DIP Episode 588 - 2025 USMLE Step 1 Free 120 Discussion Part 6 (Q51-60, super helpful for Step 2 and 3!)

Welcome to episode 588 of the Divine Intervention Podcast. So this podcast we're going to be continuing the series on the Step 1 3 120. I really want to try to get done with this series because there is a bunch of other kind of important topics I want to discuss. But again I want to try to finish this, you know, so try to manage my time as best as I can. So question 51. So this part 6. A 37 year old man comes to the office because of a three week history of itchy patches of skin and a burning sensation in his feet. He works as a dishwasher and says he frequently works in wet shoes and socks. Vital signs are within normal limits. Physical examination shows the findings in the photograph. These findings are also present on the souls of both feet. The most appropriate pharmacotherapy for this patient will inhibit the activity of which of the following enzymes. So if we look at this image, right, we see, you know, this person has things in between his toes and he has risk factors, right, you know, wet socks, wet environments. So the bonus loves those environments, but also fungi, love those environments. So this person probably has what we call like athletes foot. You know, they'll probably use the trim tinia pides on your exams and tinia pides you want to manage with an antifongal and appropriate antifongal. So basically, we want to see and I talked about antifongals at the tail end of the last podcast, just as a preview of coming attractions.

So option is says inhibiting chitin synthase. I don't know if any antifongal that is tested that does that. Option B talks about one three-beddedig look and synthase complex. So that's inhibited by a kino candins. A kino candins, we use those for serious candida infections. Again, tinia pides is caused by the trichofighting species, the micro-sportm species, or the epidermal fighting species in that order. You know, number one, number two, number three. Not really caused by candida, so that doesn't make sense to pick option B. Option C says forceful IP is D. That will be wrong. That will be wrong. So that will be wrong. I don't know if any antifongal that really works by targeting that. Option D talks about squillin mono-oxygenase. I'm going to go with that. That's inhibited by the droga trebinaphine. Trebinaphine is a pretty good antifongal. Trebinaphine. Remember, other good antifongals I kind of talked about. I kind of talked about. And remember, typically for most of these tinias, you can use topical antifongals. But if you're dealing with tinia of the toes, like of the nail sorry, the neocomyces of the head, tinia capitis, you have to use oral antifongals, like oral trebinaphine or agusio-fulfit. But again, trebinaphine works by inhibiting squillin mono-oxygenase. So, option D is right. Option E thymidylate synthase is wrong. That's the drog that's targeted by five-floor urethyl.

Also remember, it's also targeted by five flu cytosine that we used to trick crypto-cocomanian gyrides. That five flu cytosine is covered by cytosine diamines to five FU. And then it inhibits thymidylate synthase in crypto-cocasanial formants. Alright, this is the question of 52. A 10 year old boy is brought to the EDI in the middle of summer because of fever, headache, and photophobia. Several of his comp mates have had a similar illness. Physical examination shows mild no-corrigidity. Lumber punctures performed, so this guy probably has meningitis. So, look at the lab studies show. Serum glucose is 90, right? CSF pressure opening is 50 millimeters of water. Glucose is 65, total protein is 70, and glucose icon is 43 per millimeter cube, and it's 95% lymphocytes. It then says which of the following infectious agents is the most likely cause of these findings. Again, try to work things out before you jump into the answers. So, we see no-corrigidity, we see fever, we see headache, photophobia. This is clearly meningitis. So, whenever you get a meningitis question on your exams and you provide CSF labs, they are pretty much trying to see if you can differentiate or delineate. So, if you have a meningitis, if you have a meningitis, you can get a meningitis. Now, if most of the CSF values are largely normal or just a little bit elevated or out of whack, typically that's going to be a meningitis. Sometimes on exams, this is called esceptic meningitis.

But if you notice that the values are pretty high, like values are measured out of whack, then you begin to think of bacterial, fungal, or meningitis. It's mostly neutrophils that are going to be elevated because it's... It's a trophils that respond to bacterial infections. In fungal and TB meningitis, it's mostly going to be lymphocytes that are going to be elevated. But again, the values of things, like the glucose, will be very, very low. The CSF will be very, very high. Total protein will be very, very high. Why count will be very, very high? So, in this case, I'm going to go with varum meningitis. Again, I don't know the numbers, the CSF numbers of the top of my head. But these numbers look pretty, pretty good to me. They don't seem crazy, crazy out of whack. I'm not seeing a lot of triple digit numbers. Again, it's mostly lymphocytes. Remember, lymphocytes are the things that respond to viral infections. So, we need to pick a viral answer. We can probably go ahead and cross-off options, D&E, easily. Here, the thing is, herpes is an unusual virus in that. When herpes causes meningitis, it tends to look like more of a fungal or TB meningitis. Many times, it's going to cause a hemorrhagic meningitis. So, you're going to see a lot of red cells in the CSF. So, I'm going to cross-off as well. And then, options in B, so, between adenovirus and enterovirus. So, can adenovirus cause meningitis? It can. Would that be a representational, you examples?

Adenovirus tends to cause more of a firing go conjunctivitis. So, it can cause like, you know, faring yield infection. It can cause red eye. And it can also cause bloody diarrhea. You can actually cause a cause bloody diarrhea. So, I'm going to go with enterovirus. Enterovirus is a very, very common cause of a viral meningitis. Enterovirus is, I think the echo virus is a part of those. So, I'm going to go with option B for this one. So, let's go to question number 53. Ami says, 55-year-old woman comes to the physician. Because of a three-week history of right-shoulder pain that occurs when she's lying on her right-shoulder in bed, there is tenderness to bar patient of the greater tubercle. An extra of the right-shoulder is shown, the arrows indicate a calcium deposit, full examination of this patient will most likely show impairment of which of the following active shoulder movements. So, if we look at this, again, try to work it out. We see that this problem is like at the tipi top of the humors. Right? At the tipi top of the humors, you know, the greater tubercle, you know, the superspinal is kind of inserts around there. And we know that the superspinal is handles, you know, abduction is part of the rotator cuff. It handles abduction. So, the A Bduction. So, these persons probably going to have abduction problems. Right? Remember abduction, you got to know what does what. Right? So, remember the first 15 degrees of abduction that's done by your superspinal. Right?

So, if you have a rotator cuff tear, one of the first things you're going to notice is, oh, you cannot abduct. And then, to go from 15 to I believe like 90 degrees, you're going to use your deltoids. Remember your deltoids are innovative by your axillary nerve. Your axillary nerve. Remember, your axillary nerve in addition to doing the deltoids also does your tear is also awesome. And then, remember, if you want to go all the way, you know, finish up the whole thing all the way to 180, go all the way overhead. You're going to use a trapezius. You're going to use the aerosant here for that. Right? So, and to be honest with you, if they give you a shoulder question on your exam, most times it's going to be abnormal abduction that they love to test. I've just noticed this in my experience with step one, step two, step three. Most times when they're going after impaired shoulder movements, they tend to go more after abduction. You know, the classic context where you may see adduction problems with the shoulder on the exams is if, for example, they're testing like herb duchine palsy, you know, from like an infant of an abedic mom, like a big baby, you know, that injures the upper trunk of the bricchio plexus C5 and C6 where you have that whiter step deformity. Right? So, they're going to damage the muscular cutaneous nerve. They're going to damage the axillary nerve. Right? Remember, the axillary does again your deltoids and your teres.

And they remember your muscular cutaneous does your bricalis, bricuridialis and I believe coracobricalis. Right? So, they're going to have a lot of issues with abduction. So, if you cannot, I mean, I mean, like when you have all those issues, right, when you have those issues, you won't be able to abduct because you've also damaged your axillary. You can't abduct. So, your arm and forearm will be held in an adductate position. Right? And then, you know, your forearm will be, like, you know, your arm will also be internally rotated and, you know, your forearm will be pronated. Right? So, you kind of look like a waiter, like a waiter, like asking for a tip from behind, you know? So, that's usually where they test adduction. I guess since I'm talking about herb duchain, don't forget clumpy spots. See, that's a C8-T1 problem. They're going to have more of a claw hand. Right? So, honestly, like the other ones external rotation, flexion, internal rotation, they're pretty low yield. I will see if you want to learn shoulder movements for your exams. Abduction is kind of a good one. Good one to know. All right. So, let's go to question number 54. It says that 31-year-old woman with a five-year history of fatigue comes to the physician for an initial visit. She has seen for other physicians for the same condition within the past six months, but not normalities were found. She gives the physician a large folder that contains from medical records.

She says, I can barely get out of bed most mornings, but nobody can figure out why because all my tests turn out normal. I really think I have chronic fatigue syndrome. What do you know about this condition? The physician has not treated any patient with chronic fatigue syndrome before, which of the following initial statements by the physician is most appropriate to establish rapport with this patient. Right? Again, it's just like even not just being a physician, just in life. It's generally good to be honest. Right? It's good to be honest. Don't try to use your ego to say, oh, I know this when you don't. Right? Just be honest. Tell the truth. Right? That, hey, I don't know much about this condition. Many of these ethics questions just try to strike up a conversation with a patient, be truthful. You know, just use common sense, really. So let's look at the answer. So option A says, from the size of the folder you brought, it looks like you've had a very thorough examination in the past. No, that does not address that the physician does not know about this condition very much. And again, we're not supposed to know everything. Option B says, I don't have much experience with chronic fatigue syndrome, but I'm committed to learning as much as I can about it. That seems kind of truthful. Right? And again, that's kind of patient centered. Right? So I'm going to keep B. It's probably the right answer.

Option C says, I'm not familiar with chronic fatigue syndrome, except that many physicians don't think it's a real disease. You're kind of diminishing your patient. That's not a smart thing to do. Option T says, let's start over from scratch. We need to repeat complete testing. No. That is not good physician practice. Right? Not working with your brain. And just saying, I'm just going to pan scan you, pan test you for everything. That makes no sense. You should try to grovel through problems. Right? Don't take the easy way out. Option E says, when nothing abnormally is found during thorough examinations and lab studies, there's often an underlying psychological cause of the symptoms. No, you literally don't know what you don't know. Right? I think I'm going to go with option B with this one. All right. Option 55 says, a 28 year old man comes to the physician because of a two month history of a rash on his wrists and hands. He is a first year mortuary science student. He also works on his grandfather's farm each weekend. His hobbies include raising home impigions and repairing vintage motorcycles. He recently changed to a different type of laundry detergent to save money. The next examination shows a diffuse arithmetic rash involving both hands up to the wrist creases. The rash does not extend over any other parts of the body. Which of the following is the most likely cause of the patients rush? Okay. So again, try to work this out. Right?

So if you notice, this presents rash seems to be pretty well defined. It's just kind of limited to his hands up to the wrist creases. Okay. And it's been going on for two months. Right? So this certainly does not seem like exam at the moon. Certainly seems like a contact dermatitis. So let's ask ourselves is anything in his history that makes playing contact dermatitis? Okay. He's a mortuary science student. And you know, I guess he also works with home impigions, but home impigions will not cause contact dermatitis. Contact dermatitis is usually going to be caused by things like sumac, you know, neomisin, poison ivy, gloves and all those things. Right? Especially if you're present that works in the healthcare field. No, we don't think of this as healthcare, but a mortuary science student probably works with a lot of gloves. Right? So this sounds probably like gloves, remember, nickel from belt buckles and stuff. Remember, uh, these contact dermatitis is a type four hypersensitivity reaction. All right. So, um, let's see option A says change in laundry detergent. If he changes laundry detergent, he doesn't make sense that it's only affecting his hands. Right? You probably affect other regions of his skin. That doesn't make any sense. Option B says exposure to chemicals during motorcycle repair. Again, that can cause a contact dermatitis, but again, just how well it is like, it's like basically it's like a glove like distribution of symptoms.

It's just highly unlikely that that's what's going on. It's probably going to be more gloves. I'm going to go with option E here, a handling pageants. Now I'm not going to go with pageants for this one. Pesticide exposure. Remember pesticides have an osteoarthly organophosphate poisoning, right? Because some of these stains, they're a pseudo-colonessories inhibitors. So they're going to raise your levels of a pseudo-colon. That's going to cause a colonergic toxic drop. All right. Yeah, that's one of the things about step one. That makes it a little bit easier than step two. Sometimes it's that's why it's so useful to kind of walk through what's going on first. If I start burning through the answers, you usually be able to pick out the right answer fairly effectively. But step two, that's like a step to step through a whole different ball game. But again, step one is converging on lot in in its characteristics with step two and step three. But different discussion. Okay, question 56. So the answer is going to be E for question 55. All right, question 56 says 22 year old woman at 32 weeks gestation comes to the office for a prenatal visit vital signs are within normal limits, fondle height and fiddle heart tones are also normal. At the end of the examination, the patient tells the physician that her friend is a certified lay midwife and has recently convinced her to have a home birth.

The patient asked the physician if he would be the backup for the midwife in case of an emergency, which of the following is the most appropriate initial response by the physician again, let's work it out first, right. So home births, they can go well, but they can also go very poorly, right, because you just have access to fewer resources. You know, you probably may not have access to that in K, you know, get a bank in K shot, which I think I've kind of talked about in a previous podcast. And also, you may not have access to the heavy vaccine, right. And again, this physician that she's asking works in probably works in a hospital, right, doesn't do house calls, right. It's really hard to get a doctor to do house calls. So be the backup. Well, I mean, if you can get to the hospital in time, I guess we'll see. But let's, let's see what's going on here. But yeah, home births, they tend to be associated with quite a number of problems actually. So, but again, let's, we've kind of at least kind of figured out what's going on. So let's see the answer that addresses that. So option A says, I'm sorry, but I would no longer be able to be your doctor if you pursue home birth. No, right. Right. See, on the USM, the exams with ethics questions, you don't just want to conclude early because a patient expresses a concern. You want to try to talk things out with a patient. That's usually the smart thing to do. Don't be a conclude early kind of person.

So I'm going to say that that's wrong. Option B says, I would like to meet with your friend before I decide. Okay, that's a reasonable answer. Let's keep that option C says, if there's a problem, I could still act as your doctor if you arrive at the hospital in labor. Okay, you have share as a hospital in labor. You know, you're there. Yeah, you can probably help. That's a good answer. Actually, let's keep that option D says, let's set up an appointment next week to discuss your birth plan in detail. Okay, so you're striking up a conversation with a patient. Okay, let's keep that on as well. Wow. Okay, there's three good answers we can keep option E says, perhaps your midwife could act as your birth coach instead. And that's not really addressing the problem here, right? The problem here is this person is wanting to do a home birth, you know, she is not that she's necessarily wanting to do a home birth. What a friend convinced her to have a home birth and she's asking the physician can be a backup, right? But again, the physician can probably not leave his other patients and come to this person's home just to be a backup for some home birth. Right. And again, I think one thing people lose sight of with ethics and I don't know why many resources don't talk about this principle is don't conclude early, don't conclude early, right? You always want to try to strike up a conversation with a patient whenever possible, right?

So option B says I would like to meet with your friend before I decide. Okay, that that's reasonable option C says if there's a problem, I could still act as your doctor if you arrive at the hospital in labor. Again, it's option C is almost like a conclude early statement. Hey, there's a problem. I'll just act as your doctor like the thing is see try to talk things over with patients. Many times if you talk things over with them, that's usually going to be a smart thing to do. And if you see an answer that involves talking things over and not just jumping straight to conclusions. That's usually a good thing to do. So option C, I actually going to go ahead and scribble that away. Option D says let's set up an appointment next week to discuss your birth plan in detail, right? So, okay, let's talk this over. You know, let's talk this over is probably not a not a bad idea. I'm telling you this on the US ML is it's always helpful to pick answers to ethics questions where you talk things over with the patient. And not just that where you don't jump to conclusions quickly where you kind of drag things out a little bit. That's usually a smart thing to do, right? Talk things over with the patient and try to address the patient's concern. Try to address the patient's concern. The patient's concern is hey, can you be my backup option B? Honestly, it doesn't really I would like to meet with your friend before I decide.

Again, don't get me wrong option B is a good answer, but option D is just better because I feel like option D kind of addresses her problem. But not just that again strikes up a conversation with the patient whenever you can talk some old patient. That's usually a good deed on the US ML. So I'm going to go to option D for that one. All right, question 57 says at 36 year old woman with hypertension comes to the office because she thinks she may be going through early menopause. Okay, she has not had a menstrual period since her most recent office visits six months ago. During this time, she also has been gaining with around the middle, despite increased exercise. She has had a 14 pound weed game. She has no other history of major medical illness. So 14 pounds is 6.3 kilos. Her early medication is lysinopro. She does not smoke drink alcohol or use the drugs. She's 5 foot 6 inches tall, B.M. with 236 pounds or 170 kilos, B.M. is 38, vital signs are within normal limits. Examination shows a uterus consistent in size with a 24 week chest nation. Pelvic Ultrasenography shows oligohydraminus and a fetus with a mischip and cranium pericardial effusion, small bladder and echogenic bowel. The most likely cause of the fetal abnormalities in this patient's pregnancy is interference with which of the following. All right, so this fetus is clearly abnormal. So again, let's look. Is there anything bad in this question that may affect the fetus? Again, kind of a few problems here.

So let's work it out first. So this lady is clearly pregnant, but this fetus has a lot of affirmations. But we'll see all oligohydraminus. Now, let's ask ourselves what can cause oligohydraminus? Because remember, kids, the fetus is the way they work is that the P, actually a lot of amniotic fluid is maybe urine. So the P and then the swallow it, the P and then the swallow it. If anything interferes with the ability to P or the ability to excrete urine, that's going to prevent amniotic fluid from coming. So that's going to cause oligohydraminus. So if you have a problem like posterior rethrow valves, vesically or teroriflox, we have like renal egenesis. All those things can cause oligohydraminus. So I guess is there anything that can cause oligohydraminus here? Well, the one thing I can think about is lysinoprolysisinopryl is an is inhibitor. Remember, is inhibitors and arps? They are not very good ideas in pregnancy because they can cause a lot of problems. Right? They're patho-terrhodogens. I remember they kind of work on the kidneys and actually don't many many resources don't cover this. Well, this is actually something pretty high to know for the USML Es. But there's actually a lot of angiotensin two, you know, like angiotensin two receptors. Now, many people think of just the kidneys and the adrenal cortex, you know, with the zunoglomerulosa or the, you know, many people just think of those areas like effranatyrul and parts of the arinotubules.

But that's not all actually. We actually find angiotensin two receptors in many of the parts of the body. We find them in the heart. Right? There's a reason why, and let me try to make integrations for you here. So so I'm going to slow down a little bit. This is kind of important. There's a reason why is inhibitors, and I'm not going to review the entire pathophys of this, but there's a reason why is inhibitors improves survival in heart failure. They actually help with, you know, with, you know, kind of helping the heart, you know, not remodel and all these things. Right? There's definitely links between is inhibitors and the hearts. That's part of why the improves survival in heart failure. Although it's a somewhat different context compared to this, right? But proper heart development, whenever you take an incinemidator, it's not, your heart doesn't develop very well. Right? For a fetus. And then also, if you look at things from the perspective of the brain, there is actually a lot of angiotensin two receptors in the brain. So don't forget, there's angiotensin two receptors in many parts of the body. We find them in the brain, we find them in the kidneys, we find them in the, in the adrenal cortex, we find them in many ears of the body. Right? So this shot has oligodraminus probably because of a kidney issue that's caused by this ACE inhibitor. Right?

I remember if you have oligodraminus, that can lead to polysiequins, you know, pulmonary hypoplasia, you know, mischapen head issues with the limbs and things like that. Right? So let's see. So option A says fiddle long slash epithelial differentiation. No fiddle longs are factor development. No. Right? I would not, you know, option A, you know, if the lungs don't do well, but remember, if you have oligodraminus, that's going to cause your lungs to not expand and develop as they shoot. You know, you have pulmonary hypoplasia because again, all that amnodifluid, some of it kind of gets into your lungs and makes the lungs expand and develop. Right? So I guess we can maybe keep option A for now. Option B is definitely wrong because remember option B is something you have when a child is born prematurely. Option C says, and also an infant of a diabetic mom, you know, if you're an infant of a diabetic mom, you're seeing so much glucose from mommy. All that glucose you're seeing is going to cause hyperplasia of the fiddle beta cells and those cells are going to make a lot of insulin to deal with that excess glucose. They're getting through the placenta hyperinsulinemia and a fetus can actually shut down surfactant production. So that can cause that issue. But again, that's not really what we're dealing with here. This mom does not appear to have diabetes. So that's wrong. Option C says fiddle renal hemodynamics. That's probably the correct answer. We're going to keep that one.

Option D says maternal placental profusion. No, I'm not going to go with that. I'm a turn up placental profusion. You're going to see this in mom's that have hypertension or lupus, right? Or moms that use like crack cocaine and things like that. That doesn't make any sense. E says maternal person, the gland incynthesis, well, it doesn't look like mommy's taking an NSA. So I'm going to go ahead and scribble that off. I remember you want to be careful about using like very powerful NSA. It's while a woman is pregnant like in do, you know, especially after I'm not saying you can never use NSA is in pregnancy. But you want to be careful because you don't want to prematurely close the fetal doctor's arteriosus. That'll be like really bad. Right. So we're kind of between options C and A. Right. So option A talks about fetal long epithelial differentiation. Again, that's that's what happens with oligohydram news. Right. But option C says fetal renohymodynamics. The thing is, I'm going to go to option C here because it's just more. It's just a more direct answer to the question. I feel like option A is a few steps removed. Right. If you notice option C, you're going to mess up the fetal kidneys because you're taking an is inhibitor because remember is in if you take an is inhibitor. Right. It's going to cause issues with like reno perfusion. And if the kidney is not perfused properly. It's not going to develop well. You're going to have poor urine production.

That's just more directly related to the question than option A. Option A seems to have steps that are. It seems to be a few steps removed from what the problem is. So don't get me wrong. Like when you have oligohydram news, that's going to cause pomular hypoplasia. But that's more like a downstream effect than more of an upstream effect. You know, I love upstream answers, more direct answers on the USM at least. So I'm going to go to option C here. This then I just discuss is actually a very valuable test against strategy for the USM at least. All right. So hopefully you kind of catch catch that. All right. Now question 58 says 67 year old man comes to the office. So option C is the right answer for 57. So 58 says 67 year old man comes to the office because he's concerned about memory loss. He says he sometimes forgets the names of acquaintances. He sees while he's out shopping. He also has occasional work finding difficulty and forgets to buy some items when he goes shopping unless he makes a list. He leaves alone and is able to manage his finances cook and shop without help. He works part time as an accountant. He has gird and hypertension. Crime medications are he's CTC and or my personal vital signs are within normal limits. Physical and neurological examinations should not abnormality. So mental status examination is fully oriented. His speech is normal and thoughts are organized. His mood is youth time. He can be as a full range of affect.

His concentration is intact and he's able to perform calculations quickly and accurately. He can name objects accurately and fully written and verbal commands. He records three or four objects after five minutes, which of the following is the most appropriate for general response to this patient's concern. Let's work this out. So these are all person. I'm sure the MBA means you're trying to get us to pick some dementia answer. This is not dementia. Whenever you can do so many activities of daily living pretty well, you're not demented. He has pretty decent recall. He can name objects, follow reading and verbal commands, full range of affect, good concentration. This guy is not demented. This guy is just old. And that just happens. Again, don't get me wrong. The Australian things you can do to, you know, doing like crossword puzzles as an old person, being healthy and not having diabetes. There's a reason why Alzheimer's is called like type three diabetes these days. Exercise all those things. Certainly help your cognitive function. But this guy think this guy's pretty okay. So option A says I'm concerned about your memory loss. Let's discuss how to further value your memory. No, this guy is not demented. There's no need to worry now. But let's meet again in six months. Again, you see that premature jump into conclusions. That's not a very good thing to do. Don't just kind of denigrate your patients and kind of cover them on what they say. That's not a smart thing to do.

So, you know, prematurely just terminated a conversation not addressing their concerns is not smart. Option C says unfortunately your memory loss will likely increase significantly. No, this guy is fine. He's fine. I'm not going to pick up. Option D says your pieces of forgetfulness are likely just senior moments. We should obtain in depth lab test results and an MRI to be certain. Right senior moments. You're kind of denigrating. That's an insult actually. Don't don't do that. Option E says you examine findings indicate that your memory loss is likely consistent with the normal agent process. Right. This guy's finally can handle his ID else. I think he's okay. So I'm going to go to option E for this one. All right. Don't prematurely jump to conclusions. Jump into conclusions prematurely. And just kind of ending the conversation prematurely is not a very good idea on the US Emily exams. All right. So question 59 says 42 year old woman comes to the office because of a one year history of a left breast mass. She had been living in another country for the past two years. Physician in that country total that the legion was assessed since returning to the USA 12 weeks ago. She has noticed that the mass has increased in size and is now so tender that any physical contact is painful. She has not had any other breast mass skin changes on Nepal changes. She has a history of cysts in both breasts and has undergone aspiration of two prior cysts pathology examination.

Both times should know abnormalities. She has a one year history of yellow Nepal discharge from both breasts and pre menstrual bilateral breast pain. She has no other history of serious illness and tick snow medications. There is no family history of breast cancer vital signs are within normal limits physical examination shows a three centimeter firm extremely tender and partially mobile mass in the upper outer corner of the left breast. Pharmography shows a 3.1 centimeter irregular mass in the left breast corresponding to the probable area of the mass photo micrographs of an excretional biopsy specimen as shown which of the following pathologic findings most strongly suggest malignancy in this patient. All right. So let's work this out and again a very kind of useful testing principle here is this right. So whenever you see images on the US Emily's don't panic again about 80% of the time you can answer a question correctly by just kind of feasting on the actual words you were given. Although this image is kind of worrisome if you know what you're looking for. So but again let's depend on the question first before we start freaking out about the image. So you see which of four in pathologic findings most strongly suggests malignancy in this patient. Again, even without looking at this image you should probably try to look for an answer that portends malignancy.

The description of things tells you that there's probably malignancy going on and this person has a lot of risk factors for malignancy of the breast. You see she's over 40 there's a reason why we start mammograms at 40 right. Number two this mass is irregular irregular breast mass is that's usually kind of a worrisome sign. Number three this thing is partially mobile right and it's almost like a lonesome mass that's kind of worrisome. You see it's in the upper outer quadrant that's a very common location for many breast malignancies right. Okay and let's see can we pick out an answer that kind of sounds malignancy and then I'll describe all this images showing right option A says compressed ducts. No no no right option B says dense fibrosis. Yeah you can see fibrosis in cancer. Let's keep that let's see some other things option C says expanded ducts. Many times your ducts are going to be expanded if there's a lot of milk in them option D says multiple large and small cysts. That's going to be probably more consistent like fibrosistic change which is a benign breast finding option E says peomorphic irregular glands right things are irregular right again that that seems like malignancy speak.

But again and that's probably going to be the right answer but again let's look at this let's look at this pathology image right the thing is C one of the ways like in general you want whenever something is glandular you want the glans to line up well right whenever the glans don't line up well on a pathology image. Something really bad is going on right or at least that should begin to make you think of malignancy right especially look at the image off to the right you know for question 59 you see the glans are just kind of all over the place right you see them they're kind of scattered so that tells you that is almost like the cells are ripping apart right so there's probably some cut hearing problem going on here because remember cut hearing is necessary for cellular adhesion right so these glans are just kind of all over the place so honestly the answer that is just the most malignant of everything is going to be option C. It's going to be option E. I'm going to go with that one for this one right you know compressed docs dense fibrosis because dense fibrosis you can also find in a lot of benign breast problems but option E seen a lot of you know pleomorphic whenever something is pleomorphic it means that it has like different let's say like if divine looks pleomorphic that means divine looks different ways in different times so let's say I have like this act where I can look like Superman today look like X look like some power ranger to more.

Whatever can you tell the cartoons I watch when I was a kid right so I'm pleomorphic in that that would be me being pleomorphic in that way right so whenever you see cells described as pleomorphic it means that they have like different sizes different shapes you know different and if you notice these cells kind of look different some are pretty flat some look more cuboidal in appearance right that's not normal this is not normal breast tissue this is not a more breast tissue so I'm going to go with option E actually for this one that's just the answer that seems to make the most sense all right now let's do question number 60 again that I'm just trying to because again if I just try to talk as some expert it's not going to be very helpful to you right this podcast I want you to be as realistic as possible it's better to be truthful right because again I'm telling you you're going to see questions where you don't know what the image is showing but and that's the reality of the exam even for me I'm going to see questions where I don't know what the image is showing or what the radiology is showing or what the audio is showing or what the video is showing but it doesn't mean you can get those questions right again that that's why I think this series is so valuable because I'm not just going over the content with all the answers and stuff but I'm also actually trying to show you how these days you know just how to kind of think through situations and scenarios that may be unfamiliar on your exams you know with testic principles all right so again you should recommend that your friends kind of listen to this okay so 30 year old woman comes to the office because of a 40 he's drove an increasingly severe painful rash over her body and he's like her mouth the rash began over her trunk area but spread within a day to her face and extremities two days before developing of the r

ash uh-huh she had flu like symptoms with muscle aches and fatigue as well as a non productive cough sore throat and runny nose 10 days ago she began to meet with TMP SMX uh-oh uh-oh TMP SMX for urinary tract infection she takes northern medications a temperature is 102.2 degrees Fahrenheit she's tacky cardiac to kipnic and hypertensive physically examination shows diffuse brownish red macula exanthema with bullock lesions epidermis at an uninvolved site can be removed with maltengential pressure examination of a biopsy specimen of one of the lesions shows necrosis of keratinocytes throughout the epidermis uh-oh there's minimal lymphocytic infiltration within the superficial dermis which of the following is the most likely diagnosis right so this is a pretty classic situation you took antibiotics uh by the way you can also get the same problem about to discuss when you take NSAI Ds or um you take like uh you know some of these penicillins especially like um pyscilyn um or you take some of these anti-epileptics like Lamotrigine um but yeah this person looks like they have like this SGS you know TN complex right you're gonna see a pressing the versionally be exposed to antibiotics or NSAI Ds and then they're gonna have like flu like symptoms they're gonna have myalgyes they're gonna have high fevers and then after this they're gonna have big time involved in their skin is gonna look very very very very red right and you know the problem um the the the the the the the the way we categorize it is based on what percent of your body is affected right so if it's less than 10 percent of the body affected um then it's gonna be uh stiff on the Johnson syndrome but if it's more than 30 percent we're gonna call it toxic epidermone necrolysis it's is if it's between 10 to 30 percent we call it SGS TN um so this person you know they don't give us exactly what's going on right but we

see that it's over her body it's in her mouth we see that it's diffused this is probably like a lot more than 10 percent so I'm probably gonna go to option E for this one um so let's talk about the other answers and why we can kind of rule those out right so option A says erythema multi-formy remember erythema multi-formy you're gonna see a lot of target-toid lesions right like bulls-eye lesions right that's not what's being described here so that's wrong option B says linear igibulus dermatosis um well the thing is if a person has like ig related inflammation many times it's gonna cause poppable proper below the buttocks below the buttocks right below the buttocks you know so like the lower extremities we tend to find it in kids right so like for example like inoxia line preparer we tend to see that you have a lot of joint problems and you have like poppable proper below the buttocks that's not the distribution that we see here this person seems to have this kind of all over her body and again we see the recent exposure to antibiotics that's gonna make linear igibulus dermatosis uh not very I don't know if I want to go with that answer and then option C says pempicals vulgaris right uh so I know some people will be like ooh divine this is nicoski positive C you gotta be careful there are many things that are nicoski positive not only pempicals vulgaris you know pempicals vulgaris anti-desposom antibodies like anti-despoglaine antibodies right so it's nicoski positive they're gonna have these flasit bullae you know bullae that poppies if you notice they didn't talk about any bullae popping easily they just talk about how oh um if you epidermis that are uninvolved site can be removed with mild tangential pressure right so we don't see them talking about the popping of bullae but um so it's probably not pempicals vulgaris right and again there are many things that are n

icoski positive right like for example pempicals vulgaris is nicoski positive if that's the one I'm sure many of you have memorized but even option D is believe it or not is nicoski positive right stuff's cardets skin syndrome right that's gonna be in the context of a staff infection not with antibiotic exposure soption D is definitely wrong right but also even like steevones jonesine syndrome toxic epicdermonecralisis those are only nicoski positive so i'm gonna go with option E for this one this is like a very very very classic presentation of T and here's one of the things I've learned about dermatology and the usm at least is one of those things where you don't know it for you don't and the thing with dermis know the classic presentations if you know the classic presentations and the usm is they don't make derm questions harder than they need to be they usually make it pretty straightforward so if you know it you'll get it right if you don't know it you will get it wrong kind of like risk factors or like prognostic factors or like outcomes or you know most important determine of a presence outcome in xyz those kinds of questions there are things where there is no if you don't know them you will get them wrong there is no like test again principle that'll kind of help you wiggle your way around those derm also can derm MSK also kind of falls into those categories and again I have a lot of derm podcasts I have a lot of MSK podcasts and I have podcasts that I dress many of these topics as well right again my risk factors podcasts are probably some of my most popular podcasts right episodes 37 97 184 and 239 all right so I think I'm gonna go ahead and stop here so option E is definitely the right answer question 60 again if you're studying for step one or you're studying for step two step three and you have a you know you had a bad basic science foundation and honestl

y step two step three these these tests a little basic sciences you're probably gonna be very interested in the 25 hour step one review that I have coming up in the first week of May but also in this month of April I have a bunch of other classes coming up I have a test taking class bio stats class social sciences ethics quality improvement class ethics is now a huge part of step one huge part of step two and step three um so these classes step one bio stats test taking their all first step one to three and then I have a 20 hour review on a last minute review that's just for step two and step three and then in the first two weeks of June I have this two week very very high yield very very amazing uh 50 hour step two step three review um that again limited spots available but again it's gonna be it's gonna is it's gonna be such a great class that's what I'm gonna say I made separate podcasts where I talk about these classes and if you know want more information just shoot me an email I can give you some more information and then I also offer one or one tutoring for the USMLE and complex exams and I help with ER As applications personal statements recliders and things of that nature and then I also uh you know have a youtube channel where I post the videos that I make and remember I have these podcasts on Apple Google and Spotify although if you want everything from episode one you you got to go to the actual website divineinterventionpodcasts.com and then I also have another website called divineinterventionlifelessons.com many of you know I'm a Christian so I make podcasts every week about two or three podcasts from a biblical perspective address a life lesson there's actually an Apple podcast associated with that I'll call the divineinterventionlifelessons podcast again divineinterventionlifelessons.com so thank you for listening to me today I'll see you in episode 58

9 have a wonderful day God bless you and bye for now thank you

Terbinafine.

Trichophyton.

Lymphocyte predominance in the CSF pleocytosis, and generally normal or mildly elevated protein/glucose levels.

Interference with fetal renal development, leading to oligohydramnios and potential pulmonary hypoplasia.

Do not jump to conclusions; always attempt to strike up a conversation and address the patient’s concerns rather than prematurely diagnosing or dismissing them.

Pleomorphic irregular glands (indicating varied shapes/sizes of cells).

Antifungals like terbinafine; they inhibit squalene mono-oxygenase.

Enterovirus.

Interference with fetal renal hemodynamics/development.

Flu-like illness (fever, myalgias), followed by a painful, diffuse rash involving mucosal surfaces and epidermal necrosis.

Pleomorphic irregular glands.

Antifungals like terbinafine; they inhibit squalene mono-oxygenase.

Enterovirus.

Interference with fetal renal hemodynamics/development.

Flu-like illness (fever, myalgias), followed by a painful, diffuse rash involving mucosal surfaces and epidermal necrosis.

Pleomorphic irregular glands.