Board Rounds Prep for USMLE and COMLEX

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

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[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, the most common sign, along with severe abdominal pain. So when you see bloody diarrhea and severe pain, then you can right away think that it's ischemic. Also see the history of coronary heart disease, diabetes, and all those things that go along to decrease blood flow.

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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.

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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. You're not expected to remember every single piece. The goal is to memorize them all but once you get to a certain point of knowing the most important or the most commonly tested effects, oftentimes, the other things are tied in there. So once your mind goes to the right direction, you'd have all these other associated things coming in.

"Once you get the basics down, the rest is in there."

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MedEd Media Network

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 more specific road for one of these different nephrotic causes.

[10:32] More Things to Know About Renal Stuff

You need to know the different patterns for each of the different nephrotic syndrome causes. This is part of the reason people redo these questions over and over. There's a lot of memorization involved such as APGN and RPGN and what those look like, as well as microscopy. For this question, you would think through things like Goodpasture syndrome where you'd see a different pattern then you'd see that linear pattern which is that first option. And if it's in older males then you'd have respiratory symptoms because there's lung involvement. So you have to think through all the different associated organ systems with the different disorders and memorizing what the pattern looks like on each of them.

As far as symptoms, inheritance, and treatment, there are different diagnostic studies and treatments and those are the ones you can reason through based on the different disorders and what the physiologic effects of each is.

Lastly, keep in mind to know the demographics are. Some of them are more common in patients with specific histories, or ages or backgrounds – anything that can help you get to the answer more quickly will be helpful.

The immigration component must have been put in there too since there's not a whole lot of medical history available. So they could actually put in things that could be helpful or completely just inserted for background information to make the case more robust, but not necessarily valuable.

It's important to think through each piece of information in the question to make sure they tie together and you'd be able to eliminate something that clearly doesn't help you. So you don't focus too much on every specific part of the history.

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Specialty Stories Podcast

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

This is a two-step process where you have to both assume what the next medication to be added is and knowing which category has a worrisome side effect and then coordinating that side effect with the generic name of the medication within that category.

It's a bit tricky but once you can cross out the other effects then it could lead you down the right path into the category they're asking for which is the Glitazone category.

There are questions along the same lines where they don't say what medication was added to the patient and they come in with say, hepatotoxicity and just give you lab values indicating that. So that's an example of where they may give you a different option of medication and you'd have to identify the one that caused it. So you have to know the side effect as well as recognize the generic name. Not all categories for diabetes medications do have a common ending so there's some memorization required. But most of them have one or two different endings that you can remember. For instance, sulphonylureas tend to end in -ide or -mide. These are little things that can help you remember what category.

But if you can remember the overarching categories, that will lead you down the right path where your memory might kick in and remember things.

Specifically, the question is looking at adding a second medication and you can already cancel out one with the sulphonylurea. Then look down through the answer options. Just remember what the most severe side effect in each category is and be able to identify which one would be most worrisome or severe.

[12:50] Brand Names

The test doesn't look at brand names and it's nice there are these naming conventions. Brand names can be much more challenging to remember compared to generic names which have pretty repetitive patterns. In this case, besides insulin, most sulphonylureas and glitazones will have common endings you can remember.

[13:30]  Strategies for Insulin-Specific Questions

Just one thing to note since they like to ask the onset and peak for different types of insulin and just the mechanism. So you should be able to know the mechanism of how insulin works and that cycle in general. Lispro starts to act most rapidly, 15 minutes. Regular insulin is half an hour to an hour. NPH is 1-2 hours and Glargine where the onset is one hour but it actually doesn't peak. This is something they may ask as well. They tend to follow the same pattern for their peak so the more rapid-acting, Lispro, also peaks first and then the peak extends out later as they go through NPH and Glargine.

They would usually look for the basic pharmacology and pharmacodynamics and kinetics of medication on Step 1. They'd be probably asking something about the onset or peak of different preparations rather than combining them.

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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 diseases. If it's cystic fibrosis, they could ask what microbe commonly infects patients with this disorder. Or they could ask a treatment for that disorder.

[14:00] Other Patterns Students Should Know About

One pattern would be X-linked dominant. In this case, you would not see skipping of generations unlike what's in the above question. You would also see male and female as affected equally since the disease of the X chromosomes is dominant. So you think of diseases like X-linked dominant Alport syndrome or hypophosphatemic rickets.

Another interesting inheritance pattern is mitochondrial where males and females are affected equally. It would skip generations but it is only transmitted from an affected female because mitochondrial diseases come from the maternal side always. And you would see a different pattern and all of the offspring would be affected – something you wouldn't see in the other types.

Autosomal dominant, you would also see male and female as affected and not skipping generations. For instance, if two parents without the disease have a child with the disease, you'd think that the only way this could be autosomal dominant is there's a new mutation or there's some type of reduced penetrants or maybe the parent has the gene but just phenotypically normal. Otherwise, you would see this in every offspring because it's a dominant disease.

Autosomal recessive is the opposite where you see skipping of generations. For example, if you have a couple both carrying the gene without any signs of disease, there would be 25% the child is born with two normal genes from the parents, 50% chance that they have one normal and one abnormal gene, and 25% that they would receive both. Since it's recessive that's the only case where you would see disease such as cystic fibrosis, thalassemia, sickle cell anemia, or PKU (of which some are shown in the answer choices above).

Spinal muscular atrophy would be a more popular disease here, which my daughter has but me and my wife don't have, which makes us both carriers. This is going to be more popular to start talking about it on medical school and the boards because it's one of the first diseases out there that will be cured with gene therapy.

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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 which the heart is working to eject the blood during systole. It's a systolic murmur so this is the one we're hearing here. And it's the component where the answer option is asking whether there would be increased afterload. In this case, that would not be correct since we're having regurgitation. Afterload does have an effect on the stress volume because the maximum pressure of the heart that can develop becomes smaller when there's volume inside the ventricle.

During the systolic phase of the heart, this afterload is the pressure that's coming on the blood way out of the heart. As you're contracting, that mitral valve cannot hold itself shut. And you're having that regurgitation coming back in the opposite direction.

[13:04] Understanding the Terms: Afterload and Ejection Fraction

The preload is the filling pressure of the heart at the end of diastole. Once it's filled, the left atrial pressure at the end of diastole. We imagine Starling's Law which states that the heart is going to eject to a greater volume if it's filled to a greater volume at the end of diastole. That relationship can be modified by contractility in the afterload that would affect what ends up resulting.

Ejection fraction is just the percentage of the blood left in the ventricle after a contraction. So if you have systole, the ventricles contract. 50% remains and that's the ejection fraction.

[14:30] Causing Ejection Fraction

After you've determined that it's mitral valve regurgitation, you can look at the electrocardiogram. We have shown that since the patient has no symptoms, probably compensating for this is a chronic disease that's why he's not coming in with any specific symptoms other than the murmur heard. Most likely, he has dilated his left atrium or left ventricle to compensate. Most patients with chronic mitral valve regurgitation have that.

Then you have this retrograde flow happening over that mitral valve. So you would probably see a slight decrease in his afterload because of the resistance across that valve. The most likely though is you would see increased ejection fraction.

[16:20] Starling's Law

Think of the volume of the heart at the end of the diastole phase. That's going to give you a filling pressure, which is the preload. You would see that if you have that increased volume and pressure of blood in there to start with, that's going to lead to increased volume in systole and it affects contractility and afterload. But it's just sort of a volume and pressure play and less to do with the actual muscle fibers.

If you look overall the spectrum of clinical cases, you can see mostly that it all comes down to volume and pressure.

[17:45] More Options to Think Through

This question is great because it brings up not just all the different types of murmurs that you have to run through but it also gives you all those different scenarios to think through for all the different murmurs. So you would have to go through all these options and assess each.

If you just think through where is blood flowing during what phase of the cardiac cycle, you can almost figure out which answer you can immediately eliminate. This is the nice thing about cardiac physiology is that once you can think through oeach of the different causes of the murmur and think about afterload and preload and each one, it's something you probably won't forget because you've made sense of it, and not just memorized it.

[19:55] Some Tips to Help You Study Effectively

There are mnemonics you can use for the different types of murmurs so it's easier for you, like to know which sound and during which phase can lead to whether mitral stenosis or mitral valve regurgitation or aortic regurgitation. So if you're someone who can easily figure out how to memorize this then this is something you can jot down for sure.

Moreover, rheumatic fever can also be something to consider that can cause aortic stenosis as well. If you know the basics and you know how to recognize mitral regurgitation and understand the physiology behind it, then you'll be able to lead yourself to any of those types of questions.

Again, understand the causes of any of these murmurs. Know the signs. For instance, in aortic stenosis, that slow rising pulse is going to be in the question almost definitely, since that's one of those really unique cardinal signs of aortic stenosis, or the opposite is the collapsing pulse in aortic regurgitation. Knowing some of those clinical signs is super helpful in these types of questions.

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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 change.

"Make sure your scores are not only competitive but trying to shine so much that they can't ignore your application."

Moreover, if you don't see a DO in a match list, then don't let that be a self-perpetuating prophecy. Reach out to the program and tell them you're an osteopathic student and you want to come to their program due to xyz. Ask them what you should be doing to make yourself competitive and see what they have to say.

[16:35] The Next Steps After Having a Fail Grade

The pass rates are quite high. USMLE last year was at 94% and COMLEX was at 96%. If you haven't taken the test yet, don't panic. That being said, the biggest mistake people do is they hide and don't want to talk to anyone or tell their school about it to the admissions people at the school because they're embarrassed due to the stigma around. But there's so much help. So get all the help you need to be successful. You'd be surprised at a network of people you can have once you open up. A lot of schools have these remediation programs too that are willing to pay for additional prep materials in some cases.

"Every school has incredible resources for people who didn't pass. And you'd be surprised once you open up about it."

Moreover, you may want to also change how you study if you feel that your studying strategy was completely ineffective. Or there could be minor tweaks you can do. But this shouldn't be looked at as something negative or a hopeless situation. If anything, you have the advantage to get a high score on your next attempt.

[20:30] What If You're Not Ready to Take the Test?

Every school is different. Some may require you to not take clinical rotations until you passed Step 1. While others have different rules and guidelines on that. But Board Vitals has worked with students where they took half a year and joined the clinical rotations a few months later so they could retake their Step 1. Again, talk about this to your school as they could help you make accommodations or give you time or whatever else you might need.

[22:40] Data for Nontraditional Students

There are a couple of studies showing that nontraditional students tend to score lower on both their grades in school and on their USMLE or COMLEX exams. There's no clear reason as to why that is, however. If you're a nontraditional student, it's a good place to look at the various reasons that have been considered such as family commitments.

"Look into your family or whatever support systems you have to make sure that you can really maximize that study time and do the best you can."

Recognize some amount of time where you might have to shift your focus. Try to look back and think about why or look at what traditional students are doing differently, how much time they're spending or how they're studying. It could be a technology gap or lack of using online resources.

[25:55] Other Data Available Based on Gender

There's data showing that males score higher on the USMLE and COMLEX. This is an interesting data point they've seen come across many times. As to why there could be so many factors involved such as pay gaps and gender differences that still exist.

[27:00] General Tips

As with anything else, self-care is important. Taking a little pressure off is the best thing people can do. So much pressure can build up over the years from undergrad to MCAT, the med school admissions process and so on. And if you don't let that ease a little bit once in a while, you'd just end up extremely unhappy and burned out. Identify what makes you feel better and feel better.

[28:30] Board Vitals

Check out Board Vitals for their QBanks for Step 1 or Level 1. If you're further on in your journey, check out their Shelf Exam materials as well. Use the promo code BOARDROUNDS and get 15% off.

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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 well. In fact, Andrea has received questions on whether this is a good strategy to take Step 1 and purposefully fail it to see if they could go in and get a strong score. Unfortunately, the rates for residency matching for people who fail on their first attempt is quite low. So no matter what you get on that second attempt may not outweigh that failure. So it's always best to do the best you can.

[14:15] Mistake #5: Spending Too Much Time Studying in Ineffective Ways

Several students still use textbooks to prepare but this strategy has never yielded high scores for those Board Vitals has spoken to. Those are not clinically focused but only basic science textbooks meant to get you through that course. That's the purpose of the school component, but not the purpose of the board exam. Instead, focus on things that are meant for preparing for this test. And do it in a way that does the highest yield for you.

"Don't waste time on the textbooks that you use in those first two years of school. Those are not geared toward this test."

As you go through this process, you need to be self-aware of where you stand. Are you solid enough with your foundation? One of the best predictors is doing well in your classes. Did you do well on those or did you struggle? Do you have that foundation to jump in and do questions and review? Or do you need something more substantial to get you up to the level to get you prepared to do those?

[18:57] Be Realistic!

If you didn't score well, remember that not everyone is a great test taker or study-er. So if you didn't do well in your preclinical classes, maybe keep a more realistic goal for Step 1.

"Be realistic about it and not setting goals that are so far outside that you will only end up disappointed."

Additionally, don't look at what other people are doing. By your second year of medical school, you should know what works and what doesn't for you and do that. Don't try and do something completely different now for this test. Stick to what's worked for you in the past.

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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. Otherwise, it's best not to open another tab or window.

"It's will power but it's a month of your life and it will be worth it and you'll be glad that you didn't worry about your social media for a few days."

[18:38] Practice Questions and Reviews

Just use the question bank and there's a sheer number of questions you can look at and practice to help you. Again, this was the strongest correlation with the high score. So look at it as doing blocks of questions in different ways. For instance, today, look at the cardiovascular system and do a full day of questions in that area. This way, you're randomizing different materials and your mind has to go to all those different places.

Additionally, after answering the question, immediately click a box to open the explanation to see if you're right or wrong and why. Their explanation will then go through each option why it was not the correct answer. This is the best way to start out since you're still in the knowledge-gathering phase, more so than the assessment phase.

Then as you progress and you see your scores get closer to your goal, that's the time you can go to the test mode and do more assessment.

With BoardVitals, you can create any length of the exam you like and any format you like. So you can set your own time. On average, the time students spend on each question is based on about a minute and a half. If you focus around that minute mark, that's going to get you finished on time.

[23:44] Predicting Your Score

Andrea says you can't really predict that but you can't fully simulate a real test environment or each person's knowledge on the specific topics they're going to get on that day. There's always going to be variation.Finally, just do as many questions as possible and even if the topic may not be exactly the same.

[28:00] Manage Your Life

"Make sure that dedicated study time is truly dedicated as possible."

Exercise. Start your day doing something active. This way, you're going to enhance your ability to retain knowledge so much more than just staring for four to five hours. It's really all about being intentional with your day to set yourself up to success.

Use the promo code BOARDROUNDS to sign up and get 15%. In every sign up, BoardVitals will donate a vaccine to a child in need through the GIVEVACS program.

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