muscles right and again they have chronic diarrhea that's very high you'll to keep in mind for for your exam right and again these people many times they also have like skin hyperpigmentation you may try to trick you into thinking that this is adhesives disease but again this will be in an old guy right and many times for some reason these people have like my absorption of vitamin D right so they actually get like a secondary hyperparaparitis as a result of this right you tend to get secondary hyperparaparitis right again don't forget those ps positive foamy macrophages that's very high you'll to keep in mind for exams right and again the way we treat these people on exams right we're gonna give them self-traxone for you know for about two weeks right you're going to memorize the duration and then after that we're also gonna give them like back treatment from self-traumatopolisis all for a whole year if these people are not consistent with therapy the bug will not be eradicated right so these are people that is almost like treating TB right you need like very long term therapy to completely eradicate this organism so I think I'm gonna go ahead and stop here as I do at the end of every podcast again I I have these podcasts on Apple Podcasts on Spotify on Google podcasts so if that's if that's a part if you use one of those podcast appa modalities the most 1,150 podcasts will be will be right on there and then it's a Word Press role if you want to hold the podcast from my episode one to I guess episode 318 which is this podcast and you need to go to the website and then I have a You Tube channel divine intervention usmly podcast and videos that's why I post my videos and but although if you want the slides that I associate the many of my videos again go on the website and just look on the specific episode and you'll find that right there and then I'll

offer one to learn from any exams step one step to CK step three pre-clear informets call exams 30 a shelf exams but again the major thing I offer these these are the the USML review courses for step to CK step three and the MBME testing in strategies course I'm gonna be afraid of step one review is gonna be coming up soon I'm gonna make an announcement on that soon because again my schedule has just got in extremely busy so meeting one on one with people is vastly limited for me for me these these so thank you for listening to the podcast I do hope that you find it to be helpful and I want to share a quick life lesson today and one quick life lesson I want to speak to today is dealing with despair right so dealing with despair so what is despair despair is I mean spelled D.E.S P.A.I.R despair is something that a person faces when like a really bad circumstance happens to them right so say for example a person has just failed an exam let's say you've again because I know that a lot of my audience medical students are people involved in health care right so let's say a person has just filled a USML exam or a block exam or a shelf exam right well it's just lost a loved one those things can all cause that feeling of despair right so the thing is when you're going through despair what what what happens in those circumstances right you feel terrible you feel awful you feel like there's no point left to live on this earth you feel like there's nothing you can do with your life you feel like everyone that you cannot go forward right just a lot of negative thoughts kind of hit your mind right but the thing is many people have gone through despair and the thing is like every situation in life you can either deal with that situation constructively or you can deal with that situation or destructively right so let's talk about some ways of dealing with despair the first thing I w

ould say is a very first and I'll say at least from my own perspective again many of you listen to those podcasts you can probably surmise that I'm a Christian one of the first things I always encourage people to do or I do myself is to just pray literally just pray about it right I mean there's this part of the bible that says that you know be anxious for nothing like literally don't let anything make you anxious be anxious for nothing I think it's in the book of Philippians chapter four be anxious for nothing either Philippians three or Philippians four so it says you know be anxious for nothing but in everything with prayer and supplication with things given make a request to go on to God right so you know I just love that attitude of praying it just really really helps in those circumstances always have this peace of mind after of prayer now what are some other things you can do don't isolate yourself do not isolate yourself many times when people are going through despair they want to isolate themselves they want to sit in bed close their doors don't talk to any of their friends I'm telling you when you isolate yourself you're setting yourself off a failure right because sometimes it's in people like I mean like how many people have used in commits suicide in a public environment no most times when people commit suicide they do it in a very private space right so don't isolate yourself right reach out to people that are trustworthy right again obviously it's not everyone you reach out to because some people are not very helpful right so reach out to someone trustworthy and just pour out your heart to them right pour out your heart to these people do not isolate yourself when you're facing despair because again you're not in control of your thoughts and a person that is not in control of your thoughts is not going to be in control of your actions right so again do

not isolate yourself do not isolate yourself right I'm not saying put everything out on Facebook on Twitter and everything no right but do not isolate yourself and then the third thing that I tell people is a constructive way to get out of the spirit is to then ask yourself what went wrong what went wrong was there something wrong about the way I studied for this exam because again I feel like you can lie to everybody but the person you really should like I don't encourage people to lie you shouldn't lie right but you can let me put it this way you can deceive people but you cannot deceive yourself right you know where you messed it you know where you got into problems right just be honest with yourself right this is part of the Bible that says let everyone examine himself literally examine yourself ask yourself where did I miss it in this process did I not study long enough did I not use the right materials was I jumping from material to right just have an honest evaluation of yourself right take stock of what you did so you don't make the same mistake again and then come up with an action plan use that as motivation to succeed on the next try right because to be honest with you right like for example like last night after I watched the liquor game that he lost and you know they were knocked out of the first 100 of the playoffs I felt really really sad like extremely sad last night again it doesn't compare to a person don't get me wrong this literally doesn't compare to to a person I feel in the US Emily exam or losing a lot of wine I'm just giving an example from my life right but like a recent example I can think of I felt like very sad very despondent last night right but again at the end of the day right like you can use this as you can say okay you know what like is is this a good situation no right you know injuries kind of knocked them down and all those thin

gs although that's no excuse they also plead played out pretty pretty terribly but the thing that for me is like oh you know what is that of having this despair let me be thankful that oh we won a championship last year that's actually another strategy for dealing with despair just be thankful for what you have be thankful for what has been done for you in the past right so I'm like oh you know I'm grateful last year won a championship oh wow I'm grateful that we have a good call group of players you know even if we need to do all these offseason moves but you know if we get in like good shooters a good third star we can probably do a lot of damage next year I mean this you know the season starting this year right and then I'm like oh you know what this is also an opportunity for people to rest and recover right because again people have just been banged up a lot of injuries if you notice the things I'm focusing on I'm not focusing on the championship we just lost I'm focusing on the positive things that have happened and the positive things that can happen in the future right many things in life is just about perspective right like looking ahead to the future looking ahead to a brighter future looking ahead to the positives right the thing you focus on would determine what your demeanor in life will be if you're focused on all the negatives you're gonna get a lot of negativity but if you're focused on positives you can get a lot of positivity right so again these are just all things you can keep in mind and you know I'm like you know what and you find a team that I want to cheer for with the rest of these playoffs right and kind of moving from there so you know just these are just all constructive tips for dealing with dealing with despair so again hopefully you found this to be helpful I'll see you in the next episode thank you and God bless you

Miniature disease (or Protein-losing enteropathy).

Low peripheral protein/serum protein ratio (<0.5), low peripheral LDH/serum LDH ratio (<0.6), and pleural fluid LDH < 2/3 upper limit of normal serum LDH.

Epithelial lymphocytosis (lymphocytes within the epithelial tissue).

Megaloblastic anemia, low intrinsic factor production, and involvement of the body of the stomach (Type A gastritis).

Diphyllobothrium latum (fish tape worm).

At least two of three systems working: Dorsal columns, vision, and Cranial nerve VIII (vestibular/cochlear).

Decreased plasma oncotic pressure or increased hydrostatic pressure.

Destruction of parietal cells leads to loss of intrinsic factor (IF), which is necessary for B12 absorption in the terminal ileum.

A "watermelon appearance" due to dilated, bleeding vessels.

Symptoms are temporarily associated with food intake, but there are usually no significant lab abnormalities (e.g., iron or vitamin deficiencies).

Celiac disease involves villous atrophy and lymphocytosis; Tropical sprue occurs after travel to specific regions and often spares the terminal ileum.

Vitamin B12 and fat-soluble vitamins (A, D, E, K).

Foamy macrophages seen with a positive silver stain.

Decreased plasma oncotic pressure or increased hydrostatic pressure.

Destruction of parietal cells leads to loss of intrinsic factor (IF), which is necessary for B12 absorption in the terminal ileum.

A "watermelon appearance" due to dilated, bleeding vessels.

Symptoms are temporarily associated with food intake, but there are usually no significant lab abnormalities (e.g., iron or vitamin deficiencies).

Celiac disease involves villous atrophy and lymphocytosis; Tropical sprue occurs after travel to specific regions and often spares the terminal ileum.

Vitamin B12 and fat-soluble vitamins (A, D, E, K).

Foamy macrophages seen with a positive silver stain.