444-460

[dora]

444.
Original Clinical Case Copyright ValueMD and Family:

We previously discussed cancers. Did you know you could be presented in clinics and USMLEs with a case addressing cancers and different organ types? KNOW that the most common cancer in any organ is metastatic and DO NOT say primary type. Now here it is:

Q) That said, you have an older gentlemen named Crandle and he comes to you with spiking back pain. On exam, he has loss in his arms and legs, loss of motor function. You suspect metastatic cancer of the prostate to the SPINE. What are the classes of drugs you will be asked to master for this MOST COMMONLY diagnosed cancer in the US (LUNG Cancer is the most common death from cancer, but PROSTATE is most common in DIAGNOSIS)

A) There are several, and you may be asked all of them, the MOAs, and their side effects. They may give you like a drug series and asked the drug class missing. And their MOAs and Side ffects/ SE may be decribed or in a pictorial form. So know that YOU HAVE to master the below information like your father’s birthday.

Finasteride, KNOW it is anti androgen, KNOW it acts to block 5 alpha reductase. KNOW it blocks NOT testosterone directly, but the conversion of testosterone of testosterone to dihydrotestosterone (A critical fact). KNOW the SE involves liver failure and loss of libido and impotence.

Flutamide, KNOW it is a NON STEROIDAL, an antiandrogen confused with Finasteride. It is a MOA involving androgen binding and uptake (these MOAs sound the same but are drastically different especially on the USMLE and in “pimping?) All of these will be answer choices, and you will forget Flutamide from Finasteride!

Leuprolide (Lupron is OH SO COMMON) ?KNOW that its MOA involves a synthetic nonapeptide analogue of GnRH that acts as a potent inhibitor of gonadotropin secretion, that is, LH and FSH is decreased.

Bisphosphonates, I told you he had bone pain, right? KNOW that they stop bone resorption via osteoclasts and NOT reving up osteoblasts MOA (another common answer pick mistake)

Paclitaxel (Taxol), Prostate cancer is hard to treat with chemo, but you will have to know that the MOA binds tubulin!

Prednisone ! I betcha you didn’t know that, right? It helps via MOA of lowering PSA levels.

Hydrocortisone Cream—KNOW positively the MOA--which is blocking inguinal capillary permeability and inhibiting WBCs leaking and causing inflammation to the prostate. KNOW that you MUST ASK if the patient has thyroid issues..

Ketoconazole: EVEN AN ANTIFUNGAL IS GIVEN! KNOW that this MOA Produces responses similar to that of anti androgens. They block a variety of cytochrome P-450 enzymes, including 11beta-hydroxylase and 17alpha-hydroxylase, which in turn inhibit steroid synthesis. Could you remember all of that? If you don’t get a question on this on STEP 1 you WILL be asked at some other time ALL of the ABOVE INFO.

Q) What is the market that doctors look for to see Prostate cancer?

A) PSA and alpha feto protein!!!!!

Read the ABOVE POST MANY TIMES, it is confusing! At least thirty times because there are 444 possible questions in the above post!

Q4) Also, I forgot to mention, what SPECIFICALLY DO YOU TELL TO a patient you are IDed as risks for PROSTATE CANCER?

Q5) Besides age, due to its genetic linkage, prostate cancer is more frequent in patients with a strong family history of prostate cancer. Likewise, people who smoke, African American males, and patients who consume a diet high in animal fat or high in chromium have increased incidence. DO NOT FORGET! I SHOULD HAVE BROKEN THIS POST INTO 44 posts, but I WANTED you guys to lump them together! For better recall!!!
_________________
445.
Regarding PROSTATE CANCER and the previous case:

Q) You suspected prostate cancer in a second patient who comes in after the first one name Harold. Harold though, has an enlarged prostate from the famous M3 student consult anal exam, and you start anti androgen treatment. He does however decribe his bone and sense pain with AN EXTREME EMPHASIS ON ABRUPT SUDDEN ONSET OF LEG PAIN too. You continue with prostate cancer tx. Then six months later, your senior attending got sued and lost his Mercedes and is bicycling to work.
What KEY mistake and dx did YOU MISS? VERY important!


A) You missed the easily and common mistake that the older guy with a large prostate actually had SPINAL CORD COMPRESSION/SLIPPED DISK which needed an Emergency surgery with an ORTHOPEDIST. Very common mistake...
_________________

446.
Q) Still, another guy with another enlarged prostate...you are running short of surgical gloves...presents with the same symptoms as the first patient. You start prostate cancer therapy again but CHECK the CT to rule out spinal cord fracture to not repeat the same error. A new hematologist comes by and asks if you need her but you say no way...
But then...the replaced attending AGAIN is sued a year later and you see both of your past attendings losing their Mercedes and riding on a tandem bicycle to work together. What COMMON dx did you overlook and fail to rule out?



A) Many, many, leukemias and lymphomas can mimick the presentation clinically of prostate cancer patients. YOU HAVE BEEN WARNED BY VALUEMD AND ME! You had to have chosen a different treatment. Say goodbye to a good residency slot...sorry....
_________________

447.
NOW, you have seen a fourth patient name Jordan who is an older African American who smokes two packs a day for 40 years, eats only steak meat, has 6 children and wants no more kids or sexual relations in his life, and all his male ancestors had prostate cancer....he heard about your past two attendings and your mistakes...and he refuses all RADIATION THERAPY AND MEDS FROM YOU because of your common mistakes. But he still likes you and you are part of his limited HMO plan.

Q) You offer a surgical intervention, and he accepts... What is the NAME of the intervention and what did you do to him that WAS PROVEN IN MANY RESPECTED STUDIED TO LIMIT PROSTATE CANCER IMMEDIATELY?


A) You did a radical prostectomy and orchiectomy. That is, you castrated him. Not too pleasant, but very effective, and VERY ASKED!
_________________

448.
OK, you get a fifth patient in who just saw Jordan your last pt limping out with pain from the surgery. The fifth guy KNOW everything now and was refered to your clinic and is only asking advice. His LOCAL PROSTATE CANCER is being controlled with meds, but his GLEASON score is 6. (KNOW the Gleason grading since PROSTATE cancer is oh so common)

Q) He asks what are the chances of METASTASIS (which is often fatal) for him?

Q) Also, what is the MOA the metastasis if he is good with his meds intake?


A1) After stage Gleason 6, metastatic cancer is expected. About half of all localized prostatic cancer WILL metastasize even will full meds tx.

A2) The reason for this--even though aggressive meds are used--is due to resistance from ANTI ANDROGEN HORMONE REFRACTORY DISEASE FROM CANCER CLONES.
,
Now, you must remember your readings in PSYCH texts on how to "break bad news". Really, something like this happened to me. There are a lot of tears and it is VERY VERY awful. And I am serious.
_________________


449.
MANY MANY USMLE WRITERS want you to understand BASIC NUTRITION. For real...

So...
Q) A sixth patient a 15 y.o. high schooler, walks into your clinic named Siegfried. He had a father named Roy who just died of prostate cancer at 45. He has ALL the risk factors on history. You tell him because he asked, that IT IS TRUE THAT CASTRATED MALES LIVE LONGER. And he is so afraid also of meds, but he tells you to "put away the scissors, I am still a young boy who wants to date girls..and guys". So he asks you about how he can change his diet? You answer what?

A) Have him eat a lot of tomatoes, broccoli, Asian green tea, soy products, licorice root, selenium, and antioxidants and the vitamins. Seriously, the NBME will ask you to answer some basic dietary questions.
_________________

450.
Q) Finishing up, what med can be asked and can be used if all the mentioned drugs fails? AND give me MOA?
Q) I forgot to ask, what is the difference in MOA of drugs Leuprolide and Abarelix? (YOU KNOW TO KNOW THIS FOR STEP 1).

A) You can give Suramin for refractory pts w/ MOA of INHIBITING GROWTH FACTOR for prostate cancer tx.

A2) Leuprolide is a GnRH analog and acts via competition so lowers LH and FSH.. BUT.... drugs like Abarelix are GnRH receptor antagonists...so be ready to know that the MOAs are different, but both lower LH and FSH and thus .... dihydrotestosterone.
_________________

451.
--If you see enzyme disorders, and are asked by your attending or NBME, what is the mode of inheritance (YOU HAVE TO KNOW ALL OF THEM COLD), then "usually" this is Autosomal Recessive

--If you see musculoskeletal, structural protein, endocrine thyroid pancreas, and neurofibromas, then guess Autosomal Dominant.

[Of course there are exceptions, but I am desperately trying to "lump" because it helps if all else fails]
_________________
452.
Dear Future M.D.s,

I am now flooded with questions in my various mails. I love them because helping is fun! At least I think so. And the same questions come again and again..

1) For IMGs, a serious problem that just won't quit is the language barrier. I think this is the MOST difficult one to handle because time is a necessity. Please read one of the past posts which addresses this well.

2) Some of us IMGs are asking what books to study. This question is definitely one of the top five questions ever asked. I feel you need to start with First Aid and choose ONE or TWO of the series:

BRS, Kaplan Notes, HY series, or Board Simulator Series or Step-UP.
AND two additions are Goljan's Notes and a GOOD PATHOLOGY/MRI atlas! (Here you could do Robbins or do Webpath). People do not realize how visual the test is. They had 99.9999% of their tests in life without any pictures. But whoa, some of my students get image after image which all look like a case of pharyngitis.. or they get these abnormal HISTO PATH pics of lung diseases which all look the same. So, you must must pick a VISUAL source for your studying.

© 2003, 2004 ValueMD Incorporated. All rights reserved.

Then, you must read and re read the same material. If you keep switching, I saw students getting confused and lost. Also, the ones who stuck to JUST ONE SOURCE like BRS Biochemistry, ended up almost MEMORIZING the words and pictures. It happens to everyone. You pick up like FA over and over and then you for example....know that in the Pharm section the microbiology drugs are discussed first. It helps with memory skills.

3) Many asked about question banks. That IS critical. I have heard some say they passed with ONLY DOING QUESTIONS. I think this approach MAY work for some who have the basics DOWN but I do NOT recommend this for most. But if you lack the fundamentals, then doing Kaplan QBank or BSS is really just wasting your time. You are better off watching a movie or giving your significant other a backrub/backsctrach. Because you will not retain the information. I saw students continue doing like QBook over and over and over and they were getting higher scores because EDUCATIONAL THEORY TELLS US THAT YOU ARE ONLY MEMORIZING QUESTIONS. It comes up again…you are like driving down the road to your work and there are vague stuff around that guide you. But you cannot stop and tell me the name of the road after “USMLE avenue?or the number of right turns after the gas station. The brain forms these patterns…and they will not repeat on your real exam. Especially if you are doing questions at random without linking subject material together in a “SPIDER WEB?like configuration in your brain.
SO...my advice is?YES, do ValueMD questions first, they are done by former Step 1ers who are constructing new novel material that will prepare you for the real exam because they understand the focus and theme and flavor of the exam to make you a better doctor. Also, when you sit for the real exam you will be amazed at the sheer VARIETY of the questions. Some are detailed, some are short answer, some are IMPOSSIBLE, some (just a couple) will actually just like point an arrow to the nose and ask, “What is this?”…meaning, a couple of the questions will be very easy. But the sheer variety is what makes me believe the NBME USMLE Step 1 is like the universe. Of my hundreds of students, hardly a single exact question repeated when they naturally discussed them over nights, lunches, etc. BUT, THE SAME CONCEPTS CAME UP IN ALMOST EVERY TEST. A perfect example of this is the second messenger concept. I tried to give a mnemonic that works miracles for me…but it may NOT work for you.
Thus, I suggest doing questions (after the ValueMD ones) by grouping them. Kaplan is good, but then do BSS and Princeton Review, and then Board Review Series, then Pathology Review by Robbins (with pictures), then NMS. Naturally, you will run out of time, but at least you are using the right method. Again, do questions by system and subject or you will not retain anything. That is why in the OLD DAYS prior to the printing press people memorized by LUMPED stories, using rhyming techniques, timed repetitions, etc. to memorize texts as thick as the BIBLE. They had to…how do you think you got the present version of Homer’s “The Iliad? If those same people just picked up the BIBLE at random, read a verse, shuffled the pages, read another verse, they may someday catch up, but the time for mastery is unacceptable. Admittedly, there are some, just a few of my students that blew me away in their capacity. They were only a couple out of thousands, and many never wanted to use their powers of memory for anything. So again, doing organized systemized questions in a formalized interval is the solution.

4) Many many questions are coming up about QBank analogies and the general time frame for preparation that I recommended for STEP 1. Mastery of QBank is only a rough measure of how you will score on the real exam.
After taking many polls, I found all sorts of statistical anomalies. One of my best friends matched in a competitive Radiology program and blew through 250/99 but was reportedly scoring about 65% on QBank. NOW, before you get too excited, there were students beating 70%-75% on QBank but failing!!!!!!! Also, a close relative of mine was scoring consistently around 50% and barely passed. After many many statistical points, I would argue that if you are getting around 50% on QBank, you are “close?to passing. But what examinees do not realize is the REAL STEP 1 is HIGHLY VARIABLE IN MATERIAL. Thus, good sources told me that some had deep emphasis on pharm, others on pathology, others on virology…one girl said she got mostly all immunology. And through a third party, I heard of a brilliant US med student who was aceing med school and doing 80% on QBank but failed his first time because he got a lot of questions on difficult new research in Molecular Biology. Thus, I recommend what I said before. I do think QBank is a VERY good source of questions, but you need varied question sources but you have to organize them properly.
Also, many asked me for a solution and detailed their situation where time was a serious problem. Some had to prep for STEP 1 within a few days only, and some had the time for prep but the situation was too unwieldly…many, because we are the IMG family have unusual circumstances. Several desperate mails came because the students had children or sick parents. My heart breaks…because how will you push a square peg into a circle? YOU MUST RECEIVE THE TIME YOU NEED. Unlike a few tests that rely on math, or interpretation skills (LSAT comes to mind), life experience in literature (SAT I Verbal Section), the USMLE STEP 1 material cannot be gathered by life’s chance or opportunity. For instance, you will see Xeroderma Pigmentosum because it is a wonderful concept involving DNA and thymindine dimers and repair defects. But did you know that maybe if you are lucky you will find only 1000 people in the entire WORLD of 7 Billion with the disease? That is why THIS TEST NEEDS AND DEMANDS YOUR 100% ATTENTION and SUITABLE TIME that you need. Again, if you need maybe six months of 12 hours/day prep, do not feel that you are less smart than someone who studied in three months. Common society has determined that the second person is “twice?as smart, but that is NOT TRUE. There can be ONE MILLION reasons why one needs more time, but what I personally found was a “VARIABLE?related to reading speed and another “VARIABLE?related to processing speed. I knew of one of my friends who went to U of MICHIGAN and works at NASA. He was a super smart guy and blew everyone in my high school away (For you IMGs, U Michigan like U California, U Virginia, U Miami, U Washington, U Texas are among an ELITE GROUP OF COLLEGES EQUAL TO THE USA IV LEAGUES LIKE HARVARD.) Anyhow, my point is that some people are smart enough but I researched there are about a dozen measurable quantifiable “intelligence?points of reference. It is like a MACHINE that has many parts. All the machines can finish the work, but some take longer because maybe one part of the machine is not as efficient. BUT, that “slower?machine may produce higher quality products. Think of a HP PHOTOJET and HP LASERJET series #. The PHOTOJET makes BETTER CLEARER pictures, but the LASERJET is faster. But BOTH make copies and BOTH have value and BOTH are HELPFUL. So, you need to understand yourself and your limits and what exact time you need. If you do not approach this properly, then you WILL BE ONE OF FAILURE STATISTICS.

5) I will need to continue this thread of concepts because I note that there are additional questions in my mailbox. But please digest the above information. Oh, by the way, I believe my suggestion of notecards are effective. Make some up with say Pharm which are easier to develop. Then start front card #1 and move backwards. If you are getting say card #26 wrong, then move that card forward so your repetition schedule for that question/concept will be seen more often. If say you mastered cards 40-46#, then they will end up toward the back of your index card box. Thus, you can start scientifically measuring your RETENTION LEVEL and READING SPEED LEVEL. There is a whole science to this that I feel I should tell you, but I need to go for a while. So, for the 2 Ross students and 4 East European students, etc. you SHOULD be worried about the time and scheduling.

6) Quickly, also know that the US students are NOT smarter than IMGs but they are better at the STEP 1 because of many reasons. Some include that they JUST FINISHED THE BASIC SCIENCES while some of the IMGS had them long ago. Also, many of them are “coached?by their schools from Day ONE with USMLE type questions (pics and all). Plus, the ones that write the test are mostly the ones that teach and test the US students. So, I believe that ALL IMGs and USAs are equally smart for the most part…Even if that was not true, it is NEVER a reason to give in.

LOVE Tommy

453.
Quickly, you are viewing an radiology report and seeing polyps in the colon--hundreds of them?

Q) What is this disease and the genetics and will this proceed to cancer?




A) After R/U IBD, this is Familial polyposis coli, which is AD and mostly becomes malignant!
_________________

454.
ON CLINICS, USMLE STEP 1 you have to KNOW lead poisoning because...about 5% of all children have elevated blood lead and about 25% of all low income US children living in pre-1950 homes have elevated blood lead which can cause mental delay, anemic symptoms, bizarre behavior, GI upset. STEP 1 needs you to understand that LEAD POISONING IS SO COMMON BUT SINCE it is easy to miss (symptoms are non specific), you need to be aware because if you fail to order a blood lead level test on an at risk pt, you might as well become a city car ticket handler because you will lose your medical license:

Case: A boy named Donny Dosman comes in with nonspecific symptoms like hyperactivity, diarrhea, and occasional tired spells. YOU suspect Lead poisoning.
Q) What is the MOA of the medicine that you will pick as the DOC?



A) As we mentioned once, BAL or Dimercaprol works via chelation and is water soluble and rapidly crosses the blood-brain barrier. Forms a nonpolar compound with lead that is excreted in bile and urine. DOC in patients with acute lead encephalopathy, in whom first dose is given and then the second dose is given combined with calcium EDTA after a four hour interval. Remember that the Ca salts can also treat hyperkalemia! BTW, you found that Donny ate PAINT CHIPS from his old apartment.
_________________

455.
You Lead intoxicated patient, Donny, then tells you from his history (he is an African American patient), that he has something called G 6 PD def.
Q) Do you continue with the BAL treatment?




A) NO! BIG legal mess. And you may kill the patient. BAL in G6PD def pts can hemolyze blood cells.!
_________________

456.
Q) Donny's mother then tells you she has a sister with a baby who is living with NO LEAD INTOXICATION RISK FACTORS in a new house. You see the baby named Shazam in your clinic at his one year birthday. Do you need to do a lead screen?


A) Yes, you still have to do one, and every 2 years thereafter on this low risk baby.
_________________

457.
Your patient Shazam (recall, he is a baby), is 100% breast fed. His mommy asks you if she should give IRON supplements b/c she read it in a magazine.

A) NO, breast milk has enough iron. Give IRON supplements to formula fed patients unless the Formula can says "supplemented with IRON".

(This sounds advanced, but I KNOW it IS STEP 1 material)
_________________

458.
Yow! Donny's Father then walks in for a quickie checkup. In his PE, you ask to see his tongue to test CN 12 but you note that you see something awful...he has ORAL HAIRY LEUKOPLAKIA. (Review picture) In such a case, what..

Q1) What two common patient populations will you get with this devastating dx?

A1) AIDS patients and heavy smokers and drinkers.



Q2) What virus if asked/pimped is involved? (Do you recall the viral structure and Family?)

A2) This is Epstein Barr Virus, EBV. IT is Double stranded, enveloped, linear, and part of the HERPES family DNA. It is also a cause of Burkitt's and mononucleosis!

Please do recall ALL the points here. The USMLE and attending may trick you and ask if the EBV is an RNA bug, which is wrong. And so you will have gotten so far but ended up short....
_________________

459.
Your previous bad luck with all those prostate pts is forgotten, now Donny brings in three relatives with back pain (YOU WILL SEE THESE EVERY MINUTE DURING ROUNDS AND IT IS A CRITICAL CONCEPT)...

Q1) Donnycousin1 is 20 yo and is lifting heavy boxes for UPS as a job. You sent him on his way after ruling out deadly causes and confiming a "pulled deep back muscle". Did you do right by him?

A1) I KNOW I am sounding "picky" but you are mistaken. The NBME needs you to know that even a young man with a recent pulled back muscle should be advised to wear a "weight lifter" hip belt.


Q2) Donnycousin2 is 40 and has back pain with NO Hx of trauma or neoplasm. What may you see on Lumbar Puncture?

A3) In such a presentation, consider a bug that made its way into his spinal column!



Q3) Donnycousin3 is 65 (older cousin) and oh NO! He has lower back pain with INCONTINENCE and with CONSTITUTIONAL SYMPTOMS (Fever/chills/headache). Now what tests do you order, because you are fearing????


A3) As I said with questions, consider carefully the age, sex, ethnicity, diet, meds, etc. of the patient. Here is an older gent with the HINTS of incontinence from tumor pushing a local mass effect on the sacrococcygeal area and the CONSTITUTIONAL SYMPTOMS!


NOTE: The above cases are so common and tested and asked and pimped because back pain is so common. I saw more pts coming in with this than the flu!!!! So you MUST RULE OUT MALIGNANCY, even with younger patients...
_________________

460.
'Case: Donny's cousins have a few second cousins, weird...all have back pain with same BAD symptoms.....What I and NBME and your attending NEEDS you to KNOW are the slight differences in the bone producing tumors of the spine...b/c the tx's are different!!!!!! KNOW....

Osteoid osteoma - Benign and locally self limited

Osteoblastoma - Benign but locally expansile and aggressive

Osteosarcoma - Malignant spindle cell lesion which produces osteoid



Q2) Sorry, you must distinguish the bones and cartilage: KNOW the

cartilage producing tumors of the spine which are...

Osteochondroma - Benign lesion with cartilaginous cap.

Chondrosarcoma - Malignant cartilage producing tumors that histologically demonstrate round cellular stroma in a chondroid matrix.



Whoa, look at this:

Q3) As I mentioned lymphomas can mimick simple back pain. It is exactly the kind of question USMLE needs you to KNOW how to differentiate...AND I KNOW THIS IS A VERY VERY HARD AREA....



Consider the Lymphoproliferative tumors...

Multiple myeloma and plasmacytoma are derived from plasma cell dyscrasias, which histologically appear as sheets of plasma cells, and remember lytic lesions and back pain?

Lymphoma - Associated with a large infiltrate of lymphoid cells

Q4) Sorry, we are NOT done yet!!!! Remember the

Tumors of notochordal origin?

Chordoma - Identified by the characteristic physaliferous cells.

Round cell tumor - best seen with a Webpath pic

Ewing sarcoma - Malignant tumor of childhood associated with large sheet of homogenous small, round, blue cells, and you KNOW we talked about this one.


EVERYONE THOUGHT THIS BACK PAIN AND ALL THESE TUMORS WERE IMPOSSIBLE TO GET STRAIGHT BECAUSE THE NAMES ALL SOUND THE SAME. I ALSO WAS SO STRAINED TO MEMORIZE THIS FOR STEP 1.
_________________