DIP Episode 660 - USMLE Step 2/3 Rapid Review Series 139 (Super HY Stuff)

All right, welcome. My name is divine. This is episode 660 of the divine intervention podcasts and into this podcast We're gonna be continuing our rapid review series for the US Emily step 2 CK and step 3 exams This is actually gonna be series our 139 I believe all right So what if they give you a question about a 31 year old female and you're told that she's a gravitor 2 par 1 And she's at 20 weeks just nation and then she'd tell you that She has reported you know decreased fetal movement for the past two days and that you know You're then told in the queue stem that in the office A Doppler ultrasound is done and it does not detect fetal heart tones Right and then they tell you that hey, you know, so you do an ultrasound Autosanography you don't see any cardiac activity with the fetus and Then they ask you which of the phone is the most appropriate next step in management I'd really hope that you're choosing an answer that talks about Evacuation of the fetus right Because one thing that can certainly happen after an intrauterine fetal demise is Is DIC right that is something that we're really really worried about right?

So obviously maybe if you see an answer that talks about empathizing with the patient that's something you want to do first But the thing is after you empathize with the patient you need to start making some kind of plan for evacuating that fetus Right because the thing is whenever fetal tissue begins to die, you know, you have like an acotic fetal tissue Necrotic placental tissue right the thing is it That an acotic tissue starts producing tissue factor right thromboplast in tissue factor Right and that tissue factor is going to enter the circulation of mom is going to activate the coagulation cascade Right and the thing is as it Activates the coagulation cascade right you're going to consume up your clotting factors your platelets Right, so you're gonna have a consumption quagulopathy you're gonna have DIC the person is gonna start bleeding right in fact on your exams If they give you a question about this person like a few days later beginning to have like nosebleeds and all those things That person has gone into DIC right and sometimes they can even give you an arrow question You know they can make something like this a two-part question where there's the intrauterine fetal demise in the first part of the question And then the second part of the question is an arrow question where the woman comes back You know she she didn't come back to the physician and then she's brought to the emergency room being very high-potensive Bleeding from the nose and whatnot and then they can make an arrow question from the second part and they will say oh which of the following best represents The lab findings that will be seen in this patient well on your exams You you want to pick the answer choice where the person's a PT And you know the the person's PT and PT televated the platelet counties decrease the D dimers elevated right and the Fibrino gene is reduced right so I'm gonna say that again right so because again.

This is basically DIC right so the person's PT and PT T will be elevated right because you've used up many of your clotting factors Your platelet can't be down because you've used up many of your platelets your D dimer will be up because you're making a ton of those and your Fibrino gene will be down right and fact sometimes on the USM The exams they will ask you which of the following is the most sensitive most sensitive lab measure in DIC Actually going to be fibrenogen you're gonna see a decrease in fibrenogen in a person that has a DIC now I just said that oh Thromboplasty that is released so that's tissue factor that is released from an ecotic fetal or placental tissue is the thing that's causing the problem here What other association I want you to kind of lock into your mind with Thromboplasty no tissue factor being released is gonna be in a person that has Emile acute pro myocytic leukemia remember many times that's gonna be a my lord malignancy That is associated with a person potentially having DIC or the thing is those blast cells in Emile remember 15 17 translocation right those things can release tissue factor and that tissue factor can trigger the Coagulation cascade right that tissue factor can trigger the Coagulation cascade right so that's pretty high you to know for your for your exams all right now What if they give you a question about a 27 year old woman, you know, she's a gravity a three-power one about a one right She's a 22-weeks gestation and they tell you that hey an intrauterine fetal demysis diagnosed an ultrasound right?

You know because she's had a you know absent fetal movement for a few days right and then they tell you that on Otter's sonography you notice overlapping fetal skull bones overlap overlapping fetal skull bones right overlapping fetal skull bones The thing is they can actually make a basic science question out of this and ask like was the most likely mechanism Behind this find it right was the most likely mechanism behind this finding well the thing is if you see overlapping Fiddle cranial bones on otter sonography Then it pretty much tells us that we have like some kind of Equifaction necrosis that has gone on in the fetus right some kind of liquid fraction necrosis right again guys The fact that you're taking step two and step three does not mean that basic science magically disappears Right this is one of those weird things that you find in almost no resource But is very very high you to know for your exams right so you see overlapping fetal cranial bones on otter sonography It means that the baby is dead right means that the baby is dead right there's liquid fraction necrosis liquid fraction of the brain that has basically happened After fetal death right in fact many times that tells you that we this baby has been dead for a long time This baby has been dead for a long time right and then they will ask you which of the following is the most appropriate next step in management Go ahead and do and a D&E pick the D&E answer right do a dilution and evacuation answer right do a dilution and evacuation answer Right now one thing I'm gonna say on the for us mainly purposes with fetal demises I strongly encourage you to not pick a C section as an answer Okay, whenever there is an intrauterine fetal demise whenever there is an intrauterine fetal demise I strongly encourage you pick the answer that talks about some kind of vaginal delivery of some sort right Induced labor r

ight do a dilution and evacuation right or you can do a medical induction right give the woman misoprostal to Right in the cervix to induce labor right those things are acceptable So either answer of like medical induction of labor with misoprostal and then Libra induction delivery of the fetus that's fine or you can do a dilution and evacuation That's fine.

Please for intrauterine fetal demise do not do a C section on your exams I'm gonna say that again do not do a C section on your exams is not recommended right because the thing is You're just giving mom an unacceptable surgical risk right and there's no feed-out benefit the babies already dead Right the babies already dead the babies already dead right so keep that at the back of your mind for your for your exams Right and the thing is sometimes again They can make a two-part question of these and ask oh which of the four is the most appropriate next step in management Right the thing is there is a bunch of things actually that you may want to keep in mind here right so like for example They may want you to do like Some kind of autopsy of the fetus right because it's like wait Why did this fetus die like what in the world happened right so you want to do some kind of autopsy You may want to do some kind of pathology pathological examination of the placenta right just to see like hey Was they your placenta in sufficientcy or anything along those lines right so keep that in mind Keep that in mind for your for your for your exams all right Now what if they give you a question about a 34 year old woman, you know the tell you that hey She has had a you know two previous unexplained pregnancy losses You know let's say the first one was at eight weeks second was at 22 weeks right and they tell you that the fetus was morphologically normal especially for the 22-week a Fiddle loss right and they tell you that hey She's presenting for a first prenatal visit that a last menstrual period was 10 weeks ago Right and they tell you that oh they do a work-op right and the notice that our PT's is prolonged An alluposantic wagulant is also positive right What if you see something like this?

What should you be thinking about you're like me and the van you're talking about Insure you don't feel the mice a lot well the reason I'm talking about is that seems to be a thing that it kind of seemed to like Quite a bit these days on the exams So if you see this what are you thinking about well? I would really hope you're saying divine I think this person has antifusophilipid syndrome antifusophilipid syndrome right APS APS right APS right Right so remember what are the diagnostic criteria actually for APS for antifusophilipid syndrome? Typically you're gonna notice, you know positive antibodies, you know on two occasions usually about 12 weeks apart What are these classic positive antibodies you may see on your test? You may see these anti-cardiolipin antibodies, right and you can also see these Lupus antifusophilipid syndrome antibodies sometimes you can also see the anti-beta to glycoprotein antibodies, right? So you're gonna see these positive antibodies two occasions like 12 weeks apart, right? And you're gonna see like a lot of unexplained fetal losses right whenever you see something like this Think of a person that has antifusophilipid syndrome, right? And then they will see which of the following interventions will most likely decrease the risk of this person having adverse outcomes with pregnancy Well, I was strongly encouraging to pick the answer that talks about low dose aspirin low dose aspirin, right?

So that person should get low dose aspirin and the person should get a low molecular with hipring, right? Throughout pregnancy low dose aspirin low molecular with hipring throughout pregnancy, right and up to About six weeks postpartum right up to six weeks postpartum One of the ways they're gonna try to get you a question like this is they will give you an answer choice that talks about 325 milligrams of aspirin. Don't do that, right? That's what we give for people that have my accredited infarctions Lodos aspirin is 81 milligrams of aspirin, right? And then this person should get low molecular with hipring They should just get you throughout throughout pregnancy, right? And up to about you know six six to twelve weeks a post postpartum, right? six to twelve weeks postpartum, right? And sometimes on your exams they can actually integrate a pharmacology question with this and just Basically try to see if you remember from a ecology from step one, right? Like it's like hey, they can say which of the full Invest explains how the the administration of you know, heprin will improve this person's maternal maternal fetal outcomes. Well, they will give you an answer that talks about Inhibition of factor two and factor ten, right? Or inhibition of thrombin and factor ten activity, right? Because again, that's what heprin does remember heprin is an activity of anti thrombin three, right? And it's going to basically prevent placentor thrombosis is going to improve profusion, right?

But again, supercharging anti thrombin three so that you inhibit factors two and factor ten inhibit factors two and factor ten, right? So again, they can give you which of the following Most likely explains the beneficial effect of heprin on maternal fetal outcomes in this person Big the answer that talks about preventing a placentor thrombosis, right? Because again of its anti-coagulant effect Or they can even say improves placentor profusion, right? Because again, if thrombosis doesn't happen profusion is going to be better, right? Or they can even You know, just give you something about like aspirin, right? So again, make sure you know the mechanisms of actions of the common drugs remember aspirin is an irreversible Cox one and Cox to inhibitor, right? Cox one and Cox to inhibitor, right? Now remember one thing I want to say here One answer they can give you to try to trip you up is to give a warframe don't give warframe while a person is pregnant Don't don't do that right? That'll be a terrible idea why because remember warframe can literally cross the placenta And it's a terrarogen is a terrarogen especially in the first trimester, right? It can cause a very very nasty Embryopathy, right? So don't do that right? And it can even cause hemorrhage with the with the fetus, right? Lomo lechula with heprin. It doesn't cross the placenta. So it's not gonna cause any problems Warframe does cross the placenta, right?

It can cause a lot of it can cause a lot of problems Okay, it can cause a lot of problems, right? Now one other thing that also people try to tend to fall for on these exams. I don't know what is really getting me down this rabbit hole today But one thing that many people tend to fall for on the exams is that oh This person has antifus fully bit say this person's pt is prolonged They cannot have a hyperacoragulable disease and no you want to be actually really careful with that right? So the thing is people that have Antifus fully bit syndrome right? It's kind of strange. They are hyperacoragulable, right? But their pt may be prolonged the pt may be prolonged. Okay? The pt may be prolonged, right? It's a hyperacoragulable disease, but the labs look like they're heavily anti-cogulated, right? So it's just something you want to keep at the back of your mind for for example Something you certainly want to keep at the back of your mind for exams. All right now What if they give you a question about a patient? And you're told that this patient is a 67 year old male, right? He has a decompensated cirrhosis, right? And you're told that his ejection fraction is 30 percent You know, you know, they tell you that he has a pass, you know, he has had a Ischemic cardiomyopathy has had an MRI like a few years ago, right?

His ejection fraction is 30 percent and you're told that he he's been admitted to the hospital with You know with tens of studies and has he has been requiring like weekly paracentices, right? And then they tell you that the patient, you know, has you know has another friend with cirrhosis That has also also gets paracentices with him and you know, they tell you that the patient you know says that he's his friend has got in a Tips procedure, right? Transjogula intraeparica porosystemics shown procedure, right? And he has that hey that you know, I keep having this you know, paracentices every week. Is there anything I can do, right? Can I can I get this tips procedure and then they'll ask you which of the following is the most appropriate next step in in management, right? The thing is for for this the the key point I want to get at here is this, right? If you have heart failure, you absolutely cannot do a tips procedure, right? You absolutely cannot do a tips procedure if you have severe heart failure if your ejection fraction is terrible, right? And this is something that for whatever bizarre reason many resources don't cover, but it's actually very very high you to know for your Exams, right? So you may ask yourself like divine this doesn't make any sense to me. Why is it that if a person has severe heart failure a tips procedure is contraindicated? Well, let me let me break it down.

Well think about this literally what does a tips procedure do literally look at the name transjogula intraeparic porosystemic shunt transjogula intraeparic porosystemic shunt. What does he do? The thing is it pretty much bypasses your liver It literally bypasses your liver, right? So essentially the thing you're doing is you redirected a large volume of Blood from your porosystem directly to the systemic venous circulation where you're pretty much bypassing the liver and getting that blood almost right into the IVC, right? The thing is what do you think that's going to do to your cardiac preload? Ooh, that's going to cause a pretty huge rise in your cardiac preload, right? And the thing is if you have a bad heart that cannot pump that Blood very well, right? That large rise in preload, right? When you have reduced systolic function because of the heart failure, right? You cannot accommodate this increase in venous return, right? So you're going to literally precipitate a CHF exacerbation in this patient You can precipitate a CHF exacerbation in this patient. This is something they love to do on the exams Right? This is something they love to do on the exams Right? So you see a person that gets a tips procedure and then the person has like just very very nasty pulmonary dima afterwards Right? It's going to be a cardiogenic pulmonary dima the PCWP the pulmonary capillary wedge pressure Which is a surrogate for left heart pressure.

It's going to be it's going to be 18 or greater on your test Why? Because again, the person has like nasty nasty pulmonary dima you pretty much have induced a CHF exacerbation by way of the by way of the Of the Tips procedure that you that you did right? So that's something that's pretty high you to know for your test Another contraindication you may actually see on your test With regards to tips procedures is if a person has like really bad Porn air hypertension right? So like if for example your pulmonary artery pressures are like greater than 45 Millimeters of mercury you absolutely positively should not do a tips procedure because again It causes a large rise in preload and if you have pulmonary hypertension the right side of your heart is not going to be able to handle that Problem right and also if you have like severe hepatic and cephalopathy right if you have severe hepatic and cephalopathy Then you also should not do a tips procedure right because again remember a tips procedure is going to raise your risk Is going to raise your risk for hepatic and cephalopathy you're gonna be like wait divine Why would a tips procedure raise my risk of hepatic and cephalopathy again tips procedures divert Porto blood they literally divert portal blood remember the blood in your going through your portal system What do you think it's rich in that blood is super rich in ammonia?

That blood is super rich in neurotoxins from your god remember all routes from your GI track lead to your portal system Right and remember you know your your your GI flora can produce ammonia right that can cause problems They can produce nitrogenous compounds that can cause problems right? So the thing is blood that is in your portal circulation is very rich in ammonia is very rich in You know like neurotoxins from your GI flora right your liver plays a very important role in detoxifying those things But if you're bypassing the liver you're bypassing the urea cycle you're bypassing your cytochrome p450 system You're pretty much putting all those toxic things directly into the systemic circulation You're bypassing hepatic metabolism. What do you think is gonna happen? Well that thing is gonna go to the right side of the heart Go through your pulmonary vessels go to the left side of the heart and then go to your brain It's gonna get pumped to the brain right and those high high ammonia levels that's gonna be a problem right And by the way How you gonna manage this person say panic and cephalopathy right if they develop it from a tips procedure Well give them lactulose give them lactulose What in the world does lactulose do lactulose is going to acidify your colon It's gonna acidify your colon because it's converted by your GI flora to lactic acid right? So it's gonna basically trap ammonia within your GI tract right?

It's gonna trap you within the GI tract right that ammonia the hydrogen ions are gonna bind to it You're gonna form ammonia am right and that's gonna reduce the absorption of that ammonia right? You can also give refaximin you can also give refaximin right? Refaximin is more second-line though. What exactly does refaximin do? Remember refaximin is a non-reabsorbable antibiotic refaximin is what it's a non-reabsorbable antibiotic right? It pretty much kills off your gut bacteria that produce ammonia right and that's gonna be very very helpful for For reducing that ammonia loot that is causing the hepatic and cephalopathy Okay, that's causing the hepatic and cephalopathy Okay, so please again keep this at the back of your mind as you're prepping for your exams Be keep this at the back of your mind as you're prepping for your exams Don't forget these associations with tips procedures right again tips procedures. What are the classic times? We're gonna do a tips procedure on your exams You're gonna do a tips procedure When a person just has very refractory assidies right? You know, you've tried like a lot of diariesis you've tried a lot of parasentices Right and the person just keeps having a recurring asides recurring asides Right?

So the person is like getting like parasentices like more than twice a month Whenever a person is getting parasentices more than twice a month You really need to strongly consider that that person should maybe go ahead and get a tips procedure And also if a person has a sovajil varicies that are bleeding right and it has been On-responsive to endoscopic therapy the person has not improved with eGD therapy Then you really really want to consider doing a tips procedure in that person as well But again, don't forget the complication don't forget the complication hepatic and cephalopathy And don't forget the contraindications right severe pulmonary hypertension right severe heart failure and things like that Again guys the usml is with all their pull changes and all those things These are things they like to go after on the exams right these are things Absolutely like to go after on the exams make sure you know the stuff and make sure you know it pretty well for your for your test Make sure you know the stuff and make sure you really pretty pretty well for your test right now Last time I'm gonna address today.

So what if they give you a question about a 29 year old guy And you're told that he's a type 1 diabetic right and you're told that he's on you know He's on a gladgian and he's on Lisbon remember gladgian is the long-actin insulin Lisbon is the rapid-actin insulin you get with meals right so you know Detail you that this patient you know calls the physicians office or comes him for a primary care visit right because the person has a Febraal you are right, you know And he tells you that he's been nauseous. He's not being eating right and he tell you that in the office his finger stick blood glucose is 310 milligrams per desolid right and They're asking you for appropriate the which of the fully represents the most operator recommendation to this patient in terms of Insulin management right and they'll give you an answer choice that says to discontinue insulin completely Don't do that. Don't do that in fact this infection this person has and the fact that the person is a type 1 diabetic Right that can trigger a decay.

You don't want to do that right So they cannot ask you like which of the fully is the most operator recommendation right the most operator recommendation You want to pick on your exams is to continue their basil insulin right continue their basil insulin right continue their insulin Glargine remember you all the basil insulin is missing your exams right dead amir right to DETEM IR or degludeck D E G L U D E C right degludeck so insulin glargine dead amir degludeck right so the thing is if a person is not eating if they're not having meals At least they should consider their they should continue their basil insulin regimens They are long-actin insulin regimens like glargine dead amir or degludeck right now If this person is not eating you should hold their meal time insulin They should not keep taking this pro when they are not having meals right again Those are rapid-acting insulin that you take with your meals right you don't want to tank that The person's glucose are precipitously and cause a hypoglycemic crisis right and you should also tell the person that they should also monitor their glucose They're quite quite frequently right so please guys don't stop insulin in a type 1 diabetic if they're not eating at least continue Their basil insulin right at least continue their basil insulin right because the thing is your type 1 diabetic insulin is is a life requirement is literally a life requirement even if you're not eating you need that insulin you need that insulin right because again The thing is when a person is ill that's a metabolic stress is gonna trigger a counter regulatory hormones What do you count counter regulatory hormones you need to know for your test?

What is all which other one? Glucogan which other one? Epinephrine right those things can raise blood glucose right those things can increase Keyton production they can cause lipolises right so stopping insulin is just a nice way to basically like welcome the patient to DKA because those counter regulatory hormones they're holding sway because the person has Because the person has an has an illness the person has an illness right so keep this at the back of your mind for your for your exams Keep this at the back of your mind for your exams many times infection In a type 1 diabetic is one thing that does trigger DKA all right So I'm gonna go ahead and stop here again. Hopefully you found this podcast to be helpful If you love the way I teach you love the way I make integrations you're gonna love my classes right so in the month of july I have a I have a You know have a test date so first step on all the way to step three I have a two and a half hour test taking class Four hour biostatistics class and a five hour social sciences quality improvement on ethics class again Many people have taken these classes and they found it to be extremely helpful right and then first step two for step three specifically I have a CCS key C's class That's also coming up in the month of july and then for step two and step three I do have a last mini review for step three and step two and step three It's a three hour class.

I have a 20 hour class for step two and step three and then I have a 50 hour class coming up in the month of December It's a 600 multiple choice question class that I'm gonna be going over In the month of December the first 10 days of December so of this year So they are very limited spots available for that if you're interested Shoot me an email and can give you some more information I also offer one on one to learn for all the US Emily and complex exams and then I also help with Eras applications Mox interviews personal statements and things of that nature right and then these podcasts are on Apple Google and Spotify so check those out I also have a youtube channel divine intervention US Emily podcast and videos where I post the videos that I make and then finally Another thing that also have is another website called a divine intervention life lessons.com Divine intervention life lessons.com, you know Many of you know my christ follower so every week I post like one or two podcasts where from a biblical perspective I do address a life lesson There's actually an Apple podcast associated with that called the divine intervention life lessons podcast So thank you for listening to me today again.

If you love the way I teach I think you're really going to love my classes my classes are not just like me giving definitions No, they're all based on clinical scenarios and problems that we walk through and then you're going to truly understand The physiology and how things apply on the US Emily exams. All right, so thank you for seeing me today I will see you God willing in the next podcast have a wonderful day. God bless you and bye for now. Thank you

The release of thromboplastin/tissue factor from necrotic fetal or placental tissue activates the coagulation cascade.

Fibrinogen (it will be decreased).

Severe heart failure (low EF) and severe pulmonary hypertension.

Liquefaction necrosis of the brain tissue after fetal death.

Lactulose (acidifies colon, trapping ammonia) and Rifaximin (non-reabsorbable antibiotic).

The basal (long-acting) insulin.

Anti-cardiolipin antibodies, Lupus anti-PS antibodies, and Anti-$\beta_2$-glycoprotein antibodies.

It acts as an anti-thrombin III, inhibiting Factor II and Factor X.

The procedure causes a massive increase in venous return/preload, which the failing heart cannot accommodate, precipitating acute CHF exacerbation.

Low dose (81 mg) is used for prophylaxis; high dose (325 mg) is typically reserved for acute coronary syndromes.

PT/aPTT elevated, Platelets decreased, D-dimer elevated, Fibrinogen reduced.

The liver normally detoxifies ammonia and neurotoxins via the urea cycle; bypassing it dumps these toxins directly into systemic circulation.

Anti-cardiolipin antibodies, Lupus anti-PS antibodies, and Anti-$\beta_2$-glycoprotein antibodies.

It acts as an anti-thrombin III, inhibiting Factor II and Factor X.

The procedure causes a massive increase in venous return/preload, which the failing heart cannot accommodate, precipitating acute CHF exacerbation.

Low dose (81 mg) is used for prophylaxis; high dose (325 mg) is typically reserved for acute coronary syndromes.

PT/aPTT elevated, Platelets decreased, D-dimer elevated, Fibrinogen reduced.

The liver normally detoxifies ammonia and neurotoxins via the urea cycle; bypassing it dumps these toxins directly into systemic circulation.