Divine Intervention Episode 30-Comprehensive 3rd Year Medicine NBME Shelf Review Session 2

[@anthonymansour1149]

Listening to 1 hour of you is like doing 4 blocks.. you're the man thank you

[@aryanruizaki]

The first line for aspiration pneumonia is ampicillin-Sulbactam, carbapenem. Same for lung abscess. Clindamycin is second line due to increased risk of c.difficile.

[@seeker296]

Thank you so much for correcting the audio by staying close to the mic. It is a true mark of honor, humility, and strength to accept and implement criticism. All respect to you, sir

[@Wolfparkinsonbrown]

All he did was stand still bro chill out😂

[@pigtowndanzee]

45:00 - clindamycin is not 1st line for aspiration PNA due to high risk for cdiff. now in hospitalized patients use ampicillin/sulbactam OR PCN + metro OR carbapenem. clinda only if PCN allergic

[@mxrcus3480]

rxx. 6

[@ahmedadnan6144]

1:40:19 according to First Aid, cardiac tamponade is considering obstructive shock, which is the only type of obstructive presents with high PCWP (left heart preload) similar to cardiogenic shock. The rest of the obstructive shock presents with low PCWP.

[@JaiMedicine]

Thank you from me and the countless students who watch these videos. Only few people can do what you do!

[@miguelhuayta7643]

I was doing Uworld and they said anaerobes were no longer the #1 cause of aspiration pneumonia. I chose clyndamycin as the tretament regimen but it turns out it was amoxicilin to cover gram positives

[@DrGauravThakur38]

Yes I did the same

[@AdelAliakbar]

first aid 2023 clinical algo, still use clindamycin or ampicillin/sulbactam

[@ahmedkhairy5561]

Lol same

[@mat2931]

😊😊

[@PrettyFunnyLooking]

Bx😊😊x😊d

[@KT-uy4re]

This guy is a genius

[@ahmedadnan6144]

1:10:57 according to UWorld Q ID: 2933 and the algorithm of gallstone pancreatitis management: Following the resolution of pancreatitis, early elective cholecystectomy is recommended because it significantly reduces the incidence of recurrent attacks.

[@ahmedadnan6144]

1:25:44 , Janeway lesions are Vascular phenomena while Osler nodes (painful “Ouchy”) are Immunologic phenomena.

[@momatik]

For some reason the audio doesn't work on mobile- on PC it works fine. Thank you for posting these shelf reviews

[@jessicabhandari4353]

1:15, I always keep Cryptosporidium and cryptococcus straight because sprore reminds me of Cdiff, which is also a spore, that causes diarrhea. & the other one is the other one.

[@kgooner7035]

God bless you and your genuine love for the science. So so helpfull more than you can imagine

[@tyelerr4808]

1:40: Cardiac tamponade is obstructive shock, not cardiogenic. It is unique among causes of obstructive shock for the notable increased PCWP due to compression by pericardial fluid. Functionally, it can be thought of as cardiogenic, but technically it is obstructive.

[@venkateshwaranv6897]

Immunologic phenomenon- Roth spots, Osler nodes,glomerulonephritis(diffuse proliferative) Microemboli of vegetations-Janeway lesions,splinter hemorrhages ,arterial and pulmonary embolism (Note: All features are seen only in left sided IE and NOT in right sided IE EXCEPT pulmonary embolism )

[@3questo699]

You are a truly a Genius. Thank you for sharing your gift with us 🙏

[@Wiley224]

You do great work man. Helped me out a lot

[@venkateshwaranv6897]

Hydroxocobalamin(NOT cyanocobalamin)is used for treating cyanide toxicity. It’s called as R on T phenomenon (NOT Q on T phenomenon). Also a mechanical cause of this phenomenon is ‘commotio cordis’( a sudden precordial impact can precipitate a ventricular fibrillation and lead to SCD). The R on T phenomenon occurs when a shock is delivered during the relative refractory phase of cardiac cycle (vulnerable window).This is why we perform a synchronised cardioversion (sync the shock delivery with R wave ) to prevent shock being delivered during ventricular repolarisation( T wave) to decrease the chances of R on T phenomenon.

[@jackjohnson4586]

I have had the steroid synthesis pathway memorized for years, but that trick with a 1 in the first or second digit of the enzyme is incredibly useful. If only I had found you back in med school!

[@step_zero]

so this is what peak performance looks like. amazing

[@venkateshwaranv6897]

According to NBME, the first line treatment of oropharyngeal candidiasis is fluconazole and not Amphotericin B.

[@AdelAliakbar]

oral canididiais = Treat with topical nystatin or oral fluconazole

[@deandrebrown4521]

He said nystatin for oral candidiasis and amphotericin if invasive

[@AM-gc2wu]

Guidelines changed in 2019 for OA: First line treatment is now NSAIDs

[@divineinterventionpodcasts]

For the USMLEs, I'd still go with acetaminophen as a first line agent, not NSAIDs. An even better first line answer is the use of muscle strengthening exercises.

[@luzmarianaramirez8329]

@@divineinterventionpodcasts Just got a q on NBME 10 regarding this and answer was acetaminophen! thank you!!!

[@andranikvasilyan9819]

@@luzmarianaramirez8329 ​ @DivineIntervention USMLE Podcasts and Videos interesting, uworld said NSAID was correct choice. but i have not done any IM NBMEs just yet

[@amnakazmi5201]

@@divineinterventionpodcasts Is it still the same? acetaminophen > nsaids?

[@geneveweil2938]

@@amnakazmi5201 yes

[@bryannicolalde299]

Divine, amazing presentations, help me a lot to consolidate my knowledge! Cardiac tamponade is an example of obstructive shock instead of cardiac shock

[@venkateshwaranv6897]

In secondary/tertiary adrenal insufficiency, a minimal/suboptimal cortisol response is seen (cortisol does not rise as expected )with cosyntropin stimulation test. This is because most patients with central adrenal insufficiency (pituitary/hypothalamic) have adrenal atrophy due to chronically decreased levels of ACTH causing the blunted response to cosyntropin test. Thus we sometimes cannot differentiate a primary adrenal insufficiency from a central cause (further pituitary testing is required ).However a normal response (30 min cortisol- >20microgram/l )likely rules out adrenal insufficiency.

[@mario9328]

Devine, thank you for all of your excellent content. You don't understand how much this benefits your students! At 1:08, every 1 drop of albumin is a drop in 0.8 of calcium

[@MaSSaDFTW]

That's right, every 1 drop of albumin is a drop of 0.8 in TOTAL serum calcium. Which you will correct by adding 0.8 to the ionized calcium.

[@cooperdodd9788]

Indication for abx before dental: Missing one was cardiac transplant patients that develop a valvopathy

[@maryamnayyar4909]

cardiac temponade is a type of obstrutive shock not cardiogenic.. pcw pressure is increased becuse of the compressive pressure on the heart chambers by the blood in pericardium. Great stuff divine!

[@adelaziz4927]

MVP and HOCM are the only 2 Murmurs that increase***** in intensity with DECREASED preload. MVP pathology although it regurgitates, it has different murmur presentation intensity from Mitral regurgitation. Similar to HOCM, when there is less preload, the ventricles will contract the blood against a closed mitral door and prolapse it open. But when the preload increases, the ventricles expand, and regurgitate blood back into the atrium without pushing against the valve (as much). Thats why its similar to HOCM, the mitral annulus closing in on aorta when the preload volume is low in the ventricles. But when the ventricles expand, the annulus does not fully block flow through aorta. And as you said in previous, increased afterload means more blood remaining in ventricles. By this, increased afterload will actually decrease the intensity of these 2 murmurs. I love everything else you have here.

[@emekaemmanuel5258]

I think he said everything you explained. You just made it more difficult to understand while he made it extremely easy.

[@ruthnouboussi9069]

thank you for the clarification. I got confused that's why I came in the comments.

[@udayrallabhandi3345]

Y'all two are saying the same thing, only confusion is he asked what would make the murmer "sound better". He means sound louder as "better" can be misconstrued

[@khaldoon6949]

Hey Divine, thanks for all these videos! But 22:18 you mention first line Pharma therapy for Osteoarthritis is Acetaminophen over NSAID. Idk if this is a recent change but in Uworld a few questions have stated NSAID being the first line therapy. They state the benefits of Acetaminophen in Osteoarth, do not outweigh the adverse effects. Please let me know what you think. Thank you!

[@samuelshepard1735]

For sure NSAID > Tylenol for the 1* drug treatment of OA

[@AdelAliakbar]

even first aid states local NSAID use first! , no mention for Tylenol

[@edithjemutai6065]

I just did this question a few days ago and I was just confused for a minute!!

[@etreacteurdesasante4639]

Acetaminophen in the nbme

[@hangettingstronger]

@@etreacteurdesasante4639 The older ones though

[@maguivaldez1559]

Thank you! Ya casi hago mi Step2 and your videos are very helpful.... thank you, thank you, thank you so much!!!!!!!!!😊😊😊

[@jorgesalazar790]

Como te fue?

[@maguivaldez1559]

@@jorgesalazar790 me fue mejor de lo que pensaba!!😁

[@jorgesalazar790]

Excelente Dra! Felicidades. Yo presento el 11 de febrero, a ver cómo nos va

[@maguivaldez1559]

@@jorgesalazar790 te va a ir bien. Ve mentalizado que vas a tener que leer rapido. Confia en ti.

[@jorgesalazar790]

@@maguivaldez1559 Muchas Gracias!!

[@andongiordano1896]

Shingles vaccination is recommended at ≥50 years of age, not 60. 2:23:19

[@teddoyre1099]

cut off for shingles is now 50 , no longer 60

[@lauralowe8784]

Quick correction: an abnormal ristocetin assay arises in the setting of vWF deficiency or BERNARD SOULIER, NOT glanzmann as this assay is affected when adhesion is defective. Glanzmann is an inability to aggregate platelets where as BS is a defect in adherence.

[@PersianPrincess12]

that's what he said...

[@lauralowe8784]

@@PersianPrincess12 No...he mentions Glanzmann as having an abnormal ristocetin as well.

[@sharonmaina6828]

@@lauralowe8784 2:07:59 he literally said that exactly lol what are you correcting

[@AyeshaLaraib-z4z]

MI was mentioned as common cause of death for lupus in risk factor podcast.(That seems a better option than renal issues)

[@greensky01]

@7:12 Another way to understand adrenal enzyme defects: 1) at age 11, kids only want the sweet sugar - so lacking glucocorticoids 2) at age 17, teens are only interested in the opposite sex and sweet love - so lacking androgens & glucocorticoids 3) at age 21, adults are getting all the sex they can but still want some sweet love & salty snacks - so high androgens with low glucocorticoids & mineralocorticoids

[@ApurvaPopat]

19:22 If the patient has EUVOLEMIC HYPERNATREMIA, you don’t give them NS, give 0.45 NS or D5

[@robertreinhart8886]

he said that. he was referring to hypovolemic hypernatremia --> give NS --> euvolemia --> D5 / 1/2NS

[@hellzkillerz]

This man is a life saver (no pun intended), also amazing teacher.

[@obim5733]

No mom I’m not going p😊😅😅hmmm j😮

[@ahmedadnan6144]

2:16:50 Metformin actually can cause Weight loss (according to First Aid)

[@Mahi23-i8g]

The voice is not working what shall i do?

[@beniri6843]

this man is a goat lol my igbo brother demolishing stuff god damn lol

[@user-pu9xn1fw5m]

@51:42 I think Psoas sign is when you extend the hip, not flex

[@pranavt1888]

You can ellicit psoas sign in two different ways

[@usmlestepexamreview]

Very well made presentation!

[@stevencanalesd.o.4984]

2:15:45 insulin can also cause weight gain correct?

[@UsamaSaeed1]

Euvolemic hypernatremia> 5% dextrose (Uworld)

[@gabrielarodriguez8065]

the sound isn't working for me

[@suomynonaanonymous]

Where is part two

[@PrincessSharonable]

Something is wrong with the audio

[@graysonfortin]

How do you listen to this? The sound isn’t workinh

[@anaz1635]

Heard him mention DNAAAPC a few times, can someone enlighten me in regards to what that is? Thank you

[@divineinterventionpodcasts]

Causes of eosinophilia: Drugs, Neoplasms, Asthma, Allergies, Acute Interstitial nephritis, Addison's disease, Collagen Vascular Disease, and Parasites (DNAAAACP)

[@anaz1635]

@@divineinterventionpodcasts thank you!

[@devdayal4279]

Most common cause of post viral pneumonia is strep pneumo now

[@joshb2686]

Uworld update. You SHOULD give varicella vaccine if CD4 is above 200

[@newjerseyselfdefense6199]

The better way to describe murmurs is “LOUDER OR SOFTER” not “better or worse” - that is too subjective and can confuse people, especially those who are ESL.

[@andranikvasilyan9819]

NBME will use these terms, so its nice that he warns you

[@mmaqb766]

When you say murmur gets better does that mean it gets louder or dimmer? At 27:17

[@jdiva204]

A murmur that gets better is a murmur that decreases in intensity with the maneuver

[@mikestephens180]

Think of it like you would any disease process. If you’re dehydrated, does your orthostasis get better or worse? If given a warm blanket, does your hypothermia get better or worse?

[@blakedotguidry]

Improves = quieter/less intense, Worse= louder/more intense

[@ApurvaPopat]

MVP - ■ Anything that increase amount of blood in LV → murmur softer ● Increase preload ● Increase afterload ■ Anything that decreases amount of blood in LV → murmur louder

[@Alich79865]

Is this step 2 or step 1 because it feels like I have prepared for all of this in step 1

[@zalkar-qi8pl]

where is the sounds

[@joshmcgoo]

commenting for the algorithm

[@MaSSaDFTW]

Are you the real Josh?

[@joshmcgoo]

@@MaSSaDFTW is me, joshmcgoo

[@amyamelie7]

The audio doesn’t work .... am I the only one who’s experiencing this ?

[@divineinterventionpodcasts]

Hi Amy. Tried it just now and the audio worked.

[@zohaseikha8855]

try using wired earphones

[@SimHibiscus]

240K+ views but only 1.1K likes & 100 comments? Mmmmm.

[@smart_khanx5556]

Whr is the voice

[@ujwalag4180]

I dont see the notes for this video in th link.. can anyone send it please?

[@gloryclemmens1]

divineinterventionpodcasts.files.wordpress.com/2018/05/nbme-medicine-shelf-review-session-2.pdf

[@DrGauravThakur38]

❤❤❤❤❤

[@danieldonascimentoaraujo3221]

2:03:00

[@aryanruizaki]

You don’t prophylax mac

[@divineinterventionpodcasts]

Yes. Guidelines changed recently.

[@DDD-qm1nj]

@@divineinterventionpodcasts is this the

[@Yaqrabhajahtb]

Wh about audio heeelllllpppp

[@JABDUDE]

pretty sure Acetaminophen has been determined to act as a central cox inhibitor and agonist at some cannabinoid receptors

[@Shushu0-0]

1:28:25

[@ahmedadnan6144]

1:09:30 Lipase is more specific (not sensitive )

[@rachelcarrasquillo283]

You get a wide S2 split with mitral regurgitation? Is that correct?

[@MelissaBosch-x5f]

88!5