DIP Episode 644 - USMLE Free 86 Series 6 (Q47-56, for Step 2/3)

Welcome, my name is Divine, this is episode 644 of the Divine Intervention Podcasts. We're going to be continuing the 3 D 6 series, it's going to be series 6. Alright, we'll pick up from question 47. A 57 year old man who manages his own accounting firm has a 5 year history of Maligname La Noma that has been treated with local excision and immunotherapy. He now is admitted to the hospital for evaluation of constant pain in his back and left hip and an 11 kilogram or 24 pound weight loss. He and his wife of 35 years are worried that the cancer may be back. pelvic and abdominal CT scans show multiple bone metastasis. He tells you, I just want to die, I can't bear this. Which of the following is the most appropriate initial intervention? A, adjust is an ag easy carajuman, B, arrange for him to be transferred to a psychiatric service, C, begin on tight depression medication, D, initiate hyperalimentation, E, refer him to a cancer patient support group. So for this personally, we see this guy, the melanoma seems to spread and it just has constant pain and he says I can't bear this. So let's maybe fix his pain. So I'm going to go with option A here, adjust is an ag easy carajuman. This guy does not seem to have any psychiatric problems. Fix the pain first. If he's still having this, I just want to die at a tube, you know, after the pain has been taken care of, then maybe you want to, you know, refer him for like some psych thing, right? But I think option A is the best answer here.

Again, anti-depressant medication, it does not meet the fights at a nice Cicab's criteria for depression. Hyperalimentation is for weight loss, but this guy can probably adjust fine. And then cancer patients support group no, fix the pain, right? That's the problem that is propounded in the question. All right, question for eat says which of the following symptoms will be most suggestive of a major depressive syndrome in this patient? A, anorexia, B, expressions of discouragement, C, insomnia, D, low energy, E, we draw from family. Right? So for this, anorexia, can he be linked to the cancer? Yeah, cancer makes people caquectic, makes people not want to eat. So I don't think I'll chalk that up to a major depressive syndrome in the patient, right? Expression of discouragement. Could it be linked to the cancer? Yeah, he could, he could, but I guess let's keep that although, yeah, he could, although expressions of discouragement, right? He could be linked to the cancer, but it could also be a sign of major depressive syndrome. C says insomnia. Well, the person has cancer, the person is on a lot of pain. Could that be attributed to the cancer? Yes, he could, right? So I don't know if I would say that that's most suggestive of a major depressive syndrome, D, low energy, low energy can definitely be from the cancer, right? So again, it could be from depression, but it could be from the cancer. So it's probably not most suggestive, right? It's just not as specific.

And then option E says we draw from family. I think I'll take that one, right? We draw from family, right? We draw from your family is not as a result of the cancer, right? It can be a result. Basically, that's an hedonia, right? So like, you know, you want to hang with your family, right? So if you don't want to do things you previously used to do before, that's a very good telltale sign of depression, right? So the thing is, honestly, options A through D, I wouldn't pick those because they can be confounded by the cancer, right? It could be the cancer making him know when I eat, feeling discouraged. I mean, this person just got bad news, right? In insomnia, you know, not sleeping because of pain, low energy again, because you're not eating them because of cancer and all those things get kicked here and whatnot, right? But we draw from family is not something you can chalk up to the cancer, right? You can chalk it up probably more to an hedonia from depression. So I'm going to go to option E for that one again, basically, I just picking out the answer that is more chalkable up to MDD versus, or MDD, or maybe cancer, maybe this, right? Option E is a most straightforward answer. And then question 49 says that 25 year old woman has had a second spontaneous abortion after eight weeks of pregnancy. She also had an elective abortion in the past. She has been told that her uterus is in a retro-flex position. And this finding is confirmed on pelvic examination.

The rest of the examination is normal, which of the following is the most appropriate canceling? A says cervical incontinence is frequently associated with ureterine malposition and is a likely contributor to spontaneous abortion. That's wrong, right? Pregesterone competence is something that can be caused by a history of like a loop electric decision procedure, right? And that's going to cause like a painless and second-term extra pregnancy losses. So that's wrong. Option B says progesterone therapy is likely to decrease the risk for a coroner abortion. And she'll be studied as soon as pregnancy is diagnosed. No, we don't returnly put people on progestin therapy. It's only when we're worried about them having a, you know, less than previous pregnancies they've had cervical incontinence. And we study them on progestin in future pregnancies. That's wrong. This person has not had cervical incontinence. Option C says, renal abnormalities are frequently associated with ureterine malposition. Making it less likely that successful pregnancy can be expected. That's also wrong, right? So the thing is, whenever you have an atomic problem in your uterus, like a T-shaped uterus and what-nots, then yes, that tends to be associated with renal abnormalities. Because remember, your uterus and your kidneys, they kind of come from the same ancestor. So, but not the ureterine malposition is with ureterine and atomic abnormality. So that's wrong.

Option C says, ureterine malposition should be corrected by surgical suspension prior to further attempts at pregnancy. That's wrong, right? Guys, the right answer here is E. Ureterine position does not increase the risk for spontaneous abortion. And therefore no specific therapy is indicated. That's the right answer, right? So ureterine malposition is not some abnormal thing. Your uterus can be antiflexed, so like bending forward or retroflexed, that's bending backwards, right? That's normal. Some women have either, right? So it's not a big deal. It's not a big deal, right? So it's really not a big deal. It's really not a big deal, right? So the thing is, as you get pregnant, your uterus is going to stand up straight after a while. Although I guess one association I should mention with the retroflex uterus is, when we see it in people with endometriosis, you know, like a fixed retroflexed uterus, where the uterus sacral ligament, right? So remember, the sacrum is in the back of the uterus, right? So there's a ligament that connects the uterus to the sacrum called the uterus sacral ligament. If you have the deposits of endometriosis glands and stroma, aka endometriosis on it, that can make it lose its elasticity and pull the uterus in a fixed retroflex position. But again, yeah, retroflexed antiflexed positions, they're very common with the uterus. It doesn't mean that there's some abnormality or it will prevent the one from being pregnant. All right. Question 50.

Five year old boy is brought to the office by his mother because of recurrence of bedwading at night. He has a three month old sister who is healthy. Physical examination discloses no abnormalities, results of your analysis are shown, so his specific gravity is 1.010. Glucose is negative, protein is negative, microscopic, right? We see zero to one white cells per high power field and no red cells, right? Now he says which of the following is the most important information to share with his parents, right? So, one thing I always tell people is this, right? Whenever a USM Ly question is mostly B9, pick the most B9 answer you can find. Whenever a USM Ly question is mostly B9, pick the most B9 answer you can find. Don't pick a gangbusters answer, right? So option A says the condition will seize if they reprimand him for deliberately wetting the bed. B says the condition is self-limiting and they should take care to lessen the emotional impact on their child. C says the condition is potentially serious problem and could represent chronic inflammation of the kidneys. B says the condition may be a precursor of diabetes. He says the condition signifies a serious on the line emotional disorder. Again, this boy is pretty okay. Physical examines abnormalities. He's urine studies are totally fine. Like chill out, right? He doesn't have a serious on the line emotional disorder, right? He doesn't have diabetes. He doesn't have glucose in his urine, right? This is not a serious problem.

You know, chronic inflammation of the kidneys, you know, like we're worried about maybe like an afraid, an afraid, or whatever. No, that's not what's going on here. Condition is self-limiting. I'm going to go to option B. You know, don't make a big fuss about it. Don't make a big fuss about it, right? The thing is over time the child is just going to grow out of it, right? The child is just going to grow out of it, right? So just calm down. Although if the child hits age seven and they're still bed wetting, you need to do something about it. But again, technically, yes, we diagnose you as a bed wetter if you're still bed wetting over age five. But again, this question is just showing like benign presentation, right? It's recurring, you know, maybe because his mom had a newborn, you know, you know, like when a newborn comes into the family, like the other ones can start misbehaving a little bit on me, start regressing a little bit, right? Just over time they will adjust to the presence of the newborn, right? So just chill out. Option B is the right answer. Reprimand him for no, deliberately wetting the bed. As you're a permand him, you're giving him that attention, right? So he's like, oh, okay, this is getting me attention. So let me keep waiting the bed so I can get you getting attention from my parents, right? So I'm going to go to option B for this for this one. All right.

So question 51, a 38 year old Hispanic bank executive comes to the ED because of the sudden onset of shortness or breath, lightheadedness, staff, racism, weakness. He's a febber on a quotation of the lungs bilateral, bisler roles are heard, ECG is shown, right? Which of the following is the most likely diagnosis? Uh-oh, look at this ECG. Uh, this is not good. V2, V3, V4, V5, V6. Um, we see like the tombstone in ST elevations, right? This is an MI, right? So, uh, I'm not going to go to option A, acute paracoditis. Remember in acupunic aditis, you'll see diffuse ST elevations and PR depressions, right? And acupunic aditis is anitis. He usually is going to cause fever and, um, um, is probably not going to present this suddenly, right? Hyperventilation syndrome. Well, if you're hyperventilating, that certainly does not explain the ST elevations we're seeing on this EKG, right? Um, option C says MI, so I'm going to go with that option. C is the right answer. Option D says PE, right? Or again, remember the classic EKG finding in the PE is a sinus-tachycardia. This person does not have a PE, right? And the PE is not going to explain the ST elevations. And, um, yeah, so I'm going to go to MI here and then option E says spontaneous pneumothorax. And pneumothorax essentially cause an EKG finding. And again, they will describe like, you know, decreased breath sounds, you know, hyper-resonance to percussion. They don't do any of that in this question.

So I'm not going to go with option E. I'm certainly going to go with option C. All right. Now, question 52. Uh, three-year-old white girl is brought to the office by her parents for a full-of visit. Four-eight hours after receiving a five TUPPD skin test. The test was done as part of a routine screening for enrollment in a homeless shelter. A physical examination shows 10 millimeters of injuries at the puncture site. The examination is otherwise normal. The parents tell you they are shocked by this finding since both of their skin tests were non-reactive. They see they were born in this country and tell you that their daughter has always been in good health. She has not had much medical care in the past two years, but she has been healthy. Until moving into the shelter, they have been squatters in vacant buildings, which of the following is the most appropriate step at this time. A says, call her previous physician to obtain more history. B says, order a chest x-ray. C says, order a test for HIV and TBD. D says, repeat the PPD skin test. E says, schedule gastric aspiration for culture on successive days. Right. So what does this girl have? What does this girl have? You know, she has a positive PPD and you're like, divine. How do you know it's a positive PPD? Well, I know it's a positive PPD because it's 10 millimeters of injuries, right? I remember the people that have positive PP Ds when it's 10 millimeters of injuries, health care workers, people from endemic countries.

So health care workers, people from endemic countries, IV drug users, people with diabetes and other classic ones, if you live in a congregant setting, right? So we're a lot of people kind of huddled up together. Like you see she has been a squatter with her parents. Not just that you can also see this in prisons. It's going to be 10 millimeters, right? Whenever you have a lot of people hold it together, 10 millimeters is going to be the cutoff. Remember, five millimeters is for the middle compromise, right? Like people that have HIV, this girl or her parents don't have HIV or so. HIV or exposure to a person that has TB, right? Or a person that has an immunodeficiency disease. We don't see that here. And then 15 is positive in everybody. So this person's PPD is positive. And after you have a positive PPD, what do you do next? Well, want to figure out if you have latent TB, active TB, right? So we're going to get a chest x rate. We're going to get a chest x rate, right? So the right answer is going to be option B, option B, right? Call our previous physician to obtain more histories of PPD skin tests, right? Just get a chest x after that, right? Again, guys, go for the simple answers. Stop going for the high sounding nonsense on your exams, right? Option C says order a test for HIV and TB. Again, this question doesn't really seem much about HIV at all, right? Repeat the PPD skin test. No, it's positive. Why do you want to repeat it? Repeat it again.

You're going to get the same response. Is that going to change your management? No, right? And then option E says schedule gastric aspiration for cultural and success feed, successive days. No, when a person has a positive PPD, your next step is going to be to get a chest x rate to see if they have lethal and TB or not. If the chest x rate is negative, right? We're going to say it's lethal and TB. If it's positive, then you probably have active TB. And we have lethal and TB remember you're going to do I so nice. It plus B6 for nine months. Or you can do any of the shorter or if a painting, B's regimens that can be from anywhere from a three months to four months. All right. So I'm going to go to question a 53, 54 is co joined. Okay. So 10 year old girl who has been on the going treatment for chronic juvenile rheumatoid arthritis for the past three years is brought to the office by her parents because of painful swelling of the right knee. She has had three episodes of painless swelling of her left knee and ankle, which have subsided spontaneously with rest and aspirin therapy. She has used no medications between episodes physical examination to day discloses pronounced redness and warmth around the right knee. And a larger fusion. You don't say attempts at active and passive motion cause severe pain. All right. 53, which of the following is the most appropriate step at this time? Well, let's look at this. You have a joint that is red. You have a joint that is tender.

You have a joint that is painful. Sounds like septic arthritis to me. Got to tap that joint. Resuption A is the right answer joint aspiration. B says serum a na nope. C says serum rheumatoid factor as a nope. Option D says technician 99 M scan nope. Option E says X rays of the joint. No, right. Whenever a person has septic arthritis, don't overthink this. Tap that joint. Run at those entices, which it can also be called joint aspiration. All right. Now question 54, which of the following new symptoms of findings if present would most strongly indicate the need for further diagnostic studies? All right. Option A says decrease viscosity of joint fluid. B, diffuse increase in technician 99 M uptake around the knee and bone scan. C, positive gram stain of joint fluid, D, positive serum rheumatoid factor test, E, soft tissue swelling seen on X rays. What do you think? Right. So if the gram stain is positive, in the joint fluid, that tells us that this person probably has septic arthritis, right? So you need to do further testing on that fluid like cultures and sensitivities, right? Because again, by doing cultures and sensitivities, you can figure out the bulk that's causing the septic arthritis and then you can tailor your antibody, clergymen accordingly. Right. So I'm going to go to option C here, right? Decrease face. Cocid. It doesn't really tell you much. Right. D diffuse increase in technician 99 M uptake around the knee. Doesn't really tell you much. Right. Sermer.

M uptake factor test. No, soft tissue swelling seen on X rays. Yeah, this question's in this batch. The answer choices, like the right answer is just going to mix clear of your sense. All right. So we're going to go to option option C for this, right? Okay, question 55 says 31 year old white woman comes to the office for initial prenatal care. She's 12 weeks pregnant by date of her last month's repaired. This is a fourth pregnancy. She has three healthy children. Her last delivery was by C zero in section because of fiddle distressed during labor. Her history includes heavy use of alcohol and cigarettes and multiple sexual partners. In addition to routine prenatal lab workup, the patient consents on HIV antibody test. The tests are ordered later. The HIV test is reported as positive. At a full-up visit, the patient should be cancelled regarding which of the following A, amniocent thesis is recommended to roll out congenital HIV infection. No, no, no, no, no, no, no, no, no, no, no, no, no, you don't do that, right? Because that by doing that amniocent thesis, you naturally increase the risk of the child contracting HIV, right? You don't want to do that, right? The thing is, after the child is born, you can test the child for HIV. And the things you can do during pregnancy to mitigate the mom giving HIV to her child, right? And remember, the time where HIV is passed on to the feeders is typically going to be during labor and delivery. That's like the high risk time.

Pretty much at other times during the pregnancy, it's not that big of a deal. Option B says breastfeeding will increase the risk for transmitting HIV to the infant. Absolutely. This is why breast HIV and mom is a contraindication to breastfeeding in the U.S. So that's a true statement. Let's keep that for now. Option C says immediate trombination of pregnancy will decrease her risk for progression to eight. No, the thing that's going to reduce her risk for progression to eight is studying on antiregiviral therapy. D says repeats his area delivery may increase the risk for vertical transmission of HIV. That means C section can increase the risk. Vaginal delivery can increase the risk. That's kind of a wishy washi statement. It's kind of a wishy washi statement, right? Again, what you really should be doing is antiregiviral therapy. Yeah, D. I don't really agree with D. And then he says there is for perinatal HIV transmission is greater than 50%. No, no, no, no. Even if mom is untreated, yes, she can pass on HIV to our offspring to her feeders. But that risk is not 50%. It's not 50%. I think it's like more like in the 40s or 30s or something like that. It's definitely not greater than 50%. Like no, right? Many women that have HIV have feeders, they have delivered kids and they're untreated. And those kids don't have HIV, right? So 50% greater than 50%. That's a really high number. I've got a good option. Be here, right?

Breastfeeding objectively increases the risk for transmitting HIV to the infant. So again, mom should be studied on antiregiviral therapy as quickly as possible. Like when you breastfeed and you have untreated HIV, the risk of transmission of HIV to your feed is about 10 to 20% actually, right? So I'm going to go to option B here. So breastfeeding is will definitely increase the risk. This one should be studied on antiregiviral therapy because if the viral load is low, then the risk of transmitting to the feeders is almost zero. Right? That's like the best thing she can do, right? To lower her risk, keep a low viral load by studying on antiregiviral therapy. All right. Now question 56. Last question while you're on the local nursing facility, the nurse mentions that your patient a 79 year old African American woman appears to be a poor eater. She was admitted to the nursing facility three months ago from the hospital, where she was treated for congestive heart failure. Her daughter had moved away from the area and nursing home placement was necessary because the patient could no longer function independently. Her present medications include ferozomide and dejuoxin. Physical examination is normal, except for weight loss of 3.5 kilograms, that's seven pounds during the past three months. In your conversation with the patient, she says, no, I'm not depressed. I just don't have an appetite anymore. Nothing is good to me.

I have a little bit of nausea most of the time, which of the following is the most appropriate initial diagnostic study. Man, this is a classic USMD question. A says chest x-ray, B says CBC, C says, determination of sermobular main concentration, D says determination of serm dejuoxin level, E says upper GI barium study. All right. So what do you think is going on here? I'm going to tell you right now that this person has dejuoxin toxicity, right? Man, combining like in fact, this is something that I teach in one of my classes, combining ferozomide and dejuoxin is not a very great idea at all. It's not a very great idea at all. Your dejuoxin levels can be raised and that can cause dejuoxin toxicity, right? But that's not all. Another thing ferozomide can do is it can cause hypochylemia, right? Remember, ferozomide is a lube diuretic. So because it's a diuretic, it's going to make you volume depleted. When you volume depleted, you know, you're running on your tensile outdoast run system is going to get up regularly. So you're going to make a lot of outdoast run. Well, what does outdoast run do to potassium? Outdoast run literally makes you dump potassium in your urine. So if you dump potassium in your urine, you're going to become hypochylemic, right? You're literally going to become hypochylemic and that hypochylemia can worsen dejuoxin toxicity. Well, why is that? Well, the thing is dejuoxin, the way it works is that it inhibits the sodium potassium ATP is pump.

It inhibits that pump, right? Now, the thing is to inhibit that pump. It binds to the potassium binding site on the sodium potassium ATP is pump. So if you have hypochylemia, that potassium binding site on the sodium potassium ATP is pump, you're going to have more open spots for dejuoxin to bind. So you're going to have more ditch toxic, more ditch binding. So you're going to have more ditch, excuse me, you're going to have more ditch toxic acidity, right? So the ferozomide again is raising the ditch levels and then the hypochylemia from the ferozomide is making the juxin bind more strongly to the sodium potassium ATP is pump that it inhibits. So you're going to get more ditch toxic acidity, right? Classic symptoms of ditch toxic acidity changes in vision, right? You can have yellow vision, you can cause nausea, you can cause GI complaints, you can cause a pretty cardio, right? Because you can actually you can cause it to take cardio with an AV block, right? Because dejuoxin can stimulate the vigous nerve, right? And so of this nausea also, the juxin kind of acts like chemo in a sense that it can stimulate the chemo receptor triggers on that we find in the middle, right? So that can explain the nausea that she has, right? So let's just check these ladies ditch levels. That's going to be the right answer here. That's going to be a right answer here. These are one of those questions where there is no level of test thinking strategy that will get you to the right answer.

Like you don't know this concept or you don't, you don't know it. So do you like the way I teach? You're going to love my classes next month, starting I believe on the ninth of April. I'm going to be having a 20,500 test thinking strategies course. That's for step one to three, four barios, that's class. That's for step one to three, five hour social sciences and ethics and quality improvement and hospital medicine class. That's for step one to three. Um, and then I have a 20 hour step two step through review. That's for step two and step three only. And last minute review, just for step two and step three. Um, and then I also have a step one class that I teach that is 25 hours long. That's in the month of May. Then have a 50 hour step two step through review. Uh, only going to be held once this year. It's a super comprehensive, amazing class. Uh, it's going to be held in the first two weeks of June. So if you're interested in any of these classes, just shoot me an email. They're all held over Zoom on the one that teaches the whole thing. And again, many people have attended these classes and found it to be extremely helpful. You know, even this year, I've got in people that I've got in 250's, 260's, 270's on the exams after taking my classes. They are very well put together. They are very, very well put together. Explain pathophase. I show you how these things present on exams. And I give you context when I don't just throw facts at you.

And also for one and one children for all the USMD and complex exams and also help with hearing applications, personal statements, mocking, reviews and things like that. All right. And then I have these podcasts on Apple Google and Spotify. And then I have another website called divine intervention life lessons. Com divine intervention life lessons. Com there's actually a double podcast associated with that called the divine intervention life lessons podcast. Uh, many of you know I'm a Christ follower. So I do make like one or two podcasts every week. I discuss a life lesson from a biblical perspective. Uh, there's actually many people that listen to those podcasts and find them to be pretty helpful. I really have almost 400 episodes on there. All right. So thank you for listening to me today. I will see you God willing in episode 645. But have a wonderful day. Have a wonderful week. God bless you and bye for now. Thank you.

Symptom control, specifically aggressive pain management (e.g., adjusting NSAI Ds or opioids), takes priority over psychiatric referral or nutritional support.

10 millimeters (mm) is generally considered positive; 5 mm is reserved for high-risk groups (e.g., HIV positive).

Joint aspiration and culture to rule out septic arthritis.

Combining a loop diuretic (like furosemide) with decoltequin causes hypochloremia/hypokalemia, which increases the binding affinity of decoltequin and worsens toxicity.

Administering Antiretroviral Therapy (ART) to the mother to maintain a low viral load.

A positive test suggestive of exposure or latent TB infection.

The condition is self-limiting; reassure parents that it will likely resolve over time and avoid reprimanding the child.

Positive Gram stain (indicating bacterial presence) requires immediate cultures and sensitivities.

Breastfeeding significantly increases the risk of transmitting HIV to the infant, making ART essential for maternal management.

Loop diuretic; causes hypochloremia/hypokalemia.

A positive test suggestive of exposure or latent TB infection.

The condition is self-limiting; reassure parents that it will likely resolve over time and avoid reprimanding the child.

Positive Gram stain (indicating bacterial presence) requires immediate cultures and sensitivities.

Breastfeeding significantly increases the risk of transmitting HIV to the infant, making ART essential for maternal management.

Loop diuretic; causes hypochloremia/hypokalemia.