An 18-y/o college freshman presents with increased social anxiety. He wants to make friends but is afraid of being rejected. What's his diagnosis? Links: Full Episode Blog Post BoardVitals Meded Media Follow us on Instagram @mike.natter and @medicalschoolhq

A 36-y/o male presents to the hospital because he fears his heart may be "skipping a beat." His workup and history are normal, so what's causing his symptoms? Links: Full Episode Blog Post BoardVitals Meded Media Follow us on Instagram @mike.natter and @medicalschoolhq

A 15-year-old boy has a history of torturing and killing animals. He has also exhibited violent behavior towards other students at school. What's his diagnosis? Links: Full Episode Blog Post BoardVitals (Use the promo code BOARDROUNDS to save 15% off.) Meded Media The Premed Years 373: From Art School to Med School

A 52-y/o female presents with short, reoccurring episodes of chest tightness, pounding palpations, shortness breath, and severe anxiety. What's her diagnosis? Links: Full Episode Blog Post BoardVitals (promo code BOARDROUNDS and get 15% off) Meded Media

A 20-y/o student presents with anxiety, but her other symptoms suggest her diagnosis may not be so straight-forward. If it isn't GAD, what could it be? Links: Full Episode Blog Post BoardVitals Meded Media Follow us on Instagram at @mike.natter and @medicalschoolhq.

Using our knowledge of cranial nuclei and some spacial awareness, which cranial nerve nuclei receives fibers from the carotid baroreceptors? Let's find out! Links: Full Episode Blog Post BoardVitals (Use the promo code BOARDROUNDS to save 15% off.) Meded Media

More glossopharyngeal neuroanatomy! This gland is innervated by the efferent autonomic fibers of the glossopharyngeal nerve. Name that gland!

Where does the branchial motor component of the glossopharyngeal nerve originate? Join us and see how well you know your neuroanatomy.

Can you accurately identify the various functions of the trigeminal nerve and its major divisions? Follow along to test your knowledge of neuroanatomy! Links: Full Episode Blog Post BoardVitals (Use the promo code BOARDROUNDS to save 15% off.)

A 32-y/o woman with acute cholecystitis has a past medical history of autoimmune hemolytic anemia. Which substance is likely to be found in her gallstones? Links: Full Episode Blog Post Meded Media BoardVitals (Use the promo code BOARDROUNDS to save 15% off.) Follow us on Instagram @MedicalSchoolHQ and @mike.natter.

A 46-y/o female has RUQ pain and distension following surgical repair of a splenic laceration. Which process most likely resulted in her current condition? Links: Full Episode Blog Post Meded Media BoardVitals (promo code BOARDROUNDS and save 15% off)

A 62-year-old female presents with impared taste and drooping on the right side of her face, but her hearing is normal. Where is the probable lesion located? Links: Full Episode Blog Post BoardVitals (Use the promo code BOARDROUNDS to save 15% off) Follow us on Instagram @medicalschoolhq and @mike.natter.

A 28-y/o female presents with a painful, lower-abdominal mass two days after a c-section. What is the most likely site of injury that led to this hematoma? Links: Full Episode Blog Post BoardVitals (promo code BOARDROUNDS to save 15% off) Meded Media

A 70-y/o male has hypoesthesia of the trunk, hypoalgesia, and decreased temperature discrimination. Which diagnosis accounts for residual pallesthesia and fine touch? Links: Full Episode Blog Post Meded Media BoardVitals (promo code BOARDROUNDS and save 15% off) PMY 373: From Art School to Med School with Dr. Mike Natter Follow me on Instagram @medicalschoolHQ. Follow Dr. Mike Natter on Instagram @mike.natter and check out all his amazing artwork.

A 52-year-old female with renal failure has perioral numbness, paresthesias of the hands and feet, and muscle cramps. What metabolic findings might we expect? Links: Full Episode Blog Post Meded Media BoardVitals (Save 15% by using the promo code BOARDROUNDS.)

What does this patient's decreased creatnine clearance and oliguria tell you? What risk factors are behind his condition? Would you give him contrast dye?

This adult female with persistent fatigue complains of feeling cold. Listen to the lab values and look at the image in the show notes. What is the etiology? Links: Full Episode Blog Post BoardVitals (promo code BOARDROUNDS to save 15% off) Connect with Dr. Mike Natter on Instagram @mike.natter.

Infectious Disease! A young man presents with increasing SOB and green sputum. Sputum culture shows α-hemolytic gram positive cocci in chains. Name that bug! Links: Full Episode Blog Post Meded Media BoardVitals (Use the promo code BOARDROUNDS and get 15% off.) Follow Dr. Mike Natter on Instagram @mike.natter.

A patient with a DVT has not been using his heparin, and now he's back with LLE weakness. What are his heart sounds, cranial MRI, and history revealing? Links: Full Episode Blog Post Meded Media BoardVitals (Use the promo code BOARDROUNDS to save 15% off.) Follow Dr. Mike Natter and his amazing artwork on Instagram @mike.natter

Session 33 This middle-aged male has hypertension and diabetes. Which cardiac abnormality is giving rise to his radiating, high-pitched, holosystolic murmur? We’re joined by Dr. Mike Natter from BoardVitals. Go check out his amazing artwork on Instagram @mike.natter. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [02:30] Question of the Week A 58-year-old male is presenting for an evaluation of a heart murmur that was recently discovered at a work health fair. His past medical history is remarkable for hypertension and diabetes. He has a nice chest pain, palpitations, syncope, or dyspnea. Cardiac auscultation reveals a high-pitched, blowing, holocystolic murmur at the apex. It radiates toward the axilla. The murmur does not increase in intensity with inspiration. What is the most likely diagnosis? (A) Mitral stenosis (B) Ventricular septal defect (C) Tricuspid regurgitation (D) Aortic stenosis (E) Mitral regurgitation [Related episode: USMLE and COMLEX Prep: 60 y/o Male with a Murmur] [03:43] Definition of Terms Holosystolic means you hear the sound throughout systole. It's not going away at any point, increasing or decreasing. It's just going. The apex of the heart is the opposite of the base. It can be sometimes confusing for medical students because it's almost the opposite of what you look at when you're looking at the heart. So the apex of the heart is located at the bottom. It's the inferior part of the heart. [06:17] The Correct Answer and the Thought Process Behind It If it's holosystolic, it's the systole. The ventricles are contracting. So what we're hearing is blood flowing back. It's the regurgitation through either the tricuspid or the mitral valve. Typically, where you're hearing the sound is the blood coming at you. So I'm narrowing my choices here down to either (C) Tricuspid regurgitation or (E) Mitral regurgitation. Mike points out that it's a good test-taking strategy to narrow down your choices. In this case, the correct answer is E. You want to look at pitch, location, and timing. You can grade murmurs and where it radiates, etc. Based on what's going on, we're dealing with a regurgitating murmur.  The murmur of mitral regurgitation gives you this blowing holosystolic sound and radiating to the axilla. It's a pathognomonic mitral regurgitant's description. So anytime you hear that description, it's telling of a mitral regurgitant murmur. It's essential to memorize the patterns because once that's done, you'll get those points easy. [12:08] Understanding the Other Answer Choices Mitral stenosis is characterized by more turbulent flows. Blood is trying to push through something that's basically closed. With stenosis, imagine the blood is knocking at the door and you hear a very hard clunk, clunk, clunk. It's very different from a blowing murmur or regurgitant-type murmur which sounds like a "woosh, woosh, woosh." Ventricular septal defect (VSD) is a defect between the two ventricles. What happens here is that blood is going to go from high pressure to low pressure. It sounds like a train going over a bridge "chug, chug, chug." In this condition, you're going to have the blood going from the left ventricle into the right ventricle. You will hear that extra sound in the heart as well. You could hear this on the bicuspid area although it's also going to be a holosystolic murmur. In...

Crushing substernal chest pain, bradycardia, elevated troponin, and decompensating! What are the subjective and objective signs of myocardial infarction?

Session 31 A 55-y/o heavy smoker is shown to have a peripheral, well-circumscribed mass with popcorn-like calcifications in the RUL. What is the lesion likely composed of? Dr. Karen Shackelford from BoardVitals joins us once again as we delve into another case to prepare you for your Step 1 or Level 1 exam. Save 15% off their QBank by using the coupon code BOARDROUNDS. BoardVitals has a powerful QBank with comprehensive explanation and rationales behind all of their questions. Get up-to-date board review questions. You can avail of their 3 or 6-month plan and ask a clinician. Ask one of the physicians behind all of the questions. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:48] Question of the Week: A 55-year-old male with a 40-year history of smoking who undergoes a low-dose chest CT for lung cancer screening. Imaging results show a peripherally located, well-circumscribed 2-cm mass in his right upper lobe. It has a popcorn-like calcification. Which of the following describes the characteristics of this mass? (A) is composed predominantly of fattened cartilage (B) is composed of poorly differentiated neuroendocrine cells (C) is composed of significant glandular components (D) is caused by keratin production and intracellular desmosomes (E) is formed by caseating granuloma around the causative organism [03:00] Thought Process Behind the Correct Answer The correct answer here is Answer choice E refers to TB and this doesn't sound like TB as there are popcorn lesions with TB. Answer choice A would sound more or less of a benign tumor. B sounds like a malignant small cell lung cancer. C would make you think of adenocarcinoma. [03:00] Thought Process Answer choice A would sound more or less of a benign tumor. B sounds like a malignant small cell lung cancer. C would make you think of adenocarcinoma. Answer choice E refers to TB and this doesn't sound like TB as there are popcorn lesions with TB. The correct answer here is A. A well-circumscribed lung tumor with predominantly fattened cartilage is a hamartoma. A trick that helped me remember this back in medical school is that “popcorn isn’t bad.” It's the most common benign tumor of the lung. It usually contains connective tissue, fat, and cartilage. It's classically associated with popcorn-like calcifications on imaging. They are relatively large, well-demarcated and they rarely impinge on surrounding structures. For the management of pulmonary hamartoma, it would be more beneficial not to undergo surgery. The approach to those tumors is individualized unless it's diagnosed as a stable nodule. Karen stresses the importance of not overdiagnosing people. Once you figure out it's not causing any problems, you just leave it there. [06:08] Understanding the Other Answer Choices The poorly differentiated neuroendocrine cells is a small cell lung cancer. It's a really aggressive malignancy that is most common in smokers. They usually have irregular margins and has a really poor prognosis largely because it tends to metastasize. Significant glandular components are characteristic of adenocarcinoma. It's the most subtype of lung cancer. It has both solid and ground blast components on imaging. It's a pretty heterogenous-looking tumor. It's usually peripherally located. Keratin production and intracellular desmosomes are characteristic of squamous cell carcinoma. It's a common form of non-small cell lung cancer. It originates from epithelial cells along the airways. They're usually centrally located, often associated with the larger bronchi. Caseating granuloma is characteristic of pulmonary tuberculosis around the causative organism. It...

A 55-y/o heavy smoker is shown to have a peripheral, well-circumscribed mass with popcorn-like calcifications in the RUL. What is the lesion likely composed of?

Session 29 Which of these neurotransmitters is mostly likely causing this patient’s galactorrhea and secondary amenorrhea? Where is it coming from? Dr. Karen Shackelford from BoardVitals. When you're looking to prepare for your Step 1 or Level 1 board exams, check out how BoardVitals can help you. You can find all their amazing QBanks for Step1, Level 1, or even any of your SHELF exams. Use the coupon code BOARDROUNDS to save 15% off. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:37] Question of the Week A 34-year-old woman presents with amenorrhea for six months (secondary amenorrhea). Her menstrual cycles have been regular until this episode. She has, most of her life, a period every 28 days with a menstrual period that lasted three days. Today, on exam, a white nipple discharge is noted. A test for urine hCG is negative. Which of the following neurotransmitters suppresses the release of the hormone responsible for her condition? (A) Dopamine (B) Insulin (C) Serotonin (D) Somatostatin (E) Vasopressin [Related episode: Why Is This Menstruating Patient So Sick?] [02:50] Thought Process Behind the Correct Answer The correct answer here is A. If you think about the treatment for prolactinoma, where prolactin is released from the anterior pituitary, bromocriptine and cabergoline are used to shrink the prolactinoma. They're both dopamine agonists. The patient's symptoms are suggestive of prolactinoma. It's not totally obvious though as there wasn't headaches or visual field issues mentioned. Nevertheless, prolactinoma is the most common of all pituitary adenomas. It's also the most common cause of galactorrhea. The clinical features include amenorrhea, galactorrhea, and infertility. The prolactin normally stimulates the mammary glands to produce milk and inhibits the secretion of gonadotropin-releasing hormone, which results in amenorrhea and infertility. With large tumors, like the compression of the optic chiasm that results in bitemporal hemianopsia. Dopamine is normally used to suppress and release the prolactin. When you're not breastfeeding after birth, this becomes an issue. [05:15] Understanding the Incorrect Answers Insulin is produced by the pancreas and it's necessary for the uptake and utilization of glucose. Serotonin agonist is available in several classes, used as antidepressants. They're used to treat migraines, but not for prolactinoma. Additionally, some antipsychotic agents interfere with prolactin. Somatostatin is a hormone secreted by the pancreas that inhibits secretion of insulin and glucagon. It reduces the activity to digest the system. It's not receptive to dopamine and not related to galactorrhea. Vasopressin is an antidiuretic hormone and it's not affected by dopamine agonist. [06:22] Key Takeaways The key concept is that prolactinoma is probably the most common type of pituitary tumor and is the most common cause of galactorrhea. The symptoms occur because prolactin stimulates the mammary glands and suppresses GnRH, causing amenorrhea and infertility. The dopamine agonist suppresses prolactin secretion and shrinks the prolactinoma. Links: BoardVitals (coupon code BOARDROUNDS to save 15% off)

Session 28 A patient with a 2-month-old kidney transplant has elevated creatinine, fever, and tenderness at the graft region. What other finding is likely present? As always, we’re joined by Dr. Karen Shackelford of BoardVitals as we dig into today’s case to help give you a better understanding. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:02] BoardVitals If you're preparing for your USMLE Step 1 or COMLEX Level 1, check out how BoardVitals can help you prepare for your exam. Use the promo code BOARDROUNDS to save 15% off their QBanks. They have the 3-month version with over 1,700 questions. Once you're in medical school, they also have QBanks for the SHELF exams. [02:24] Question of the Week The patient who has a history of kidney failure as a result of multicystic kidneys has an allograft kidney transplant. Two months later, she presents with fever, malaise, and tenderness in the graft region. Her lab work shows a rise in creatinine. What other finding is characteristic of her condition? (A) Hypotension (B) Decreased graft size on the ultrasound (C) Patchy mononuclear cell infiltrates without tubulitis (D) Urinary obstruction (E) Oliguria [03:20] Thought Process The correct answer is E. The oliguria is a frequent finding. She has fever, malaise, and graft tenderness. Some patients can actually be asymptomatic during acute renal transplant rejection. They usually have hypertension that's why answer choice A is wrong. The graft may actually be enlarged on ultrasound. Creatinine only rises when there's significant histologic damage. If the graft rejection progressed, there would be weakness and fibrosis. You would have a decreased graft size but not at this point. Patchy mononuclear cell infiltrates without tubulitis is a pathological description of something that occurs in patients who have a normal functional renal allopath. So the histopathological findings in patients with rejection may have findings of interstitial infiltration with mononuclear cells, sometimes eosinophils. And the tubular basement membrane will be disrupted by these infiltrating cells. This is tubulitis. Along with inch-small arteritis, it's considered the primary lesion of acute cellular rejection. Acute antibody-mediated rejection is characterized by vasculitis with neutrophils, anti-glomerular and peritubular capillaries fibrin, thrombi, or nephrosis. Then there's interstitial hemorrhage, the presence of CD4 and antibody-specific to the donor suggest an antibody-mediated reaction. In chronic allograft dysfunction, you will see peritubular basement membrane splitting and multi-layering of the basement membrane.  The antibody-mediated rejection is an albumin response that occurs as antigen-antibody complex fixes complement with the activation of multiple complement protein. C4D is the component of the normal complement pathway. When C4 is split into C4A and C4B, C4B is then converted to C4D. This binds covalently to the endothelial basement membrane and the collagen basement membrane. In a normal kidney, C4D can be found in the glomerular mesangium and at the vascular pole. But the excessive reduction of immune complex deposition disease results in accumulation in the glomerular capillaries. The CD4 deposition can be seen by monoclonal antibodies staining and fluorescent tissue immunofluorescence. Peritubular capillaries staining is useful in just renal allografts. In acute allogra rejection graft, they appear large. Urinary obstruction is not the mechanism of oliguria in patients with renal allograft rejection. [09:20] Definition of Acute...

Session 27 A patient with a history of arrhythmia is found to have atrial amyloid deposition on autopsy. Do you know what peptide is associated with this finding? Dr. Karen Shackelford joins us for another round of interesting questions to help you ace your boards. If you haven’t yet, check out BoardVitals and use the promo code BOARDROUNDS to save 15% off. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [02:14] Question of the Week The autopsy of the patient with a history of arrhythmia revealed amyloid deposition in the atria but no other amyloid was found in the ventricles. Which of the following peptides is associated with amyloid deposition in the atria? And what is that peptide's function? (A) Calcitonin and reduction of blood calcium concentration (B) Prolactin and gastric emptying (C) Acetylcholine and positive chronotropy to sinoatrial node (D) Immunoglobulin and cell-mediated immune response (E) Atrial natriuretic peptide and vasodilation [Related episode: Cardiac Electrophysiology—What is it?] [03:15] Thought Process Behind the Correct Answer The correct answer is E. An amyloid is a group of diverse extracellular proteins in variable amino acid sequences and they have common physical properties. Amyloid deposition and the extracellular deposition of the fibrils are composed of the subunit of varied serum proteins that form beta-pleated sheet configurations that lead to the histologic changes seen in amyloidosis. Isolated amyloidosis is found only in a single organ such as this cardiac amyloidosis. Alpha-atrial natriuretic peptide is responsible for deposition in this isolated cardiac amyloidosis. This is what's responsible for amyloid deposition in part. The incidence appears to be maybe part of the normal process of aging. In one autopsy series, 86% of the patients between the age of 81 and 90 had isolated atrial amyloidosis. It may lead to heart failure. Although diuretics are commonly given to patients with heart failure due to cardiac amyloidosis, beta-blockers, calcium channel blockers, and ace inhibitors may be harmful. [05:55] Understanding the Wrong Answer Choices Calcitonin is associated with isolated amyloidosis of the thyroid. Prolactin is associated with lactation found in amyloidosis that is isolated to the pituitary gland. Acetylcholine is the negative chronotropic sinoatrial node in the right vagus nerve. The stimulation of the nerve decreases the firing of the SA nodes, increasing potassium and decreasing sodium and calcium movement to the cell. Finally, immunoglobulin amyloid deposition is widespread and it's the result of its light chain immunoglobulin deposition. The point of the question was that isolated amyloidosis can affect many particular organs. This is different from more widespread amyloidosis related to immunoglobulin in terms of ideology and distribution. [07:10] The Big Takeaway Amyloid is not just that atrial natriuretic factor but you have to ask yourself where is it is as you're reading this question. Is it in the parathyroid for prolactin or widespread for the immunoglobulin or is it in the atrium for the atrial natriuretic peptide? [08:11] BoardVitals Check out BoardVitals for their Step 1 and Level 1 QBanks. Use the promo code BOARDROUNDS to save 15% off. This can be used for your SHELF exam QBanks as well. Links: BoardVitals

Session 26 A 20-year-old menstruating adult is tachycardic, somnolent, and hypotensive with GI symptoms and macular rash. What sort of organism do you suspect? As always, we're joined by Dr. Karen Shackelford from BoardVitals. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:35] Question of the Week A 20-year-old female patient presents 5th day of her menstrual period complaining about abdominal pain, vomiting, watery diarrhea, and myalgia for 12 hours. On exam, her temperature is 103.13 F. Her blood pressure is 80/60 mm/Hg. And her heart rate is 135 beats per minute. She is ill-appearing, somewhat somnolent, has hyperemic 02:04 and a generalized erythematous macular rash that involves her palms and soles. Which of the following best describes the cause of her illness? (A) Gram-negative diplococci (B) Gram-negative obligate intracellular bacteria (C) Gram-positive facultative anaerobic cocci (D) Single positive stranded RNA virus [Related episode: Biology Grab Bag of Questions for the MCAT] [02:50] Thought Process Behind the Correct Answer The correct answer here is C. The patient has toxic shock syndrome. It didn't mention in the question but she had an indwelling tampon. Highly absorbent tampons are the biggest risk factor. But interestingly, half of the women who develop toxic shock syndrome during the menstrual period are not using tampons actually. Related to the menstrual period, however, a toxic shock is usually the result of infection by Staphylococcus aureus. It releases endotoxins. But also, 05:33 axis is superantigen. And that's what triggers the syndrome. It triggers the activation of T-lymphocyte and they release massive amounts of cytokine. The post-immune response is limited in patients with toxic shock. Studies show that people who end with toxic shock, they failed to develop an antibody against the bacteria that usually developed in up to 95% of the population in childhood. The criteria for diagnosis include fever, chills, hypotension, and dermatologic findings. Evident multi-system organ involvement is at least 3 body systems and that counts the skin. In this patient's case, she had her circulatory system. She had hyperemia of her mucus membranes. The maculopapular rash would eventually desquamate after 1-2 weeks. She had nausea, vomiting, diarrhea in the GI system. Her mental status was somnolent. Some people have seizures from somnolence or encephalopathy that the other organ involvement may include intrinsic renal failure or prerenal failure. Myalgias are also sometimes resolved in elevated serum creatinine phosphokinase. hepatic dysfunction is also not uncommon. [07:50] The Treatment If there's foreign body removal, the treatment of any surgical wounds is the rapid administration of appropriate antibiotics. This includes Vancomycin and Clindamycin with the Penicillin that has B-lactamase inhibitor. [08:10] Understanding the Wrong Answer Choices You would probably suspect meningococcal meningitis but then you would have thought they would have given you a clue about the stiff neck. Rocky Mountain spotted fever for answer choice B would also be a good thought. The USMLE Step 1 is going to give you clues to the most typical case. For instance, with Rocky Mountain spotted fever, they would probably mention that the patient was in an endemic area. But they wouldn't necessarily say he was bitten by a mosquito. Finally, Dengue fever is the diagnosis for answer choice D. Remember that they're not going to hand-feed you every single detail. It's not always

Session 25 Dr. Karen Shackelford form BoardVitals joins us once again as we dig deep into a question about the hematopoietic and immune system. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:05] About BoardVitals If you're ready to prepare for your Step 1 or Level 1, go to BoardVitals. Their QBank system is set up to simulate the real USMLE Step 1 and COMLEX Level 1 exams. They have questions that are equally as hard to get you prepared for your exam. Use the promo code BOARDROUNDS to save 15% off when you purchase any of their products. [02:20] Question of the Week A 16-year-old male presents with a complaint of sore throat, fatigue and low-grade fever for three days. Exam reveals glossopharyngeal erythema with white exudates on his tonsils. He has enlarged posterior cervical lymph nodes and the posterior auricular lymph nodes are slightly enlarged. His spleen is palpable on abdominal exam. The throat culture is negative for strep and the monospot is positive. Which of the following findings are associated with the patient's diagnosis? (A) Atypical lymphocyte (B) Eosinophilia (C) Howell-Jolly bodies (D) Sickled erythrocytes (E) Target cells [Related episode: USMLE and COMLEX Prep: Glossopharyngeal Nerve Anatomy] [03:20] Thought Process Behind the Right Answer The correct answer here is A. The enlarged spleen could throw students off as it may make you think about Howell-Jolly bodies. But this is a case of classical mononucleosis with fever, exudative pharyngitis, the tender lymphadenopathy, particularly posterior in the cervical and posterior auricular nodes. Adenopathy in the anterior nodes and the atypical lymphocytosis are the hallmarks of classic infectious mononucleosis. The explanation to this question goes on to discuss the infection of the Epstein-Barr virus. It's a viral replication that begins in the oral pharyngeal epithelial cells with dissemination and infection of B-lymphocytes and the oropharyngeal lymphoid tissue. There is more Step 1 detail here. The infected B-lymphocytes produce antibodies to the viral antigens. But they also produce another type of antibody which could be heterophile antibodies that are not antibodies to the virus, but antibodies to other tissues. Active infection and the reinfection are regulated basically by the Epstein-Barr virus-specific T-lymphocyte. And atypical lymphocytes are activated. CDA plus T-cells and CD16 after killer cells appear in the blood at least 1-3 weeks after symptom onset. Fatigue can persist forever – 6 months or longer in 13% of patients. The splenic enlargement is a big caution for practitioners to remind their patients to avoid contact. The enlargement usually resolves after about 3 weeks. But even without contact, spontaneous splenic rupture is responsible throughout half of the cases. This usually occurs 2 weeks after symptom onset. [06:50] Understanding the Other Answer Choices Eosinophilia is usually associated with parasitic infection. The Howell-Jolly bodies were good distractor. They refer to the basophilic remnants of DNA. The circulating erythrocyte is usually removed in the spleen so they're found in patients who have either no spleen or 07:15. Sickled erythrocytes are associated with sickle cell disease. Target cells are associated with this disorder where the erythrocyte's cell surface is increased disproportionately to the cell volume. An example would be spherocytosis. Links: <a...

Session 24 We're joined by Dr. Karen Shackelford from BoardVitals as we talk about hepatitis and how antigens and antibodies appear and disappear during the course of infection. Please also check out Specialty Stories, a podcast dedicated to helping you figure out what specialty you want to practice. Listen to different physicians as I interview them about why they chose their specialty, what they like and don't like about it, and much more. Maximize your Step 1/Level 1 prep by checking out BoardVitals. Check out their 3 or 6-month plan where you get access to there over 1700-question QBank. Get detailed explanations and rationales for every question targeted to the Boards. Use the promo code BOARDROUNDS to save 15% off. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [02:20] Question of the Week A 45-year-old male presents a sudden onset of flu-like symptoms and yellowing eyes which he thought looks scary to him when he saw his reflection on the mirror. His past medical history reveals positive Hepatitis B infection and his lab's elevated ALT and AST levels. The consult suspects that he may not be superinfected with Hepatitis D. Hepatitis D virus can only propagate in the presence of Hepatitis B. The presence of which of the following components of Hepatitis B viral protein is necessary to allow Hepatitis D infection? (A) HpX (pX antigen) (B) Hepatitis B core antigen (HBcAg) (C) Hepatitis B surface antigen (D) Hepatitis B  e-antigen (E) Hepatitis B virus DNA polymerase [Related episode: What Does Academic Infectious Disease Look Like?] [03:35] Thought Process Behind the Correct Answer The correct answer here is C. Remember the actual viral structures. Hepatitis D envelops single-stranded RNA virus. It can't make its own surface antigens. So it requires Hepatitis B surface antigen. Hepatitis D can only be acquired either by co-infection or superinfection of an HPV carrier of co-infection. But this only resolves in 2% of the cases. HPV is a virulent pathogen.  Superinfection results in chronic hepatitis in over 90% of cases. Often, hepatitis with rapid progression of cirrhosis in about 80% of cases. But the influx of this type of viral infection has significantly declined since the development and widespread use of the Hepatitis B vaccine. However, this is still a problem in developing countries. In a lot of underdeveloped countries, it's passed on through migrants from more developed countries. It's therefore important for people to be aware of their Hepatitis B immunity and their potential for this really virulent superinfection. [Related episode: USMLE and COMLEX Prep: Tropical Medicine—Dengue Fever] [07:35] Understanding the Wrong Answer Choices Hepatitis pX is pX protein of Hepatitis B virus. It's implicated in viral transcription, replication, and increased risk of hepatocellular carcinoma through the expression of this X protein gene. The core antigen is the indicator of active viral replication. It's also a determinant of whether an individual is able to transmit the infection. But this is not the necessary component for the protein. Hepatitis B e-antigen can act as a marker of our replication infectivity but this isn't the necessary component either. Hepatitis B virus DNA polymerase is not necessary for HPV to replicate. HPV is the host...

Session 23 We're joined by Dr. Karen Shackelford from BoardVitals as we tackle a neuro question this week. Maximize your Step 1/Level 1 prep by checking out BoardVitals. They have an amazing QBank that contains targeted questions. If you have a question about a question or explanation, for instance, simply click a button. This will allow you to ask a doctor and get a response within 24-48 hours. Use the promo code BOARDROUNDS to save 15% off. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:13] Question of the Week A patient has a decreased level of consciousness and they're testing the gag reflex. The elevation of the soft palate is symmetric when he touched the left side. But when he touched the right side, there's no response. Which of the following is true relating to this patient's condition? (A) The glossopharyngeal nerve carries efferent fibers that mediate the gag reflex. (B) The ideology of that absent reflex is a lesion of the right glossopharyngeal nerve. (C) The cause of the patient's absent reflex is a lesion of the left vagus nerve. (D) The reflex is mediated through the dorsal motor nucleus of the vagus. (E) Both the glossopharyngeal nerve and the vagus nerve are damaged on the right side. [Related episode: USMLE and COMLEX Prep: Glossopharyngeal Nerve Anatomy] [02:11] Thought Process Behind the Correct Answer The correct answer here is B. The motor limb is mediated by the vagus nerve. Sensory, however, is mediated by the glossopharyngeal nerve. The vagus nerve also carries some sensory fibers through the recurrent laryngeal. If the gag reflex is intact, the soft palate will rise symmetrically regardless of which side is touched. If both the glossopharyngeal and the vagus are damaged on one side, there is no response when touching the contralateral side. The soft palate will rise unilaterally on the side that's intact. Also, there won't be any response whenever you're testing the affected side of the lesion if both nerves are damaged. The vagus nerve is the only nerve damaged and there's a lesion on the single side of it. And the soft palate rises and pull to the intact side. Regardless of the pathway, this is something worth remembering. If the glossopharyngeal is only damaged on a single side, there's not going to be a response on either side when you test the reflex on the affected side. This is because you're not receiving the sensory impulse. Whenever you test the intact side, the palate will rise on both sides because the motor fibers of the vagus nerve are still intact. [06:40] Understanding the Other Answer Choices The afferent fibers of the glossopharyngeal nerve mediate the sensory component of the gag reflex. Hence, answer choice A is wrong. For C, if the left vagus nerve or the motor nerve was damaged on the left side resulting in an elevation of the soft palate on the right no matter which side was tested. In other words, this is the lateral lesion of vagus nerve. There's also the elevation of the soft palate to the contralateral side regardless of which side you're testing. For option D, this is also wrong because the reflex is mediated through the nucleus ambiguus. For E, if that were the case, then there would be no response at all when testing the right side or the side of the lesion. There would also be no response when testing the left side because the motor portion is damaged on the side of the lesion. Hence, there'd be an asymmetric elevation of the soft palate on the contralateral side. [08:45] BoardVitals Maximize your...

Session 22 Today, we tackle a pathophysiology question related to pancreatitis. Once again, we're joined by Dr. Karen Shackelford from BoardVitals. Check out their QBanks containing 1,700+ questions for Step1/Level 1. Use the promo code BOARDROUNDS to save 15% off. [01:50] Question of the Week A 45-year-old male presents to the hospital with abdominal pain and vomiting. He began to experience a dull pain in the epigastrium two days prior to admission that has progressively worsened. The pain radiates to his back. He's had several episodes of bilious non-bloody vomiting. He has no prior medical conditions. And he takes no medications. He has a 20-pack per history of tobacco and drinks 6-10 beers daily. The vital signs vary, has a temperature of 100 degrees Fahrenheit, and a heart rate of 102 beats per minute. He appears uncomfortable. On exam, his abdomen is soft and mildly distended, with marked right upper quadrant in epigastric tenderness to palpation. There is no rebound or guarding. He has hypoactive bowel sounds and no palpable masses or hepatosplenomegaly are appreciated. Laboratory studies through the hemoglobin of 12.8 g/dL, leukocytes 14,500 cells per mm3, with 81% PMNs and 16% lymphocytes. Platelet count is 178,000 and total bilirubin is 1gm/dL with the direct bilirubin of 0.4 g/dL. Alkaline phosphatase is 90 IU/L and aspartate aminotransferase (AST) is 88, alanine aminotransferase is 78, and serum amylase is 1,447 IU/L. What is one of the pathophysiological mechanisms of this patient's condition? (A) Pancreatic duct obstruction due to a stone (B) Activation of pancreatic stellate cells (C) Viral infection (D) Intraductal stone formation (E) Toxic fatty acids in pancreatic microcirculation [04:00] Thought Process Behind the Correct Answer Hemoglobin is normally low. White blood cells are minimally elevated. Platelets are normal. Bilirubin is a little bit elevated. Alkaline phosphatase is slightly elevated as well as the aspartate aminotransferase (AST), alanine aminotransferase and amylase. The condition of the patient is actually pancreatitis. The lipase is also slightly elevated which is more specific for pancreatitis and amylase which can be released by other cells as well. The most common cause of pancreatitis is gallstone pancreatitis but this guy has a history of pretty heavy drinking. The second most common cause of pancreatitis is related to alcohol. It's not clear though exactly how they're related but most chronic alcoholics do not end up with chronic alcoholic pancreatitis. But there may also be other risk factors to be considered here. One of the mechanisms is the hyperactivation of the pancreatic stellate cells. These cells that get activated by alcohol as well as by acetaldehyde. They regulate the deposition and the degradation of the pancreatic extracellular matrix protein. They secrete the matrix proteins and metalloproteinases that degrade the matrix proteins. So they regulate all the extracellular matrix proteins in the pancreas. Whenever they're overactivated by phenol and acetaldehyde, the metabolite of ethanol, the matrix becomes fibrotic. That's one of the mechanisms of chronic pancreatitis. Another interesting thing is that the stellate cells also express ADH and whenever overactivated, it seems to perpetuate a cycle of autocrine reactivation. So it's self-perpetuated. Another mechanism of alcoholic pancreatitis is that the alcohol is metabolized by both oxidative and non-oxidative mechanisms. There are changes in acinar cells that increase the activation of intracellular digestive enzymes. Hence, there's an autodigestive component. There is a transient decrease in pancreatic blood flow that results from the action of ethanol....

Session 21 Today, we’ve got some interesting case of a 14-year-old male with some malaise and abdominal pain. Once again, we're joined by Dr. Karen Shackelford of BoardVitals. Check out the resources they have to offer. Use the promo code BOARDROUNDS to save 15% off upon purchasing a QBank. Also, they have an Ask a Clinician feature where clicking a button gives you access to a physician who will help you through specific questions or content. This feature comes with their 3-month and 6-month plan. This podcast is part of the Meded Media network where we help premeds and medical students as they journey towards becoming great physicians. [02:15] Question of the Week A 14-year-old male is evaluated for malaise and abdominal pain. He reports passing dark urine this morning. His past medical history is significant for Streptococcal pharyngitis ten days ago, for which he received Amoxicillin. Today, his vital signs are within normal limits, except for an elevated blood pressure of 145/95 mmHg. Examination reveals spatial edema with pronounced periorbital swelling. He has 1+ pedal edema bilaterally. Abdominal exam reveals mild, diffuse tenderness without rebound or guarding. Laboratory studies are unremarkable except for a serum creatinine of 2 mg/dL. What is the common finding associated with the patient's condition? (A) Hypovolemia (B) Polyuria (C) Red blood cell cast (D) Hypokalemia [03:30] Thought Process Behind the Answers The correct answer here is C. Basically, the patient has glomerulonephritis. This is characterized by red blood cell casts that are almost pathognomonic for glomerulonephritis. Poststreptococcal glomerulonephritis is not common but also not unusual. The history of streptococcal pharyngitis should lead to that conclusion. Other symptoms of glomerulonephritis include white blood cell casts, hematuria, and proteinuria. But for this question, you have to hone in on the glomerulonephritis. Other findings in the urine sediment include granular casts. Dysmorphic red blood cells are strongly associated with glomerulonephritis and proteinuria. This is clinically manifested by a slow and progressive rise in serum creatinine and fluid hypertension, peripheral or periorbital edema, and sometimes, hypercoagulability. Rhabdomyolysis may come to mind but it wasn't really an option among the choices. This could happen on the boards. There might be systemic manifestations of some underlying disease process associated with glomerulonephritis. There's a group of immunologically triggered disorders that result primarily or characterized by glomerular inflammation. It can also manifest the proliferation of glomerular tissues that damage that basement membrane, mesangium, or the capillary endothelium. [07:15] Understanding the Other Answer Choices Glomerulonephritis is associated with hypervolemia. In this case, you have the proteinuria. But with the edema, you should immediately be able to figure out that it wasn't associated with hypovolemia. The patient had pedal edema and periorbital edema. It is also important to mention that there are three primary mechanisms of glomerular inflammation. And what distinguishes a nephrotic syndrome from glomerulonephritis is the inflammation as a mechanism of damaging the glomerular apparatus. This might come in the boards that the mechanisms are either immune complex deposition as in this case. Anti-glomerular basement disease is associated with Wegener's granulomatosis, eosinophilic granulomatosis with polyangiitis, or microscopic polyangiitis. The other mechanism is the antineutrophil cytoplasmic autoantibody (ANCA) or small vessel vasculitis. It causes damage to the glomerular filtration barrier. This...

Session 20 Today, we tackle another maternal-fetal or pregnancy question. We're joined once again by Dr. Karen Shackelford from BoardVitals. They offer a comprehensive QBank for Step 1 and Level 1. And even as you continue on your medical school journey, they have QBanks for Shelf exams as well. Use the promo code BOARDROUNDS to save 15% on your purchase. Or text BOARDROUNDS to 44222 and we'll send you the link and promo code. [01:58] Question of the Week A 39-year-old G1P0 presents at 37 weeks of gestation. She has not noticed any fetal movement for the past six hours. The fetal heart rate is 110 and a nonstress test was performed and it's nonreactive. Which of the following statements is correct? (A) A fetal heart rate of 110 is abnormal. (B) Fetal heart rate acceleration results from dopaminergic stimulation. (C) Fetal hypoxemia usually leads to light decelerations. (D) Fetal head compression results in reflex flowing of the fetal heart rate. (E) Usually, a nonstress test leads to a reduction in neurologic injury and fetal death. [03:10] Thought Process The correct answer here is correct C. The non-stress test should be reactive and a fetal heart rate of varies a bit. And around 110-160 is normal. But the non-stress test is the most commonly used method. There's no evidence, however, that improves fetal outcomes in pregnancy. This is still initiated in women at about 26-28 weeks of gestation. For fetal hypoxemia and high-risk pregnancies, the older patient is a high-risk pregnancy. It actually starts at the age of 34-35. A reassuring test doesn't mean all is well. It only reassures fetal wellbeing in terms of oxygenation. The fetus moving is characterized by two or more fetal heart rate accelerations. And they peak at least 15 beats per minute above the fetal baseline. This would last at least 15 seconds before returning to baseline. That's the over 20-minute interval. A nonreactive nonstress test can reflect fetal hypoxemia or acidosis. It can also be caused by maternal smoking, fetal sleep, fetal immaturity, cardiac anomalies, and sepsis. If the mother is taking on the cardio-acting medication, it will result in changes in the fetal heart rate. But they don't necessarily indicate fetal problems. Links: BoardVitals (Use the promo code BOARDROUNDS to save 15% on your purchase. Or text BOARDROUNDS to 44222 and we'll send you the link and promo code.

Session 19 Today, we have Dr. Karen Shackelford from Bard Vitals, joining us as we break down another question. Meanwhile, have a look at Meded Media for more resources available to premeds and medical student. Another podcast medical students could listen to is Specialty Stories, where I talk to different physicians about their career and their specialty. They talk about why they chose it and what they like about it. Also, learn about what you as a medical student could be doing to make yourself more competitive for this specialty. [01:40] Question of the Week: A young woman is 26 weeks pregnant. She's 25 years old. Gravida 1 Para 0. 26 weeks gestation. She came into the emergency department complaining of leaking vaginal fluid for about three days, not huge, just some leaking. She's had some intermittent contractions but they're fairly infrequent. A sterile speculum exam is performed. It revealed some pale, yellow, watery fluid in the vaginal valve. Her cervix is dilated 4 cm. The vaginal fluid is tested, has a pH of 7.1. This is at an academic center where they still do the Fern test with arborization when the fluid is examined under a slide. An ultrasound is performed and it reveals oligohydramnios.   Which of the following measures is appropriate in the management of this patient? Her lab results and her pee is negative for Group B Strep. (A) Ovarian section (B) Flush immediate delivery (C) Antibacterial prophylaxis for Group B Strep (D) Tocolysis (E) Supplemental progesterone [03:30] Thought Process There is a premature rupture of membranes (PROM). If it were a placental abruption, we can take it to a C-section. But for PPROM (preterm PROM) before 37 weeks, you want to delay the delivery as long as you can. So the correct answer here is the antenatal steroid therapy to mature the lungs. Most women who have PPROM deliver within a week. If it is within 7 days, you should initiate the steroid therapy. The management of PPROM would depend on factors like the gestational age, the presence or absence of infection, presence or absence of labor, any sign of abruption. Fetal stability and heart monitoring should also be managed. The American College of Obstetricians and Gynecologists (ACOG) recommends that women who have PPROM who are more than 34 weeks of gestation should deliver. But it doesn't need to be a C-section. Normal spontaneous or induced vaginal delivery is fine. In women less than 34 weeks, the pregnancy should be managed expectantly just until fetal maturity development. As long as the fetus is stable, the fetus will benefit by prolonging time in the uterus. Having the antenatal steroids will improve lung maturation. But you have to balance that with the benefits like expectant management against the risks associated with like a prolonged PPROM. Placental abruption is an increased risk as well as cord prolapse or cord compression. [06:40] Looking at the Other Answer Choices In the lab results, the patient had a negative Group B Strep test. Antibacterial prophylaxis for Group B Strep is indicated if somebody delivers within 48 hours in an unknown status or a positive test. But you give these patients antibiotics as it prolongs the latency of the pregnancy. It's generally associated with better fetal results. It reduces respiratory distress syndrome and neonatal death. It reduces the risk of intraventricular hemorrhage, necrotizing enterocolitis, and all preemie problems. It also reduces the duration of neonatal respiratory support needed. There's no increase in maternal or neonatal infection to balance that. ACOG recommends the...

  Session 18 As always, I'm joined by Dr. Karen Shackelford from Board Vitals. If you haven't yet, check out Board Vitals and use the promo code BOARDROUNDS to save 15%. They have a huge database and question bank to help you get the practice you need to get the score that you need. [01:35] Question of the Week An older patient comes in with a painful rash. We have a 64-year-old female who presents complaining of a severe painful rash that is localized to the left side of her upper back and neck. She knows that the area of the rash feels hot and burning and extremely painful. She is otherwise healthy with no significant past medical history. On exam, her vital signs were within normal limits. And her exam is significant, primarily, because she has a large, red vesicular rash running along her left shoulder in confluent patches. She remarks that the lesions were smaller a few days ago and they quickly start to bubble over into larger 02:39. The physician performed a Tzanck smear to confirm her suspicions. She found the test to be positive for multinucleated giant cells. The patient will have which of the following characteristics? (A) Gram-positive, catalase-positive, beta-hemolytic and arranged in clusters (B) Branching pseudohyphae with budding yeast cells (C) Enveloped-virus with double-stranded DNA (D) Enveloped-virus with positive-strand RNA virus [04:30] Thought Process The correct answer is C. Varicella zoster virus would probably come to mind as well as shingles as the Tzanck smear showed multinucleated giant cells – herpes simplex virus 1 and 2 (HSV 1 and 2) as well as pemphigus vulgaris. Other findings you would probably see on the Tzanck smear would include acantholytic cell and keratinocyte ballooning. This test is not typically performed usually as a clinical diagnosis. But it can be performed in the office. The patient can be immunocompromised with atypical looking lesion or atypical presentation. So we'd think of herpes and varicella zoster. For the other answer choices, Choice A is Staphylococcus aureus, which isn't a choice for a skin infection. Choice B is a fungus. A fungal disease like Candida can cause a really nasty rash. But it won't be the vesicular nor the dermatomal, which this question suggests. Varicella zoster virus is latent in the sensory ganglion so it tends to erupt on one or two contiguous dermatomes, although it can erupt outside of the dermatome. But it's not going to be a big eruption and just one or two vesicles scattered somewhere else from reactivation of the viral particles. Option D is Rubella. It causes a rash and it's usually tested for IgM antibodies. If a test is needed, it's not the Tzanck smear. [07:45] Possible Question Points About the Herpes Virus About 30% of Americans will have it at some point in their lives coming from reactivation of the virus. It causes two clinically distinct diseases including chicken pox. Chicken pox would be characterized by vesicular lesions but they're on different stages of development. They're concentrated on the face and the trunk. It's an airborne virus that invades the lymphoid tissue in the nose or nasopharynx. The virus overcomes local host defenses. The epidermal cells usually react by making alpha-interferons. That's the incubation period. When the virus can overcome the local host defenses, then you've got a viremia. Then the virus downregulates your immune response through a variety of mechanisms, such as the inhibition of the expression of interferon response genes. When the virus remains latent for years in most cases, you're more at risk of reactivation as you get older because you have a diminished...

Session 17 Dr. Karen Shackelford from BoardVitals is joining me once again for another round of discussion. This week, we tackle a certain kind of pediatric illness. [01:11] Question of the Week: A 10-year-old male patient is evaluated for abdominal pain he has had for two days. He has a rash on his buttocks and thighs. It appeared about three days ago. He's also complaining of some pain in his ankles and knees. His past medical history is unremarkable. But he was seen in the clinic two weeks ago with symptoms of an upper respiratory infection. On physical exam, his abdomen has standard palpation. 01:42  He has multiple palpable purpuras on his buttocks and upper thighs. 01:50 His ankle is swollen and tender on the right. There's no warrant for eczema. His knee is tender. But otherwise, his exam was unremarkable. His laboratory study is showing a normal CBC. On urine 02:09, he has microhematuria. What is the most likely diagnosis? (A) IgA vasculitis (formerly Purpura) (B) Hemolytic uremic syndrome (C) Kawasaki disease (D) Acute post-streptococcal glomerulonephritis [03:40] Thought Process The correct answer here is IgA vasculitis. The palpable purpura on the buttocks and lower extremities is one of the criteria you have to have for purpura, without thrombocytopenia. The other symptoms this patient has, where you could have one or all of these other symptoms, including polyarthralgia, usually in the hip, ankle, and/or knee joints. GI symptoms include abdominal pain, nausea, vomiting, 05:26  or intussusception. Thi has renal involvement, without thrombocytopenia or coagulopathy. These are the two big things. As mentioned, the CBC was normal and he did have the proliferative glomerulonephritis, which occurs with the IgA deposition in the glomeruli. Leukocytoclastic vasculitis is characterized by leukocytes. Neutrophils or monocytes are around the small vessels – the arterioles and venules. There's IgA deposition. There can be IgG or IgM. There is complement C through a deposition. This is what you would see in a biopsy. The lesions are generally in the GI tract or in the skin (which are typically the ones that are biopsied). But if the patient does develop the glomerulonephritis, renal biopsy will show that. That doesn't develop in every case. The disorder is self-limited so treatment-supportive. It's an immune complex seen usually after an upper respiratory infection. In one case series, it has been associated with the MMR vaccine, although this might not have been held up in the later studies. This is also common between the ages of 3 and 11. One of the diagnostic criteria is that the patient has to be under 20. [07:35] Going Through Other Answer Choices In hemolytic uremic syndrome, you can have 07:41 purpura, although they're non-palpable and they're palpable in an 07:49 purpura. That occurs in hemolytic uremic syndrome due to thrombocytopenia. And this patient has a normal CBC. Hemolytic uremic syndrome is usually associated with E.coli infection in the previous case of diarrhea. But there's no history of that in the patient. There is abdominal pain but the rash is not limited to the lower extremities and buttocks. That is characteristic of HSP IgA vasculitis. Kawasaki disease usually occurs in children under the age of 4. The case will usually present a child of Asian descent. It's more prevalent in Japanese children who are at a high risk of IVIG resistance. They will generally have conjunctivitis and fever for more than 5 days. They have that strawberry tongue. The skin manifestations are non-palpable purpura, but there are periungual desquamation and hand-and-foot erythema. Acute post-streptococcal...

Session 16 We're joined once again by Dr. Karen Shackelford from BoardVitals. This week, we discuss a case about an immigrant from Central America who's pregnant. [01:30] Question of the Week: A 26-year-old, G1P0 female is a recent immigrant from Central America and she presents with crampy abdominal pain and vaginal bleeding. By her dates, because she hasn't received prenatal care. She's of 25 weeks gestation and her past medical history is unremarkable. She takes an over-the-counter multivitamin but no other medication. She denies alcohol, tobacco, or illicit drug use. And she spontaneously delivers a stillborn fetus. The fetus is noted to have microcephaly and imaging performed reveals thinning of the cerebral cortices, ventriculomegaly, and subcortical calcifications. Viral RNA is identified in both maternal and fetal body fluids. The virus is a neurotropic virus that disrupts proliferation migration and differentiation of neural precursor cells in the developing fetus. Which of the following is the most likely pathogen? (A) Herpex simplex virus (B) Rubella (C) Zeka virus (D) Cytomegalovirus (CMV) [03:50] Thought Process The pathogen here is Zeka virus. CMV is a pretty good distraction here since the question mentioned ventricular calcification. But with respect to being a neurotropic virus, Zeka is and has been in the news a lot. It's a single-stranded RNA virus transmitted by mosquitoes. It's also related to dengue virus and the yellow fever virus. The infection results in clinical manifestations in about 20% of people and the rest would not know they've had it. If you're infected, you're symptomatic. You have a low-grade temp. You can develop a maculopapular rash, arthralgia, and conjunctivitis. There are other neurologic complications besides the general microcephaly. You can end up with Guillain-Barre, myelitis, meningoencephalitis, seizures, and congenital spasticity which the mother has vertically transmitted during delivery or it can be transmitted through the placenta. It can also be sexually transmitted and through other body fluids. It can also be caused by laboratory exposure such as the transplant of infected organs. It's fairly infectious. [05:42] Pregnant Women Should Avoid Infested Areas Pregnant women in the United States have been advised across the board to avoid travel in regions where mosquito transmission of Zeka occurs if they're going to be less than 6500 feet in altitude. This is the same thing with malaria in some parts of Kenya. [06:12] Understanding the Other Viruses CMV is a double-stranded DNA virus. The question mentioned specifically that the virus was an RNA virus. So this would be one reason you would disqualify CMV from your correct answers. But general CMV infection can result in chorioretinitis, hearing loss, jaundice, and periventricular calcification on imaging studies. CMV is not associated with tropical travel or immigration. Rubella is a single-stranded RNA virus. Congenital exposure is primarily associated with hearing loss, cataracts and congenital cardiac defects instead of neurological defects. HSV is a double-stranded DNA virus. Congenital exposure is associated with skin lesions and obstruction of brain tissue. The candidate here can rule out HSV for no other reason than it's a DNA virus. [07:55] Expand Your Knowledge and Be Up-to-Date Zeka has been in the news a lot lately. And content gets updated on USMLE. So you should be aware of these things even if you just hear about them once or twice while you're studying. You're more likely to diagnose it than if you don't remember hearing about it at all during your...

Session 15 This week, we're joined by Dr. Karen Shackelford from BoardVitals. If you're looking for more prep with your USMLE Step 1 or COMLEX Level 1 training, visit BoardVitals and check out their QBanks for Step 1 and Level 1. Sign up for either 3 months, 6 months, or even 1 month. Your signup will have a vaccine donated through the #GiveVax program. If you sign up for the 3 months and 6 months, you'll get access to Ask a Clinician, where you can connect with the BoardVitals medical experts to answer your content questions. Use the promo code BOARDROUNDS to save 15% off of your purchase. [02:17] About Dr. Karen Shackelford Karen is a former ER clinician. She did her residency in medical school at the University of Mississippi. She eventually moved to Pennsylvania and began working remotely with BoardVitals as a contributor and editor. [03:20] Question of the Week A 35-year-old female patient returned 10 days ago from a mission trip to Nigeria. He was evaluated in the clinic a week ago, complaining of a high fever. She had a rash on the axilla, face, and extremities. The symptoms she had experienced were similar to some she had two years earlier after returning from the same mission trip. Those symptoms resolved with only symptomatic treatment. Today, her husband took her to the emergency department reporting that her fever had resolved two days ago. But she began to complain about abdominal pain and then she appeared very lethargic. On exam, her skin is cool and blocky. She had circumoral sinuses. Her pulse is weak and rapid. And her blood pressure is 80/60 mm Hg. She has a diffused confluent rash and her liver 2 cm below the costal margin. Laboratory studies are significant for a platelet count of 70,000 cells/mL. White blood cell count is 2,000 cells/mL with predominant lymphocytosis. Her serum aminotransferase is elevated. Which of the following is most likely caused by these severe symptoms? (A) Has bacterial super infection (B) Inoculation with a larger viral load (C) Antigenic drift (D) Different viral serotype change [05:08] Thought Process Behind the Answer Antigenic drift is characterized by small changes in the viral structure. It denotes spontaneous changes in the viral type. This is how viruses avoid getting destroyed by vaccines. Serotype is defined as a serologically different strain of microorganism with slight structural differences. They're classified together and have the same type of immune response. But just with a slight variation in their effect on the immune system. The correct answer here is D. The patient, in this case, is her second infection with Dengue Virus but with a different serotype. There are four serotypes of that virus. It's not atypical for somebody to have a mild case that resolves or even asymptomatic initial infection. At that time, the virus presents to a naive immune system. The second time around, it triggers a more significant immune response instead of immunity because of the antigenic differences that the virus responds to. A lot of these viruses are becoming more common in areas that people routinely travel to. A severe viral infection can resolve in hemorrhagic fever and epistaxis, hepatomegaly, circulatory shock. And it resolves through increased capillary permeability because the immune system is having a fluoric response to this second exposure to a slightly different serotype. [10:05] Third Infection If she had a third infection with Dengue Virus, it could be another viral serotype which can be potentially harmful. Although you might have some measure of immunity against the same one. When somebody comes into the office in the Emergency Department with a history of travel to the tropics and they...

Our psychiatry question is asking us to identify the description of behavior for our 38 y/o male patient. Follow along to test your knowledge of psychiatry!

Session 13 We have a great musculoskeletal question for today. As always, we’re joined by Dr. Andrea Paul from Board Vitals. [01:30] Question A 27-year-old male is undergoing evaluation for left foot weakness. On his exam, he’s unable to curl his toes. He has one of five strength with plantar foot flexion and five out of five with dorsiflexion. His foot is everted at rest and he has decreased sensation on the sole of his foot. What was the most likely mechanism of his injury? (A) Fibular neck fracture (B) Hip dislocation (C) L3 disc dislocation (D) Knee trauma (E) Pelvic fracture [03:45] Thought Process If you have a fibular neck fracture, this will injure your perennial nerve where you will have lots of dorsiflexion and the sensation on the dorsum of the foot. So choice A is out L3 is too high up as well. This involves the sciatic nerve. The patient would have felt a neuropathic pain down the back of the leg. Hip dislocation is unlikely because the patient is a 27-year-old. This is pretty uncommon. But if he did, then that would have affected the gluteal nerve. This would make it difficult for him to stand up or extending his hip. Pelvic fracture would be more of the femoral nerve, affecting hip flexion and extension. The knee trauma is the right answer here, If they had said posterior knee trauma, this would have made the exam a little easier.  Specifically, this is a tibial nerve injury. It typically runs right down the middle of the back of the popliteal fossa. So any knee injury is going to affect the nerves and vessels that run through there. When you have an injury in the tibial nerve, the commonplace for pain is the back of the knee. This is a common sports injury, although other things can cause this too. One example is when you’re wearing shoelaces being tied around the calf. Casks can cause this as well as ankle fractures. [08:47] Tibial Nerve Affecting the Knees and Ankle It’s asking what’s “most likely” so just keep that in mind. And typically, this is a very common injury known as the tibial tunnel syndrome. It most commonly occurs at the back of the knee. The tibial nerve passes right behind the medial malleus before it goes around the foot so the ankle area would be affected here too. [11:44] Board Vitals Check out Board Vitals for some help with your Step 1 or Level 1 exam. They have the 6-month, 3-month, or 1-month access to their QBanks and Practice Tests. Get custom practice test as they simulate real test conditions. Use the promo code BOARDROUNDS to save $50 off your purchase. Links: Board Vitals (Use the promo code BOARDROUNDS to save $50 off your purchase)

Session 12 Today, we have a question regarding a 65 y/o patient with a GI bleed. Our job is to find where in the GI tract she is most susceptible to ischemia We're joined once again by Dr. Andrea Paul from Board Vitals. If you're looking for a QBank to help you with your Step 1 or Level 1, check them out. Use the promo code BOARDROUNDS to save 15%. You may also sign up for a free trial to get a feel of what their platform is all about. They have over 1,750 questions for Step 1 and over 1,500 questions for Level 1 – enough to help make sure you have the knowledge necessary to get the best score possible. [02:55] Question of the Week A 65-year-old female develops abdominal pain, bloody diarrhea 24 hours after undergoing hemicolectomy for recurrent diverticulitis. Her surgery was complicated by hypotension, blood pressure down to 70/50, treated, and her medical history is remarkable for diverticulitis, hypertension, dyslipidemia, coronary artery disease, no other episodes of any GI bleeding in the past. Her last colonoscopy was normal four years ago. The patient's current condition most likely involves pathology affecting which of the following portions of the intestine? (A) Cecum (B) Splenic flexure (C) Ascending colon (D) Transverse colon (E) Hepatic flexure [04:25] Understanding the Question The key here is that the patient underwent hemicolectomy for diverticulitis which led to hypotension. So there was some interop issue. And reading her problem list, she's got a coronary vascular disease. She's prone to having some sort of ischemia somewhere. But first, we need to understand what is being asked for. So here, they're asking where along the chain of the GI tract is someone most vulnerable to ischemia. "Read the question first so you have that in mind when you're reading the whole case." [06:35] Thought Process in Answering the Question The arterial supply to the intestine is pretty complicated and not really something that makes sense intuitively. What you need to remember here is that for most of the blood supply is from the superior mesenteric artery as well as the inferior mesenteric artery. Then there's a lot of collateral blood supply too and this great. But there are some couple of areas that are particularly prone to ischemia, even a brief hypotensive episode and someone who's vulnerable like this patient. Those are sometimes called watershed areas. They're in between those major vessels and there are not a lot of collateral supply. The two most common places this happens are the splenic flexure and the rectus sigmoid junction. This is because the large vessels are compromised. There is no adequate collateral blood flow specifically in those two places. Hence, the correct answer here is B. [08:30] Understanding the Other Choices The cecum is supplied by the branches right off the superior mesenteric. It's not particularly prone. The same with ascending colon. Transverse colon receives its blood supply from the middle colic artery, which is a branch of the superior mesenteric. Hepatic flexure is also supplied by that large vessel. [09:30] Some Studying Tips Again, the key to this was the hypotension interop. Andrea says that if you've done a few hundred GI questions, you will see something about hypotension and ischemic colitis somewhere in your readings. If you haven't, the key is looking at the word "current." So it's trying to indicate not what they came in for but it's their current problem. So this could help you rethink and realize that they're not asking for diverticulitis but what happened. Ultimately, you have to make sure you understand what you're reading. A lot of the questions may not be a post-operative situation. It could just be a question about a patient coming in with bloody diarrhea,...

Session 11 Today, we discuss a more straightforward, neuro-anatomy question about the glossopharyngeal nerve. As always, we’re joined by Dr. Andrea Paul of Board Vitals. If you’re in the market for QBanks and practice tests for the USMLE/COMLEX, check out Board Vitals. Use the promo code BOARDROUNDS to save 15% on your purchase. [02:00] Question Which of the glands of the options below are innervated by the efferent autonomic fibers of the glossopharyngeal nerve? [02:14] Answer Choices You have to know what the glossopharyngeal nerve and what type of fibers are innervating the glands. Answer choices: (A) Nasal (B) Submandibular (C) Sublingual (D) Parotid (E) Lacrimal [02:45] Thought Process in Answering the Question Glosso refers to the tongue and pharyngeal refers to the pharynx area. So this is somewhere around the mouth. The interesting with glossopharyngeal is that it has a range of effects. Some of the places it touches would surprise you. But first, you can eliminate nasal. But the rest of the choices could be fair game. This specific nerve has a lot of sensory – parasympathetic and motor functions. It's tough to answer so this can be challenging to people. This nerve starts at the medulla and coming out of the jugular foramen. It's traveling through both anteriorly and posteriorly. So it has a branch that goes to the inner ear. Lacrimal refers to the tear ducts so you can get rid of this one too. Now, we're down with three choices. [06:55] Choosing Among the Three First, remember the motor functions. So it's innervating the muscle in the pharynx and then you think through the sensory functions. Glossopharyngeal is sensory to the posterior third of the tongue or the back half of the tongue. If you can remember that section of the tongue, it leads you closer to the location of the gland that may be in that area. It's also going up into the middle ear, the Eustachian tube for sensory function. Anatomically, you start to think more up anterior than sublingual. Think of it as more of in the ear area. So the correct answer here is the Parotid gland, which is the only gland that doesn't receive any autonomic innervations from the facial nerve. So it receives that from the glossopharyngeal nerve. This is the main differentiator. Hence, the exam likes to ask about it. The posterior third of the tongue and the middle ear are things they love to ask about glossopharyngeal. Also, know which muscles are innervated, which is the stylopharyngeus in the pharynx. Also, try to remember the path and the branches. It sends a branch up to the middle ear. There are five other branches. One goes to the stylopharyngeus muscle, one is the pharyngeal branch, one is tonsilar, one is sublingual, and then one goes to the parotid body and sinus. You can draw this to help give you a visualization. Afferent refers to the sensory nerves coming back towards the central nervous system and efferent refers to "going away" for motor function. In terms of understanding parasympathetic vs sympathetic, just remember that most glandular effects are parasympathetic just like most of your organs. [12:24] Board Vitals Check out the QBank and practice tests over at Board Vitals to help you be prepared for your exam. They have over 1,750 questions for USMLE and over 1,500 questions for COMLEX. Get a 1-month, 3-month, or 6-month plan. They all come with a free trial. No credit card required. Use the promo code BOARDROUNDS to save 15% on your purchase. Links: Board Vitals (promo code BOARDROUNDS)

Session 10 This week, we're going to tackle respiratory stuff, specifically about cystic fibrosis. Again, we're joined by Dr. Andrea Paul from Board Vitals. This podcast is part of the MedEd Media Network. Please share us with fellow residents as well as medical students and premeds who are also on this path towards becoming a physician. [02:41] Question of the Week: An 8-year-old boy is presenting with a history of recurrent respiratory infections. His parents are complaining that the patient complains of fatty stools. Positive sweat chloride test confirms his diagnosis. The patient will likely have difficulty storing which of the following: (A) Folate (B) Vitamin B12 (C) Vitamin C (D) Vitamin D (E) Zinc [03:11] Thought Process Most students would easily be able to identify the condition here would be cystic fibrosis. But this is not what they're asking. So the "sweat chloride" would be a strong buzzword painting that picture of cystic fibrosis. Recurrent infection and fatty stools were also mentioned so that would make you think along the lines of fat digestion and fat storage. What happens here is it brings damage to the pancreas which impairs the production of fat-digesting enzymes or pancreatic enzymes. So you have decreased ability to digest as well as decreased mobility to store fat. This would be down the fat-soluble vitamin route. Then you should be able to pretty quickly identify Vitamin D. [04:35] Other Possible Questions They may ask about inheritance patterns with cystic fibrosis. They love to talk about microbiology with cystic fibrosis. What type of bacteria is commonly found in the sputum of patients with cystic fibrosis? They may also ask about the GI symptoms associated with it. They could ask the background of the symptoms and what tests could be done or what would be found for further diagnostics or imaging of the patients with symptoms that sound suspicious for cystic fibrosis. It could be the whole spectrum of things from presentation all the way through diagnosis and treatment for cystic fibrosis. [05:53] New Therapies Coming Out With so many new therapies related to cystic fibrosis right now, it's hard to say as to how long it would take for these new therapies to be included in the tests. If it's something that came out within that year, it could just be added as a beta question and not necessarily counted in the grading, and then they're just going to add it as a graded component the following year. [07:05] More Things About Cystic Fibrosis When thinking about presentation, look at the symptoms of a patient with cystic fibrosis such as recurrent infections, chronic productive cough, shortness of breath, GI symptoms, especially in infants and young children where you have probably greasy stools, malabsorption-type symptoms. There could also be pancreatitis. On exam, if the kids are not diagnosed yet, you would see failure to thrive. The question might describe that the skin tastes salty or their sweat tastes salty, another hint that they could have cystic fibrosis. Then think about things like chest x-ray seeing hyperinflation. They could put in there what test should you use or maybe they'd mention the results of that test. In terms of genetics, think about other primary cellular dyskinesia or other immunodeficiencies with recurrent infections. Those are the things to keep in mind as differentials. Also, think about prognosis and common complications. There are long term complications of cystic fibrosis such as infertility, drug-resistant infections from having antibiotics chronically from childhood. [09:10] Final Thoughts It could be overwhelming for students with all these bits and pieces of information. But it's doable....

Session 09 In our renal question today we are asked to identify the pattern we would see on electron microscopy. See if you can find where the question leads you! Once again, we're joined by Dr. Andrea Paul from Board Vitals. If you're getting ready to start preparing for your Step 1 or Level 1exam, check out Board Vitals and their QBank. Use the promo code BOARDROUNDS to save 15% off your QBank purchase. For more resources, be sure to check out all our other podcasts on the MedEd Media Network. [02:50] A Challenging Area Renal tends to come up in the top 3 of questions where people are going back because they answered them incorrectly or that they're saving and redoing questions in this category. This indicates a level of less confidence or knowledge gap that needs to be filled for most students. Andrea thinks renal is a challenging area being a complicated system with a lot of memorization involved in the different syndromes. It's a combination of genetics and pathophysiology and pathology. You'd have to be able to do everything from figuring out the disorder and knowing what it would look like on biopsy, looking at diagnostic studies and the physiology involved in the different renal disorders. [04:22] Question A 16-year-old boy presents. He recently immigrated from Russiam, has no major medical problems. He does mention he had an episode of light red urine three weeks ago. At the same time, he had a mild cold. He has no known allergies, no recent drug use or medications. His family has traced positive for kidney disease in his maternal uncle, but both of his parents are healthy. He also mentions that he has had lately noticed that he has mild hearing problem but he's never thought much of that. It's asking a kidney biopsy. This patient would most likely show which of the following: (A) Linear pattern of IGG with fluorescent microscopy (B) Splitting of the glomerular basement membrane (C) Mesangial cell proliferation (D) Epithelial humps or a thickened basement membrane that looks like a train track [05:50] Finding the Diagnosis The first thing to note here is the hearing loss, which is something that would lead you down a specific road. So we're given a little hint here that can be very helpful. Based on history, the hearing loss would be due to Alport syndrome, which is a collage type 4 mutation resulting in abnormal basement membrane, that includes renal involvement, ocular involvement, and sensory neural hearing loss. In this question, the answer you'd look at is the splitting of the glomerular basement membrane. The other way to describe this is the basket weave appearance, also known as the glomerular basement membrane lamellation, characterized by the layering and splitting of the membrane. The key here is the Alport syndrome and remember what the findings would be and that specific disorder. [08:30] Potential Questions One possible question could be what other symptoms the patient may be experiencing. How is this commonly inherited because Alport syndrome can be inherited in a X-linked dominant way. You can also look through everything from genetics all the way through the pathology and electron microscopy for each disorder. Or maybe they won't mention hearing loss but vision symptoms or inheritance pattern they've seen in the family, which they did when they mentioned the maternal uncle. So they've hinted this as well. [09:50] What If There Was No Hint If the question would have left the hearing loss out, they would probably mention a more extensive family history so you could see the inheritance pattern. They're also mentioning hemoturia so you're led to a nephrotic syndrome. That would also help. But they'd probably give you additional information to lead you down a...

Session 08 Step 1 and Level 1 love to test the mechanisms or side effects of medications that treat diabetes. Follow along to test your knowledge of diabetic medications and side effects. Once again, we're joined by Dr. Andrea Paul, Chief Medical Officer at Board Vitals. Reminder to everyone is that you may know the diagnosis but the question is not going to be that simple. So be prepared for so many different levels of questions and knowledge that you have to know. Use the promo code BOARDROUNDS to save 15% off their QBanks. [02:00] Diabetes Medications There are lots of medications for diabetes so it makes it extra complicated and they have their own interesting set of side effects and mechanisms of action that you want to know because they're commonly tested. As you're studying medications, first look at the overarching category. You don't have to remember every single medication within that overarching category. But in some cases like insulin, it's helpful to know the different preparation because they may ask about short-acting or long-acting insulin preparation. But generally, other medications have the same mechanisms and side effects so you can combine those together and just remember by the generic names. Most often, what the test is going to be asking about is mechanism or side effect. [05:00] Question of the Week It's a 56-year-old man with adult-onset diabetes who's visiting his primary care physician. He's been on medication while controlled and his glucose levels have improved. But now, he is presenting with his glucose levels trending up over the last 6 months. His A1C trending up and they want to add a second medication. There's a worrisome side effect of the second medication and it's asking you to narrow down, looking at the different options of what you could add to what he's already on. So you need to think about which of those has a worrisome side effect. He's on Sulphonylurea and when you think about that category of medications, you start thinking that glucose normally triggers an insulin release from the pancreatic beta cells. They mimic the action of glucose so they close those channels in the cells and that depolarizes them which leads to insulin release. Then when you think about toxicity, that's the category of drugs where you think about disulfiram reaction and hypoglycemia. With insulin, if you take more than what's necessary, there's a worrisome side effect of hypoglycemia. Then you start thinking through which of the other categories have something that they would categorize as extremely worrisome. That would knock out things like hypoglycemia because that's the side effect of almost every antidiabetic medication. You'd start thinking down the path of severe toxicity and the only medication that has that is the Glitazone category. Those are the medications where their mechanism is they bind receptors that modulate insulin sensitivity. They will increase your insulin sensitivity and decrease gluconeogenesis, increase the number of insulin receptors. They're known for cardiovascular and hepatotoxicity which is something you have to remember about that category. If you look through all of the other diabetic medication categories, none of them have as worrisome or a severe side effect as that category does. [08:20] What's the Worrisome Effect? In this case, the answer is hepatotoxicity. The way you can narrow it down is knowing that he's already on a sulphonylurea and they're adding something that causes a very worrisome side effect. You can immediately narrow it down and find the medication in the list of options that fall into that category. Choices: Hypoglycemia Renal dysfunction Liver dysfunction Peripheral neuropathy Gastrointestinal dysfunction [09:30] Getting to Your Answer...

Session 07 We often associate biochemistry with undergrad, but biochemistry is present in many specialties! Let’s dive into the types of biochem questions you may see! We're joined once again by Dr. Andrea Paul from Board Vitals as we help you prepare for your first board exam so you have what it takes to score high and match into your specialty of choice. Use the promo code BOARDROUNDS to save 15% on your QBank purchase. [03:30] Why Biochemistry? Biochemistry is more applicable to some specialties than others. But just basic genetics and metabolic diseases, for instance, are seen in many specialties. Biochemistry comes into play especially when you talk about metabolic diseases. Hence, it's a commonly tested subject on the exam, more than the other basic science components. [04:41] Question for this Week: A healthy married couple has a child who develops clinical symptoms of what you suspect to be a rare disease. Genetic testing revealed the patient's mother carries the mutated gene, but the father is not a carrier. However, the father's brother had the same disease, which has also occurred in one of his sisters' sons. This pattern is characteristic of which of the following diseases? Note from Andrea: The question is drawing you a pedigree. You can jot down a little diagram of pedigree for yourself as you're going through it. You have to figure out the pattern from the pedigree but know which diseases of the options fit that pattern of inheritance. Answer choices: (A) G6PD (B) Cystic fibrosis (C) Phenylketonuria (PKU) (D) Alpha-1 antitrypsin deficiency (E) Tay-Sachs Disease [05:50] The Thought Process Behind the Answer Once you've drawn that pedigree and determined what the inheritance pattern is, you can go through each option and cross out what doesn't fit or jot down what pattern each one has. In this case, the couple is healthy and not showing any disease. But the one child does and the father is not a carrier. This gives you another hint. So if he's not a carrier, how is that possible if the child is showing the disease? Then you're seeing that it's present in the father's brother and one of the sisters' sons. Here, you can see a distinctive pattern where this is not an autosomal recessive type pattern. This leads you to a dominant X-linked route. As you draw this out, you will start to see the pattern where the children follow up to them. The mother is a carrier, the father is not. And the child has the disease. It's likely that the child is a male because they're receiving only an X from the mom. So this would be an X-linked pattern. Now, you would only see one that follows that X-linked disease – G6PD Looking at patterns and pedigrees can really help you. Another algorithm Andrea found helpful is to ask: does the child with the disease have a parent with a disease. If no, then you're skipping a lot of things. You're left here with X-linked recessive which is 50% more common than a male child. Therefore, it's an X-linked recessive disease. [11:02] Tips and Tricks to Help You Memorize and Understand Better Most students are using mnemonics to remember all of the X-linked recessive diseases. This is most common for autosomal recessive or autosomal dominant. There's no way to think through them in a way that doesn't require memorization. The names of the disease don't really help in this case. All this being said, Andrea recommends using mnemonics. You can also use visual mnemonics you can look at or silly drawings to help you remember stuff. [12:37] Other Possible Questions Probably, if the question talked about a food that this person that this person may develop symptoms with, then you could probably remove some answer choices out. For example, G6PD is one of those...

  Session 06 Today, we start our board content. We thought that there is no better way to start than with the heart. As always, I'm joined by Dr. Andrea Paul from Board Vitals, a company that helps you with your board prep. They feature an amazing QBank and software platform to help you maximize your score. Save 15% off any of their QBank packages by using the promo code BOARDROUNDS at checkout. [03:11] Scenario of a Heart Murmur in a 60-Year-Old Male Case: A 60-year-old male is undergoing evaluation for a heart murmur. He's asymptomatic and his physician discovers a holosystolic murmur at the cardiac apex. The frequency of that murmur is increased when he expires and an echo confirms that there's a diagnosis to be found. Question: Compared to a normal patient, which of the following hemodynamic changes would be most likely present? Note: This involves multi-steps where you have to figure out from the murmur and it's confirming there is something so you could look at the murmur and decide what you think the diagnosis is. From there, you go one step further and say what physiologic effect that would have. [04:10] Knowing the Types of Murmur First, you have to know the types of murmurs out there. Holosystolic means that the murmur is present during the entire systole phase. There are some that fade off before the end or would just be a click sound at the beginning of systole. Holocystolic refers to the sound that is present the entire time. It can be one consistent sound for all systole or maybe it's something that starts at an increased volume or decreases. So you're left with different options. In this case, it says it's in the cardiac apex. You have to look at other components like the student's age to determine what exactly is causing the murmur. But here we're lucky since they're telling us here that it's right in the apex. [06:35] Mitral Valve Regurgitation When you're hearing this whole systolic murmur at the cardiac apex, you immediately start to think of mitral valve. When you look at the diagram, you will find different areas where you can picture where the apex of the heart is and what would be causing a sound in that direction. If you're visual, you can picture the mitral valve in the direction of the flow. If it weren't functioning properly, it would be right to the apex of the heart. So this would lead you to suspect mitral valve regurgitation. Another thing you can think of is mitral stenosis, however, that's diastolic so it would be heard in a similar area at a different time. Other things to think of when you have mitral valve regurgitation is that it kind of fits with the patient. If the question had said something about an irregular pulse or displaced apex, that would be the first thing that would fit with mitral valve regurgitation as well. Although the patient here is asymptomatic, common symptoms would be rhematic fever, palpitation, fatigue, shortness of breath, and it can go as far as having signs of heart failure. So any of those components in any combination could be present in the question that would lead to the same answer in the end. [09:25] Answer Choices A Increased after load B Decreased pre-load C Increased ejection fraction D Decreased ejection fraction E Decreased contractility Now, you have to understand what all of those components mean. In most cases, mitral valve regurgitation would be easily heard during expiration. This specific murmur isn't one that is always so strongly correlated. But this is something to keep in mind that expiration is more positive pressure down on the heart, more pressure on the ventricle and potentially easier to have a bit more of regurgitation. [11:11] Understanding the Terms: Afterload Afterload is the pressure against...

Session 05 USMLE Step 1 and COMLEX Level 1 scores can play a major role in the specialty that you match in to. Let’s talk about the score that you want to shoot for! We're joined as always by Dr. Andrea Paul from Board Vitals, a testing platform to help you prepare for every step of your journey as a medical student, whether it's Step 1, Level 1, Step 2, Step 3, or all of the Shelf Exams that you have to take as a medical student, and beyond that once you're out in practice. They offer QBanks and everything they have to offer you, you're sure to be prepared for your test when it comes to test day. Save 15% when using the promo code BOARDROUNDS. [02:12] What Scores to Shoot For Andrea says that USMLE has a secret recipe that they score with but they don't disclose it but the scores range from 1 to 300. (But they won't officially say that.) Most people score between 140 and 260. The average in 2018 was 229 with a standard deviation of 20. So you're looking at a 209 to 249, which is incredibly high. Andrea thinks the reason for the increase in average is that people recognize competition and the high stakes of this test. "People recognize the high stakes of this test more than ever before. We haven't been expanding numbers of residency programs but we have expanded in the number of applicants." [05:40] Average Step 1 Scores for Different Specialties The landscape of competitiveness of different areas has changed for some of the specialties. Anesthesia used to be one of the most competitive. But this changes over time for a lot of reasons. But specialties that have stayed on the top of the list include Dermatology, Orthopedic Surgery, Oncology, ENT, and Neurosurgery. For 2018, the average USMLE score for people who matched in Orthopedic Surgery was 248. Dermatology is not too far off with 249 and ENT was 248, Neurosurgery at 245. Even the least competitive specialties had quite high average scores. Family medicine was 220, the highest it's been. Scores are just continuing to increase. "It's just the sheer number of people competing for these few spots that really require people to study harder and score higher." [08:07] Beyond Your Scores Of course, if you want to get in Dermatology, for instance, then you've got to be aiming for something over that 249. That said, other things still matter like the geographic area you're looking at, your experience, letters of recommendation, etc. Hence, the variation of scores and no specific cutoffs. So even if you're not in the range, it's good to still apply. "It's good to still apply even if you're not in the range. It does not hurt to still try." The Step 1 score gets you in the door for a lot of these areas. But after that, they're not going to pick a 249 over 248 just based on the score. That being said, it's good to aim high. [11:29] Breakdown of COMLEX Scores The scores fall the same way as USMLE does with Dermatology as the highest and Family Medicine as the lowest. Their average score for match candidates was 566 in 2018. For some of the high scoring specialties, Radiology was around 615 while Family Medicine was at 520. [12:20] Data for Osteopathic Students There's anecdotal data that osteopathic students in some geographic areas in some specific institutions have a disadvantage but there's no specific data. If you're an osteopathic student and you want to apply to a more traditional MD institution, you may want to consider as this could help in the institution's diversity. But try to make sure your scores are not only competitive but trying to shine so much that they can't ignore your application. There could also be a lack of information in some geographic areas on what background DOs come in with. Andrea believes that as this merger happens, this may start to...

Session 04 Every year med students around the world prepare for their boards. Many of those students are making mistakes preparing for USMLE Step 1 and COMLEX Level 1. Once again, we’re joined by Dr. Andrea Paul from Board Vitals. Be sure to check them out because not only do they have the Level 1/Step 1 QBanks, but all of the shelf exams as you continue to move forward through your medical education! [03:03] Mistake #1: Not Giving Your Full Attention Students can find themselves doing so many stuff that they forget to focus on what they really need to focus on. If your mind starts to stray away, then that's a signal that you need to take a rest or break. Reset so you can get back to focus instead of just pushing through. Otherwise, you may just miss how many important points. So get up. Take a stretch. Take a minute. And then come back and be fully focused again. Slow down and it will help you in the long run. "The length of time isn't necessarily reflective of the quality of the time that you're studying." [04:35] Mistake #2: Studying Too Many Days in a Row There's a lot of data looking at how many days the students study per day and interestingly, once people went beyond 35 days, the scores started to go down. This is related to inefficient studying or maybe fewer hours per day. But there's a strong correlation that you can't study for too long. Hence, dragging out the day and staying up all night is only going to hurt you. "You only have so much stamina in a day to sit down and these questions are intensive, they require a lot of thought and you only have so much to do that per day." Board Vitals recommend studying for about 20-25 days with about 8-10 hours a day of studying. All of their data show that below or above it is just going to give them low scores. that said, it really varies depending on how your scores are looking. If you're already on the high range of your goal, then you probably don't need to spend the whole month rehashing everything again. Otherwise, doing so may only hurt you. So recognize where you're at then make a plan on the length of your study based on that. [07:25] Mistake #3: Going Through Content Too Quickly and Missing to Review Have a spreadsheet or notepad beside you so you can keep a list of what you missed and why. Was it an error or did you misread the question? Was it the way that question was worded that tricked you? Maybe you need to pay more attention to questions worded that way. Or it can be a specific piece of knowledge that you missed. Then go through the list at the end of each day or the week and you'll start to see patterns. "Keeping a really good track in analyzing how your own mind is working in answering these questions -- right or wrong -- is really important." Board Vitals provides feedback so you can see which areas you may be stronger or weaker. [09:45] Mistake #4: Thinking It's an Insignificant Amount of Pressure Unlike in high school or undergraduate where you just want to be competitive against others, this is different since it's an individual goal. It's something that's going to affect your life. But you just don't have one option. You may really want to do a certain specialty, but you may be just as happy doing something else. So it's not the be all and end all of life. "You want to stay motivated but not to the point that your nerves overpower your instincts on exam day." People who are scoring so high on their question banks, they get to exam day and the pressure is just so intense. So breathe and relax. Medical school is already an accomplishment. So just do the best you can. The boards actually don't allow retests like they do for the MCAT. For the MCAT, you can void it at the end of the test. I wonder if people are doing this on the boards as...

Session 03 Board Rounds is back with BoardVitals and Dr. Andrea Paul to discuss when you should start preparing for the USMLE Step 1 and COMLEX Level 1 exams. This week, we're going to dive into when you should start preparing for these exams. The Step 1/Level 1 are going to be one of the most important pieces in your residency journey. And so we need to make sure you're preparing as best as possible and when you start doing that. [02:11] When to Start Thinking About Preparing for the Boards Sit down and start with setting a goal. Which specialty are you planning to apply to or would you like to be able to apply to? What's the minimum score would you feel is acceptable or competitive for those areas. Then look at your schedule to see what time you're available or what time do you want to dedicate for studying. And sticking to that is really important. Be present and work harder on those hours. Always have some flex days, especially towards the end. [04:49] Setting Dedicated Time You need to schedule dedicated time during all those classes. So if you're doing biochemistry, you need to carve out an hour on few days a week where you're going to do biochemistry related questions on your USMLE prep materials. This way, you're able to connect them earlier. To help you score higher, start preparing early. Know what scores you need and test yourself to see if you're getting towards that. "If you start making those connections early... it all helps you down the road." [08:30] What Resources to Use and Average Study Time Andrea thinks that paper textbooks are not always the most user-friendly. The great thing about online resources is that you can take them anywhere. You also get to customize what you're learning. Most students study for Step 1 during their preclinical curriculum, during the first year of medical school. And then the intensity increases during that dedicated time. Most of them would average 11 hours of studying per day for 35 days, usually covering 4000 practice sessions during that amount of study time. "Most students now are averaging about 11 hours of studying per day for Step 1 and that's for about 35 days. That's an incredible number of hours to study." Moreover, their data says that the number of days people study didn't correlate with their scores. Right around the midpoint was when the scores were highest. But students think more and more is better. So this is something to keep in mind. Also, their strongest correlation with high scores is the number of practice questions they took and their grades in school. Ultimately, Andrea says it's all about a combination of someone's work ethic and being a good test-taker that leads to a good score. [14:42] Simulating the Test Environment and Eliminating Distractions When you're interrupted with a text message or when you're on your phone, it takes about 15-20 minutes to get back into the flow of where you were before that interruption. if you add those three into an hour, well, it's not a very effective hour, isn't it? It is therefore important to simulate the test environment. When you're in a question bank and doing questions, you're not going to have the phone or someone knocking on the door, or any distractions. That being said, you want to make the most of your study time. Put that phone somewhere else or turn it off. And simulate that same environment as much as you can. Even when you need to utilize your resource online, don't have other things or windows open. Keep a spreadsheet maybe open and just minimized so you could take notes. Avoid breaking up the actual studying with looking up some side information you might have thought of. Instead, keep that checklist and make quick notes of what you need to go back or what you need to go and review more on....

Session 02 Once again, we're joined by Dr. Andrea Paul from BoardVitals. In this episode, you will learn all you need to know about Step 1, how long to take it, when to take it, and what makes it different from the MCAT so you know what to expect before we jump right into the actual test prep! [01:10] More About Board Vitals If you need more help, check out Board Vitals and you get everything you need to expect from a board prep company including challenging questions, time and untimed question banks, progress tracker and advanced analytics and reports to help you direct your studying. This is something most students don't take enough advantage of. You really need to know what you're doing or missing, or what you're getting right to be able to know what to do tomorrow. Plus, you get to see how you rank with your peers. With over 1,750 questions in their USMLE question bank, BoardVitals will make sure you have access to the questions you need to be prepared and confident going into your USMLE exam. Don't worry DO students! They've also got over 1,500 questions in their COMLEX Qbank. Get 15% using the promo code BOARDROUNDS when you sign up for BoardVitals and they will donate a vaccine to a child in need through the Give Vacs Program. If you're not ready to use it yet, just buy now and you can start up to 6 months after purchase. [03:15] How Important is USMLE Step 1 Going through medical school, Andrea eventually realized that this was something she needed to pay attention to and start to prepare for quite early. And the stakes have gotten much higher since then. The goal for everyone is to get a residency they want in the specialty area they want. And for many students, that means being in a competitive location and a competitive medical specialty. So the scores serve as a gateway to get an interview for one of those positions. "It's a very high stake particularly if you're someone who is interested in a more competitive area, geography or specialty-wise." In fact, the NRMP match data suggests that those Step 1 scores are the determining factor if whether or not you're going to get an interview. [06:20] MCAT vs Step 1 Both are completely different tests in many ways. Andrea says that until you start preparing for it and seeing what format of questions are like, you wouldn't expect that people think of it as a more intense basic science exam similar to the MCAT. But in actuality, the new Step 1 exams are clinical and really require a lot of correlation between those basic sciences and actual medical practice. The MCAT is a test to see how well you can take the MCAT but when you get to Step 1/ Level 1, it's knowledge that you have to have to be a competent physician. You have to have that base knowledge so you can learn how to be a physician once you're out in residency. Moreover, the exam has changed a lot since. They have slowly transitioned now to a more practical and clinical correlation with basic science. [07:55] Breakdown of Step 1 Exams The USMLE Step one covers Anatomy, Behavioral Science, Biochem, Microbiology, Pathology, Pharmacology, Physiology. And they try to integrate those into a way to asses your knowledge of those things within the constricts of clinical medicine. COMLEX is similar as they do most of the subjects in addition to tests on some osteopathic-specific areas as well. They're now focused more heavily on "triple jump questions" or tertiary type questions where they could give you a clinical presentation but they're not telling you, not only what the disease entity is and what you would treat it with, but also something about that medication. These are a classic type of questions you need to practice. [10:00] Duration of the Exams Step 1 or...

Session 01 The Medical School Headquarters and BoardVitals are going to help you prepare for your first board exam with questions, pearls of information, and guidance to make sure you have what it takes to score high and match into your specialty of choice! Board Rounds is a podcast for medical students as they prepare for Step 1 or Level 1 of the USMLE or COMLEX exams. Please follow us along with all our other podcasts on MedEd Media Network. BoardVitals is an amazing test prep company that helps medical students and almost everybody in health care with their exams. Whether it's the Shelf Exam while you're doing rotations or your clinical years, or even later on as a physician studying for your boards, BoardVitals has got something that will help you every step of the way! Today, we're joined by Dr. Andrea Paul and learn all about her journey and all about BoardVitals. [02:00] About Dr. Paul and BoardVitals A physician by training, Andrea took the Internal Medicine route and transitioned to Pathology residency until she decided to pursue her business idea before proceeding with her clinical training. Hence, the birth of BoardVitals, which she has been running since 2013. What got her into the field of medicine was having family influence having family members who are doctors. Following the traditional path, she enjoyed science and realized she loved learning and being involved in the education component more than the practice of medicine. [03:10] Her Thought Process in Jumping on the Education Route In residency, Andrea realized that the way people were studying and learning was inefficient and really low tech. She thought it was crazy and that she had to figure out a way to put content into a material that's more accessible and that it can be used wider than just one residency program. This was when the idea was born, starting with some medical specialties and working backward. Then they ended up focusing on all the medical student exams. Over the last five years, BoardVitals is now in 60 different all professional and medical exam areas covering everything from surgical tech, radiology tech, and nursing, all the way through to medical students, pharmacy students, and nursing students. Plus, the various medical subspecialties as well as some of the dental and podiatry areas. "Once we had a good platform and system, we realized that you just need to insert the content into that same learning system and it really works for every different area." [05:35] What Correlates to a Good Score Andrea explains that what correlates to a great score is to spend a number of questions that people take -- simulated exam questions with good, detailed explanations. Textbooks, lectures, or other things didn't move the meter as far as getting into that top core area but the number of questions that people did really made the difference. This then became their sole area of focus. They have questions along with detailed, informative explanations for each question. [06:45] Finding People to Write Their Questions The company has over 400 physicians, nurses, etc. across all areas that are creating their content. They look for people who have recently taken the exam or those involved in academics teaching students to prepare for a specific test. It's an expensive series of review afterwards. The initial writers go through medical editing and copyediting. Then, the get some feedback about any updates or changes that recently came out submitted right to their editors, who respond within two business days. [08:40] Medical Students Preparing for the Boards Andrea points out that Step 1 is so high stake and so important that they would recommend people to start using it as soon as they start medical school....