DIP Episode 159 - USMLE Step 2CK Rapid Review Series 18 (IM)

Welcome. My name is Divine. I am a resident. This is a episode I believe 159 of the Divine Intervention Podcasts. And I will continue the rapid review series for the USMELIS.com 2 CK exam. This will be an internal medicine focus podcast. I would love to make more podcasts than I do on a daily basis. It is literally time is my big limited factor. Okay, let's just jump right into it. What if you get a question? The thing is I try to write a few or at least mentally come with a few vignettes. USMELIS style vignettes. So I'll read them out, read the answer, talk through, mentioned throughout some answer choices there and then we'll talk about the answer choices. What if you get a question about like a 65 year old male comes to the PCCP, has a 2 week history of hematuria and then other than like an unintentional 20 pound width loss over the last 3 months, he has no other complaints. He worked in a sheep year for 20 years as a plumber before retiring 5 years ago. His physical exam is unremarkable. He has no evidence of super pubic pain or pressure. He is prostate, he is smooth and non tender on digital until exam. His medical history is notable for granulomatosis with polyangitis which has been well controlled with appropriate medications. And then he smoked 2 cigarettes every day over a 1 month period while studying abroad in China 49 years ago. Eukationally has a glass of wine with dinner.

Your analysis is positive for gross hematuria but negative for nitrites, leukocyte histories and dysmorphic red blood cells. What is the most significant risk factor for this patient's presenting symptoms? So what is the most significant risk factor for this patient's presenting symptoms? So the first answer choice we have a guppitional history. Second one is history of smoking. Third one, let's call it history of alcohol abuse. Fourth one, let's call it medication exposure. And then fifth one, let's call it prostate malignancy. So first option of guppitional history, option B, history of smoking, option C, history of alcohol abuse, option D, medication exposure, option E, prostate malignancy. So the right answer here is actually medication exposure. So I can already imagine like some polysensors broadcasts already throwing their arms up like, oh, divine weight. What's going on here? So first thing is first, right? This person likely, I mean, again, I told you for every MD me question, what is the first thing you should always do? Should always make a diagnosis, right? So the diagnosis here, right, is bladder cancer. This person's got bladder cancer. And I'm sure you've probably listened to some passport cast I made where he said, oh, what is the biggest risk factor for bladder cancer? I said, ooh, smoking. But now I'm asking, I'm seeing medication exposure, right? So, but think about it, right? This guy has smoked two cigarettes every day for a month.

And this was like 49 years ago in China. Does that sound like smoking will be the most, again, that's why again, you can't just memorize facts on USMELY exams, right? You also, again, have to like actually like understand the context of the question. That's kind of important, right? So this person, right, has a history of Wigners, right? So like Granolomatosis, Ripoli, Angiitis. And remember that that is usually actually treated with steroids and cyclophosphamide, right? So remember that cyclophosphamide actually can is a risk factor. It's actually a fairly significant risk factor for the future development of bladder cancer, right? And remember, I mean, cyclophosphamide in and of itself can injure the bladder. Although you can kind of prevent, it can cause like hemorrhagic studies, you can prevent that by, you know, giving mesma because you'll bind up the acrolyne, mastia, byproduct. And you also want to do, you know, very vigorous hydration. And again, like I said, smoking is the biggest risk factor for the development of bladder cancer. But the person smoking history is too limited, it's too remote, can be, it cannot be bladder. That he's smoking cannot be the reason he's developed a bladder cancer, right? And then remember that your next step, essentially in evolution of this patient, where you want to make sure you know, get a cystoscopy of biopsy. And also don't forget that she's to swim in hematobium, right? So if you talk about a person from Egypt or whatever, right?

She's to swim in hematobium. That's also a risk factor for bladder cancer. And again, classic presentation of bladder cancer, right? Like hematuria, we're literally seeing like playing like not like the smurfing red blood cells or any of that crap. You're seeing like literally like literal red blood cells in a person's urine. So like rebut hematuria, new onset varicoseol in like a long-term smoker. And then maybe they give you, yeah, like new onset varicoseol long-term smoker. They will just, in fact, let me take a step back. If you see, if you see, let me put it this way so I don't confuse myself. So let me check back a little. So if you see hematuria, long history of smoking, right? And you didn't mention anything like a flank mass or anything like that. You're likely to be doing bladder cancer. But if you see like hematuria, or you see like a new onset varicoseol in like a long-term smoker. And let's say this smoker has like a flank mass. You're probably thinking about like renal cell carcinoma, right? And I remember one of the most common types is the clear cell type, right? And one high yield thing, one of not about renal cell carcinoma is you don't buy up serious cell carcinoma. You just do an effect to me and that's it. Kind of like testicular cancer, right? Those genome allegiances in general. Especially for like renal cell carcinoma, testicular cancers. Usually not a good idea to buy up those things so that you don't see the cancer.

And remember RCC has a strong association with a polycyphemia, right? Because EPO can be produced like every throat-boating can be produced in a primary or plastic fashion. Now what if you get a question about like a 23-year-old female, you know, she comes to the ED, she has like some roommates that are concerned because they've noticed that yeah, over the last two weeks, have behavior has changed completely, right? And then they tell you that oh over the last week she has been working on multiple projects that she says, oh, these projects will cure world poverty, right? And then they tell you that she sleeps less than to us every day, but she has like insatiable energy to like she can like she's like like energize the body, can go through the whole day even with to us of sleep. And then they tell you that oh, let's say like you have like you know you're assigned a metasturant to interview this patient. And the metasturant is finding it difficult to get in any work during the interview, right? And then they say you know before these behavioral changes started, this person was actually like, she was a street student, she was a barista at Starbucks, and she recently like studied dating like a new boyfriend. And then they tell you that you know you get a urine toxicology screen, it's negative, you check blood alcohol levels, they're all within normal limits.

Now this question then says, so let's assume the endemic question then says, in addition to beginning, dival prox therapy, right? So like, viproec acid, what is the next best step in the management of this patient, right? And then let's say option A says urine pregnancy test, option B says reassurance, option C says sexually in therapy, and option D says, I don't know, I'm throwing clasping, how why not? So clasping therapy, right? So hopefully you may see it define this is a psych question, what's going on here? I think you, right? Again, first thing, you need to realize that the MDME, they can make, they love to integrate things, so they can give you a question that is seemingly a psych question, but it's really for the most part of medicine question. That's kind of like my thought process with this one, right? So this person, if again, if you're making a diagnosis, this person's got bipolar disorder, right? This person's got bipolar disorder, right? So the right answer here should actually be to get a urine pregnancy test, right? Because remember, viproec acid is super heterogenic, right? So you definitely want to make sure that you get a UPD, and you also want to make sure that you check their liver laps, because for pre-cases like, hipato toxic, and it's actually kind of high you to know some key drug associations with like some patient populations, right? So like for example, isotretinoin, right?

You should only study it after, again, you obtain the pregnancy test, and you've confirmed that the person has like two types of birth control on board. Lithium, remember, lithium can cause Epstein's anomaly, right? To remember where you have like, itchialization of the right ventricle. In fact, for the most part, if a person has bipolar disorder in pregnancy, you can actually, if I'm not mistaken, the first line these days is the first line medication, these days is hollow peridol, the liver or not. And then, again, remember, for woman is over 35, and she smokes, or she has like, you know, significant initial, like thrombone and bollic disease. So let's say like, she has like a priori-hissio-dvt, you cannot give the woman a combined dose of CP. So I remember, if you get like a guardian variety, okay, I shouldn't use that term, but if you just have a female that is reproductive, age and has hypertension, the most likely cause of hypertension in that female, again, especially if she doesn't have significant risk factors, is likely going to be her use of combined dose of C Ps, right? And again, remember, ACE inhibitors, AR Bs, you don't want to use those in pregnancy. And remember that ACE inhibitors, right? If a person has a risk of like, bilateral renal otter stenosis, or has hereditriandroidema, right? It's where you have like a C1 estri, inhibitor, efficiency, you can give ACE inhibitors. So you may see divine, why is that? Well, think about it, right?

For a person who has bilateral renal otter stenosis, the GFR is already in the toilet, it's terrible. So you don't want to add on something that will tang GFR even more, because remember, angiotensin II is a constrictor of the e-front arterial, right? So that maintains GFR. So if you give an ACE inhibitor, or you give an ARB, right? That would essentially like blunt the effects of angiotensin II, you would dilute the e-front arterial, and if that happens, your GFR will drop. If your GFR drops, that can through the person to flurry the renal failure. So you don't want to do that. And then, if a person has a C1 estri and inhibitor deficiency, so an estri is inhibitor to make things easy, just think of it as something that breaks down really kinding. I mean, yes, it breaks down really kinding to inactive metabolites. So the thing is ACE, also angiotensin convertitinsign, breaks down really kinding to inactive metabolites as well. Let's just simplify that way. That's a gross oversimplification, but it would do. Now, if, for example, a person already has a deficiency of C1 estri is inhibitor, well, you've knocked out one of two high-alt pathways for breaking down really kinding. So now, they're left with that es pathway. That es pathway is all the half, really matters to them. So if you then decide to take that away by giving an ACE inhibitor, then you've knocked out two high-alt pathways for breaking down really kinding.

So you no longer have the ability to break down really kinding, and then you get into trouble, because you can then begin to start having, because remember, really kinding can cause bronchoconstriction, it can increase vasculoprimiability, so this will have the aphysswelline respiratory compromise and all that stuff. So those are people that you should not be giving ACE inhibitors or ER Vs too. Now, what if you get a question about like a 50-year-old female, you know, she comes in, has like a large left-press mass, and then they tell you that physical examiner is notable for skin dimplain, neporitraction, levery, I don't know, like orange peel appearance of the left-press. And then they tell you that she has a long history of depression that has been well-controlled with peroxatine, and then they tell you that her mood, her affect, that's all appropriate, and then she tells you that she's not interested in knowing the diagnosis. And then the MV My question is, what is the next best step in the management of this patient? What is the next best step in the management of this patient? So let's say option A says, tell the patient the diagnosis and order to consider immediate treatment. So that's option A. And then option B is, respect the patient's wishes and do not tell her the diagnosis. And then option C is verbalized to the patient that you think it's best for her to know the diagnosis. And then option D is to call the patient's husband and tell him the diagnosis.

And then option E is to ask the patient why she does not want to know the diagnosis. So I'll read those again because this is again the classic tricky ethics question. I love writing questions. It's just it takes a ridiculous amount of time to write questions. So again, tell the patient the diagnosis, urge her to consider immediate treatment. Option B, respect the patient's wishes, don't tell her the diagnosis. C verbalized to the patient that you think it's best for her to know the diagnosis. Option D, call the patient's husband, tell him the diagnosis. Option E, ask the patient why she does not want to know the diagnosis. So what do you think the best answer here should be? Again, I really, really hope that you are saying the answer E. So this patient likely has like inflammatory breast cancer. So the patient likely has inflammatory breast cancer. Now three of the answers don't make any sense. So like option A where I see tell the patient the diagnosis. This patient is lucid, she's there, she's not delirious, nothing like that. You can break patients autonomy. So that's a bogus shouldn't choose that. And then option C says, verbalized to the patient that you think it's best for her to know the diagnosis can do that either. That's ridiculous. Like you can't tell the patient that you know what's best for them. No, patients have autonomy. So that's a bogus answer. And then option D, call the patient's husband and tell him the diagnosis.

Sure, there'll be a very nice attorney that will be very willing to take your life sense and take maybe your life savings and whatever you can make for the next couple of years. So don't do that, right? That's breaking hip hop. That's not smart at all. And then option B actually sounds pretty good, right? Like you know, respect the patients which is don't tell her the diagnosis. Versus option E that says ask the patient why she does not want to know the diagnosis. Here's the thing. Let me teach you guys a salient rule of ethics questions on MBME exams. The thing is if you went to adoption B you essentially doing what the patient wants. But here's the thing. I will encourage you on ethics questions. This thing works. This rule works extremely well. Especially like on the more difficult ethics questions that people are like, men, all these things are all good answers. Or like I'm stuck between two. Wherever possible, always try to pick an ethics question answer that encourages more discussion with the patient. It's very important, right? Encourages more discussion with the patient. Or at least enables you to obtain more information from the patient. Right? You know, just to kind of understand the decision. The thing is if for example you ask the patient like what I said in option E like, oh, as the patient actually doesn't want to know the diagnosis, the patient is like firm, competent and still refuses to know the diagnosis.

Then yes, option B will then be appropriate on that those are circumstances. Right? Again, you very likely see ethics questions on your test. Ethics questions show up on the US Emily Step 2 CK exam. Be sure in ridiculous amounts on the Step 3 exam. So those are ethics you just want to be good at it because it's just one of those things you'll never go with. And even like the medicine residents, the medicine boards, those things have ethics questions for sure. Now, when you forget a question about like, you know, like a 45 year old female, she has like a past year of Crohn's. And it's well controlled with like a tenor set. Right? And then she comes to the eb and she's been complaining of dysmia. And then she tells you, man, you know, I've not been feeling myself, you know, for the past 12 days and I've had to skip work because I'm feeling tired all the time. And then they tell you that her review of systems, you know, is positive for like a non-productive cough. She's had like low grade fevers. She's had my allergies. And then they tell you that you do a rapid flu screen and it's negative. And then they tell you that, you know, a temperature is 101.4. White count is 14,000. So, I mean, obviously she's February. She's she has a Lycosythosis. Asylium is 131, which has a mild hyponitremia. And they tell you that a P little A02, right? So like heartereal, oxygen 10, shallots 57, which is obviously very low, right? And then they tell you all of the labs that within normal limits.

And then they say a chest x-ray is notable for diffuse ground glass. So let's say they tell you that, oh, in chest x-ray you see diffuse ground glass interstitial infiltrates. And they tell you she hasn't had any recentric contacts. And then that you did a PPD screen like three years ago and it was negative. And then they say, what is the most likely of, so let's say this is the question. What is the most likely of fending organism responsible for this patient symptoms? Right? So what is the most likely of fending organism responsible for this patient symptoms? And let's see, they give you option A and it says like, I don't know, like my co-bacterium tuberculosis. And then option B, let's say it's a pneumocystis-jurvetse. And then let's say option C, um, they tell you it's Legionella pneumothala. And then let's say option D, they tell you that, oh, it's the influenza virus. And then let's say option E, let's pick something generic like strep pneumo. So what do you think the answer here should be? And we'll really hope that you're telling me that the answer here should be option B, right? This person has a new PCP pneumonia, right? And what are the things that can sort of help you with, uh, going with the diagnosis of PCP pneumonia? Well, a few things here actually, right? So, uh, if a person has like, you know, like severe hypoxia, I mean like really look, if you look at the question, the person has like severe hypoxia, right? She has hyponitrineia.

Believe it or not, the friends at the MBA may have started going after this relationship between PCP pneumonia and SIDH. Remember, if you have like any like brain or pulmonary pathology, those things can actually cause SIDH, right? So, um, and you can see a symptoms of kind of being like subacute, you know, gone for like the last 12 days and then they tell you, here's the kicker, right? That she has bilaterally and testicially infiltrates on chest x-ray, right? This is all classic for PCP pneumonia, right? And again, some other findings I guess that I didn't necessarily mention, but remember that in PCP pneumonia, those people tend to have like very elevated LGH, right? And really the way you make the diagnosis is you can do like an induced pyrump sample, you can do like a bronchial viola lavage, right? And you will see like organisms that are silverstein positive. If you see that, you know that you're dealing with PCP pneumonia, I mean, you see it divine, but this one doesn't have HIV, nothing. When does PCP pneumonia well? Think about it, right? She's on a, uh, a tanner set. A tanner set is a, is a tnf inhibitor, right? So she's immunosuppressed, right? Remember in general, before you start a patient on a tnf inhibitor, you do actually need to screen them for TB. It's very important to know. And then you also have to screen them for HB, because HB and TB, remember your B's, HB, TB, those can be reactivated when a person starts on a tnf inhibitor, right?

And then some other I guess high-yield things, right? I guess since we're talking about pneumonia, remember Legionella, right? Legionella, I think of it as causing pneumonia plus. So it's like a person who have pneumonia, and then they'll have like severe diarrhea, they'll have hyponitramia, they'll have thrombocyanopenia, they'll have abdominal pain, they'll have all these, like other systemic symptoms. But the thing is, classically, for them to make you think of Legionella, they'll almost always give you something about like exposure to like air conditioning, or like a waterfall, or like a business conference, right? So the thing is because I would purposely put that hyponitramia in the question, to kind of mess with people's heads a little, right? The thing is, if information is not giving you, giving to an NV Me question, don't assume it to be there. Everything you need to answer an NV Me question is in the question, right? Is in the question, right? So don't try to make assumptions, so that, oh, that, like let me bring in my own piece of information, so that you'll fit the sensor and really consider it in my mind. I promise you, you'll fit that answer and you'll pick the wrong one, right? So you gotta be careful, you gotta be careful on your exam, right? If information is not accused, then don't introduce your own information, right? That is one very nice way of friends at the NV Me, get people to pick their own answers. And why is it not stripping you, my mean?

Stripping you more, right? You'll cause like a low-bar consolidation, and the patient symptoms will be more acute, right? You can have, I promise you, you can have stripping you more pneumonia, for 12 days, and be like, you know, chilling, and like, oh, you know, I feel bad on the 12, let me come to the, no, trust me. If you have stripping you more, like, those people tend to have like, sometimes, there's this preceptor I had, he called it a teeth-chattering fever, right? With the presence, like, the person just feels like sick as just can't use certain words, but really, really sick, right? So, yeah, so stripping more calls like a low-bar consolidation, the patient symptoms will be more acute, it'll be more severe, right? So you'll be like, oh, like two days ago, they were fine, and they're definitely like crap, right? And then if a person has TB, right, they'll have like, significant B symptoms, like, they'll have like, very high fevers, night sweats, weight loss, hemoptysis, and again, usually TB will show like, a cavitory lesion in the upper lip of the lung, right? They will not generally have interstitial infiltration if you're thinking about TB.

Now, what if you get a question about like a 33-year-old female, comes to the hospital, you know, should they have like a two-month history of fatigue, and then they tell you that she has lost interest in many things that previously made her happy, and then they tell you, oh, she's gained 10 pounds, but she has had no increase in appetite, and then they tell you that, oh, on physical exam, you notice that her bilateral lower extremities are, you know, moderately swollen, and that she has missed her like, halas two periods. And then they say that, oh, the rest of her exam is within normal limits. And then they ask, what is the next best step in the management of the patient? What is the next best step in the management of the patient? So let's say, optional A is like check serum TSH levels, right? And then let's say option B is to begin an empiric trial of fluoxity, right? And then let's say option C is like, you know, get a monospot test for infectious monoidal increases, and then let's say option D is to perform like radioactive iodine or optica scan. Oh, so what do you think the best answer here should be? Well, I hope you're seeing to check serum TSH, I hope you're seeing to check serum TSH. I mean, this lady most likely has hypothyroidism, right?

Well, to be honest with you, if this were an all-be-guy question, I would very likely go off, I mean, I know it's not an answer choice that I put out there, but actually getting a urine pregnancy test is not a bad idea in this person, because guess what? Gingweat, sweating of the bilateral extremities, missed two periods, that could be pregnancy, right? So this is not going to keep in mind, but that's not an answer choice here. That's why I'm entertaining hypothyroidism, right? So this woman is likely hypothyroid, right? So you want to go ahead and check TSH, you'll obviously be elevated. Remember, the most common cause of hypothyroidism in the US is Hashimoto's thyroiditis, right? And the thing is, usually, usually, on exams, people that have like Hashimoto's, they tend to have like autoimmune crap going on, like Vidaligo or like preneciacinemia causing B2 O deficiency stuff like that, right? And remember that again, so other autoimmune disease, like if a person has one autoimmune disease, it places them at high risk of having other autoimmune diseases, right? And remember that Hashimoto's right, these are sort of like antibodies against thyroid peroxidys. So anti-TPO or anti-thyroid peroxidys antibodies. And then they'll tell you that, oh, if you check out the thyroid gland on hostology, you see like a lymphocytic infiltrate, that's all classic for Hashimoto's.

And then, remember that if a person has Hashimoto's initially, like early in the course, they can actually be hyperthyroid because that inflammation can release the preformed thyroid hormone and then they can be hyperthyroid. In fact, some people call that Hashitoxicosis, right? So they can have like a thyroid toxic phase initially. And really the way you treat Hashimoto's is, you know, you do a level of thorax in replacement. Remember, they can actually give you a question about a person they say that, oh, a person has a long history of Hashimoto's and then over the last like two months, if I'd like this rapidly and largely in neck mass, blood, blood, blood, blood. If you see that, think about thyroid lymphoma, right? Think about thyroid lymphoma. And again, if a person has primary hypothyroidism, right? Obviously, you'll have like an evident TSH, low T3, low T4, right? But if they told you that a person has like low TSH and low T3, T4, right? What are you thinking about? Now, I hope you're thinking about secondary hypothyroidism, right? So remember, there are things that can cause secondary hypothyroidism like craniofiring, genome, so let's say you have something like compressing the pituitary or person has a shi-hand syndrome, right? Those can all be associated with secondary hypothyroidism. And please, please, please don't forget, right?

For pressing as craniofiring, genome, your friends at the MBMEB love to ask what's the embryologic origin of a craniofiring, genome, please think about the derivation from a rafky spot, okay? That's one thing that believe it or not still shows up on, you may say, oh, divine, that's step one crap. I promise you, it's also step two CK and step three crap. So please don't don't don't forget just bring into your brain forever. And then if a person has hypothyroidism, right? You know, the T43 is low, that will actually cause an increase in TRH, so thyroid tropine release in hormone. And the thing is, thyroid tropine release in hormone is also known as a prolactin release in factor. So those people can have a secondary hyperprolatinemia and that has suppressed the HPG axis, right? So that's why this one has missed the last two periods. And then I guess some other high, you know, quicker thyroid pathologies, right? So the querian thyroiditis, right? Those people, it's also called subacute thyroiditis. These people have like, they can be hyper thyroid or they can be hypothyroid, okay? But the hallmark feature on MBME examples is they'll have a painful thyroid gland and then they'll tell you that, oh, this person has like a histro, like you're saying, you show viral respiratory infection, although sometimes they won't give that at all. And remember, if you do a rAU scan, they'll be like decreased or like very, almost very, almost no optic on a rAU scan.

And then there's this thing called a U thyroid six syndrome that occasionally pops up on MBME examples. And really it's like a diagnosis you consider when you, you know, get a question about a person that's like super sick and the TSH and T3 T4, like marginalilo, it will not be like profoundly low, it'll be marginalilo. And then hyperestrogenism, right? Do you remember if a person, you know, has high levels of estrogen from like BCOS or if a person is taking OC Ps, that can actually increase the levels of a thyroid binding globule, right? And if your thyroid binding globule increases, that will raise your total T4, or your free T4 will be normal. And remember, free T4 is like the active, like physiologically, useful form of, that's the one that's, you know, that's physiologically active, free T4, not the bound T4. And then remember, most direct cancers, right? They tend to be hypofunctional, right? And for the most part, the person has a thyroid cancer, you want to do like an ultrasound with biopsy. So most times, the person has a thyroid cancer, the TSH maybe, you know, elevated because the cancer is a hypofunctional. And again, classic presenter of thyroid cancer, they'll likely describe a person, you know, that has had like some kind of, some kind of, um, um, radiation therapy for some like upper body, neuroplasma, like leukemia. And then the person presents with a thyroid nodule. Remember, the biggest risk factor for thyroid cancer, right?

It is prior history of radiation to the head and neck. And don't forget that the most popular kind of thyroid cancer is papillary, thyroid cancer. So remember, papillary thyroid cancer is popular, right? So that's a nice way to remember that. Um, and remember, right, it tends to metastasize to lymph nodes. And that's the one that has the San Momobodies and the aunt, auntie, orphan, Annie, I, whatever nuclei. So that's how you to know. Uh, contrast that with follicular lymph, uh, thyroid cancer, right? That doesn't spread to lymph nodes, it spreads in my toe, genusly. That's a boss freeze really do need to remember for exams. And, um, um, the medallary thyroid cancer, right? Remember the association like MEN2 A, MEN2 B, or the Zomo dominant in heritans, retogen mutation. And remember, if a person has a issue of MEN2 A or MEN2 B, they do need, um, they do need a prophylactic thyroid, dr. Because it's not really a matter of, if they will get thyroid, medallary thyroid cancer, it's more a matter of when they will get medallary thyroid cancer. Your risk of getting medallary thyroid cancer, if you have MEN2 A or MEN2 B is 100%. Okay? So that is something you absolutely need to keep in mind for, for purposes of the exam. And remember that the tumor marker, right, for, for medallary thyroid cancer, is calcium toning. So they can give you a question about a person that has a neck mass. And then they tell you they show you an e-key, you know, the prolonged cutie interval, right?

You should be able to link those ideas together like the prolonged cutie interval is from hypocalsemia, which are rules because calcium toning, which is the tumor marker for medallary thyroid cancer, calcium tones down your blood calcium levels, right? So that's how we can integrate all that mess together. And then please don't forget, right? That medallary thyroid cancer, right? They can seal on histology, all you expect, right? You want to, you obviously, if you do the congruert staining, you'll see like the apple greener by refringes. So those are all high your things, you want to keep in mind. So I think this is going to be like exactly 30 minutes. I'm going to go ahead and stop here. I will try my best to make a ton of podcast. So for the next few days, I just have so much I really want to share, but just timing is just a really an issue. So as I do at the end of every podcast, you know, I don't offer one or one tutoring for most exams that, essentially if you're listening to this podcast, I probably tutor the exam you're preparing for. So like step one, two CK, step two CS, step three, if you're medicine resident, the intranin exam, the IBIM board exam, if you need tutoring for like the preclinical med school subject. So if you're if you're an M1 or M2 student, if you're 30 a met student in your shelf exams, I offer tutoring for those. And then I do like this long, you should know tutoring.

I've talked about diagnosing in my last few podcasts where if you're first second or 30 a met student, tutoring for like your shelf exams or your block exams. But at the same time, I tutor you for the USML exam you have upcoming. And again, everyone I've done this with, they've actually been extremely, extremely, extremely successful. So if that's something you're interested in because at the same time as I'm tutoring for your block exams, I'm just so say for example, your second year med student, as I'm tutoring for your block exams, I'm also tutoring you for step one at the same time. So you essentially cover those two pieces of knowledge during that time frame. And then if you there this USML booster course that again, I offered for a few months, but I was like let me test it out first before I start mentioning on the podcast, but basically it's like 10 hours for step 2, you can step 3 or 20 hours for step 1, we're basically just listening to the podcast where I talk about it. But essentially, it's ideal for people that are in the last week of their prep or the institution really feel like the new most of the information pretty well. And they want to integrate things together. Very quick course, but we review a lot like a very vast majority of the high-yield things from every subject that are tested on the USML exam you're teaching.

And then if you're med student applying to residency, so like an ERAS application or a college student applying to med school, so I'm a CAS application, I do it for like one-on-one like advising or you can see coaching for those. So like personal statements, rec letters, mock interviews, editing applications, and then I guess the last thing, if you have a buddy that needs to learn for like Gen CAM, OEM, physics, histology, biochem, physiology, over to learn for those days. So have a wonderful rest of your day. I really cannot wait for the new MBA season to start. I don't know, I just feel like I don't really want much in the way of TV other than MBA. So and I guess like gospel, like messages and music, but yeah, I really don't need the MBA to come right back. So I'm really excited, at least next week, pre-season start. So I guess I'll take what I can get. So I will see you in the next podcast. God bless you. Thank you.

Diffuse ground-glass interstitial infiltrates.

Papillary thyroid cancer.

Hashimoto's thyroiditis.

ACE Inhibitors (or AR Bs).

Low TSH levels along with low T3/T4 levels.

Pneumonia plus severe diarrhea, hyponatremia, and thrombocytopenia.

Pituitary/hypothalamic compression (e.g., craniopharyngioma) or Sheehan syndrome.

Anti-TPO (anti-thyroid peroxidase) and anti-thyroglobulin antibodies.

Calcitonin; Hypocalcemia.

Papillary tends to spread via lymph nodes (cervical chain); Follicular tends to invade locally/via vascular routes.

MEN2 A or MEN2 B syndromes, or a germline RET proto-oncogene mutation.

The Hypothalamic-Pituitary-Gonadal (HPG) axis.

Pituitary/hypothalamic compression (e.g., craniopharyngioma) or Sheehan syndrome.

Anti-TPO (anti-thyroid peroxidase) and anti-thyroglobulin antibodies.

Calcitonin; Hypocalcemia.

Papillary tends to spread via lymph nodes (cervical chain); Follicular tends to invade locally/via vascular routes.

MEN2 A or MEN2 B syndromes, or a germline RET proto-oncogene mutation.

The Hypothalamic-Pituitary-Gonadal (HPG) axis.