DIP Episode 641 - USMLE Free 86 Series 3 (Q21-30, for Step 2/3)

Alright, welcome to episode 641 of the Divine Intervention Podcasts. In today's podcast we're going to be continuing the free 86 series for step 2 and step 3. Again, these are specs questions and if you're downloading this podcast or you're listening to this podcast, if you've gone to my website, I include a link to the PDF that contains these questions. These questions are extremely good. Think of it as another free 120, but in this case it's not 120 questions, it's more like 86. So this is series 3, we're going to pick up from question number 21. Alright, so a 29 year old woman comes to the emergency department because she has had increasingly severe lower abdominal pain and nausea for the past two days. She's sexually active and does not use any contraception. Her last menstrual period ended six days ago. Temperature is 101 degrees Fahrenheit. Physical examination discloses abdominal tenderness in the lower quadrants bilaterally, with rebound and garden. pelvic examination discloses lucoria at the cervical oz and tenderness of the uterus to palpation. The atnexal mass, the atnexal areas are tender but no mass is apopable. Which of the following is the most appropriate diagnostic study? Option A, cervical culture, option B, kudosynthesis, option C, laparoscopy, option D, serenbeda HCG concentration, option E, ultrasoundography of the pelvis. So we need to ask ourselves what's going on here, right?

This person has lower abdominal pain, sexually active, doesn't use contraception, right? And then she has rebound, garden, lucoria at the cervical oz and it's in inflammatory discharge and whatnot. This sounds a lot like P80. This person probably has P80. This person probably has P80. By lateral atnexal tenderness, cervical discharge, this is pelvic inflammatory disease. And you're going to do a culture because that should guide your antibiotic therapy. Although remember, if they're asking you to pick antibiotic, so I'm going to go to option A for this one. If they're asking you to pick antibiotics for PID, right? You want to use a combination of septriaxone, right? Doxysyclid and metronidazole, septriaxone, doxysyclid and metronidazole because it's a polymicrobial infection. So you need to include something that can give you anaerobic coverage, like metronidazole, right? Kudosynthesis is when you withdraw fluid from a woman's cold assack from the pouch of doubles. That doesn't really make any sense here. Laparoscopy, you know, is something I'm going to do for maybe like ovarian torsion or something along those lines. Serum beta-hicg is something we'll do for worry that she's pregnant, but it's kind of hard to be pregnant if your last menstrual period ended six days ago, right? You're probably still in the follicular phase and not in the luteal phase.

And then option E-autro-sonography of the pelvis doesn't really make sense here when you can easily make a good clinical diagnosis of PID, right? I don't think we're worried about any topic pregnancy or anything like that here. All right. Question 22. A group of women of Scandinavian descent comes to the office because of fatigue, generalized weakness, and palpitations. She's divorced and lives with her four-year-old daughter. Medical history is significant for hyperthyroidism and mild ophthalmopathy caused by gravestisies. Before initiating therapy, the patient wants to know what she can expect in the future. In advising her about the prognosis, which of the following is the most accurate statement, right? It's something I really hit on a lot in my classes and I also hit on a lot in this podcast. Prognosis is becoming a very big thing on the USMEL exams, right? So let's look at this option. E says gravestophthalmopathy will resolve a styrofoam on secretion is lowered. Not necessarily, right? Not necessarily because remember, if a person has gravestisies, they have these are thyroid stimuli in immune globulitis. Those things are like TSE receptor agonists, right? As long as those thyroid stimuli in immune globulitis are stimulating TSE receptors, you're going to have the ophthalmopathy because remember, gravestophthalmopathy is driven by fibroblasts, laying glycosaminoglycans in the person's eye, right? Fibroblasts do have TSE receptors.

So those thyroid stimuli in immune globulitis can stimulate those TSE receptors on fibroblasts and cause the ophthalmopathy. So lowering the thyroid hormone is not the thing that's going to fix the problem. The thing that's going to fix the problem of the ophthalmopathy. Let's figure another way to get rid of those antibodies, right, in some way, shape or form. All right. Now, option B says malignant degeneration of the thyroid gland is a common complication. I'm going to say no, right? No, right? Remember, the most common thyroid cancer is papillary thyroid cancer and the biggest risk factor is prior utherapy to the head and neck, right? So that's, or chest, that's wrong. Option B says, you will not be able to become pregnant. No, hyperthyroidism does not preclude pregnancy, that's wrong. When D says the thyroid will continue to increase in size with any non-surgical treatment, that is not necessarily true, right? Non-surgical treatment, because like, for example, what's the standard of care for money, chain, gravestis, disease? It's I-131 radiotherapy. That is non-surgical. That will completely obliter thyroid. If you obliter thyroid, how's the thyroid going to keep growing? All right. So that's wrong. Option E says, untreated patients had an increase risk for cardiac arrhythmias. That is definitely right. Why? Because remember, when you have hyperthyroidism, you're producing a lot of T3.

One of the jobs of T3 is that it increases the insertion of beta-1 receptors on the surfaces of your cardiac myocytes. If you increase the insertion of beta-1 receptors on the surfaces of your cardiac myocytes, the thing that's going to happen is that you're going to become hyper-responsive to cardiac colomines. That can increase your risk of atrophy relation. Remember, A-fib is the most common arrhythmia in people that have hyperthyroidism. All right. We're going to go to question 23 and 24. Those are, you know, colloidin items, right? So, a 38 year old woman returns to the office for a full op of tension headaches. We shall not improve with trials of several appropriate medications. She has been married to a policeman for the past six years and has four children, ages five to 12 years. When asked if she has been under extra stress, she begins to cry. Bruce is evident on both arms. On further questioning, she says her husband hits her whenever he's drunk. Which is at least two nights per week. She says he is nice, a good husband when he's sober. When he drinks, oh, he is awful. He accuses me of cheating on him. Last night he said he would kill me if I try to leave. Whoa. A husband is also your patient. All right. So, question 23 says which of the following is the most appropriate intervention? Option A says advice her to leave her home with her children and moving with her relatives. Option B.

After her husband's supervisor to discuss recent stress levels on the job, option C, gather more information while remaining neutral since both the husband and wife are your patients. Option D. Refer her to a domestic violence program option E. Seeker is training order against her husband on her behalf. Right. So, this is a clean court case of intimate partner violence, right? Intimate partner abuse. Right. Typically, the thing you're going to do in this circumstances as the patient is there, safe at home. Right. And also, you want to create a safety plan for the patient, a safety plan like a shelter shake and go to or whatever if things were to really go awry in those circumstances. Right. So, the answer that makes sense for that is going to be option D. Refer to a domestic violence program. Right. She is the one that has to seek her is training order not you. Her doctor is not a restraining order. Seeker. Gather more information. This seems like information enough. We can pretty easily conclude and the patient has pretty much given us all the information we need. Right. Contacting the husband's supervisor. That's likely going to escalate things at home. So, you should not do that. Option E says, advice or deliver home. You're not a you're not a marriage counselor. Right. As a physician. So, that's wrong. So, question 24 then says, which of the following is the most important question to ask at this time? Option E says, do you think this might be causing your headaches?

What do you think? You don't say. Option B says, has your husband lost his temper with any of the children? Option C says, have you been drinking at the time of the fights? Option D says, have you or your husband be receiving any kind of counseling? Option E says, why have you stayed in this marriage? Right. Option E is absurd. Right. Your questioning why she's staying in the marriage. That's not your rule as a physician. Option D says, have you or your husband received any kind of counseling? The thing is, for this question, honestly, I probably go more with option B because the thing is that this point we're kind of worried about child abuse. The husband is pretty violent, especially when he's drunk. That can make the kids unsafe. In that regard, a line is drawn. Child protective services would have to be contacted if the husband has basically raised his hand at the kids. So, as your husband also lost his temper with any of the children, if that's the case, then CPS has to be the next step. Option B kind of screams for child abuse, so that's a better answer. That's a better answer because her headaches are likely caused by the abuse. Right. Have you been drinking? It's not really much about her drinking in the Q-stem, right? Has she been receiving any kind of counseling? No, like the thing is, the child abuse is a more pressing issue. Deal with a more pressing issue first before you start worrying about all these other things that could calm down the line. Right.

So, a four-year-old boy is brought to the office by his mother because he has become a manageable at his D-care center. At previous visits, he exhibited behavior problems to which his mother did not set limits. Parents set limits. He constantly interrupted situations, seeking his mother's attention. She now reports that during the past few months, his fighting, refusal to obey the D-care workers and violations of time-out have become much worse. He began D-care at six weeks of age so that his mother could return to work. His father works as a house painter and has alcoholism. The boy has a six-month-old sister who also attends the same D-care center. Records show his height and width at the fifth percentile. And his growth velocity is normal. There were no complications during the pregnancy with this child, and he has not had any significant medical problems. Physical examination today discloses no abnormalities. Which of the following is the most likely cause for this child's worsening behavior? Alright, option E says, aggressiveness to compensate for a poor self-image caused by short stature. Wow. Option B says ADHD. Option C says a reaction to his father's drinking. Option D says, reduction in his mother's attention because of his new sibling. Option E says, a toxic reaction to organic fumes from his father's clothes and work materials. Right? So notice, notice, notice. Right? This boy has become unmanageable. Right?

And during the past few months, things have just escalated big time. Well, let's ask ourselves, what changed within the last few months? Well the what that changed is that a new sister was born. Right? Obviously a newborn has a lot of needs, right? So unfortunately, you're not going to be able to give as much attention to the other kids as the newborn because newborns are in need without your help, they will not live. Right? So this child is basically, and this is something that can happen in kids. So it's something you have to prepare for, train for, you know, something that is correctable though. Right? But basically like this mom has to spend a little, she needs to like section of like an hour or two during the, you know, it doesn't even have to be an hour or two. It can even be just 10 minutes, where she just spends time with her, with a four year old son, right? I mean, it's not excusing the child's behavior, but this child is yearning for attention. So I'm going to go to option D here, I'm going to go to option D here. Organic fumes, you have to make so many assumptions for that. That's wrong. Right? Reaction to his father's drinking. No. ADHD. No, no. This, the thing is, if you can see a cause for this child's behavior, then don't be diagnosing ADHD. This child is just yearning for attention. Option E says, aggressive needs to compensate for a poor self image. For your old, minimal self image, I don't know about that. Right? So I'm not going to pick them.

I'm going to go to option D for this one. All right. So at 13, question 26, a 13 year old girl is brought to the office for health maintenance visit. She was diagnosed with Turner syndrome in infancy during a workout for a court decision of the order. During today's visit, her mother reports that the girl has been talking about babies. You have been the patient's physician for the past six years and no, she's pre-pubescent. You consult the girl that if she wishes to have a family, she will need to do which of the following. Right? So option E says adopt option B says have amnesia and TCC gets pregnant. Option C says have an operation. Option D says receive genetic canceling. Option E says receive hormone treatment. Right? So this person has Turner syndrome. When people have Turner syndrome, they have strict ovaries. They undergo premature ovarian failure. So the chance of this person becoming pregnant is almost zero. It is extremely difficult. I'm not saying impossible, but it is extremely difficult for people that have Turner syndrome too. Because again, if you have no eggs, how you're going to get pregnant. Right? So this child should probably consider adoption when she's off of age. So option A makes the most sense. Amnesia and TCC, like you got to get pregnant first to do amnesia and TCC. That's wrong. What operation are you going to do? Like transplant a new ovary. That makes no sense. Right? Genetic canceling. Well, we know that she has Turner syndrome.

Receive hormone treatment. No, right? That's not necessarily going to be her pregnant because again, the hormones, their job is to stimulate the gonad. But if the gonad is non-functional, if it's a failed gonad, hormones are not going to be very helpful here. All right. So going to go to question number 27. So you are asked to evaluate a 78-year-old German American woman who is admitted to the hospital for replacement of her left knee joint due to degenerative joint disease. She is a retired sim stress. She has type 2 diabetes mellitus, a long history of hypertension and chronic renal failure, presumed secondary to diabetes mellitus and hypertension. Reversible causes of renal failure have been excluded, shown the winter tonsilectomy at each nine years, and a laparoscopic colisic septomy at each 68 years. Certain creatinine concentration on admission was 6 milligrams per deciliter. Prochlorine therapy includes a low sodium, low protein American diabetes association diet. In allopryl and acetyminophen, she and her husband live on a farm 90 miles from the nearest dialysis center, dialysis facility. In considering long-term treatment options for this patient, which of the following is the most appropriate factor to consider? Option A, her legibility to receive Medicare, option B, her histrov and abdominal operation option C, her histrov arthritis option D, her suitability for home dialysis option E, her willingness to move to the city.

So guys, this person has really bad renal disease, right? Really bad renal disease, right? This person needs dialysis, but the dialysis facility is 90 miles away. That's a long drive. That's probably like a drive of like an hour and a half, an hour, 40 minutes, right? So this person is going to probably should consider home dialysis because this person's kidneys are so far destroyed, right? They're going to need some kind of dialysis, right? So option D is going to be the right answer. Option A is wrong because this person is definitely eligible for Medicare, right? If you're over age 65, you're eligible for Medicare. Now a person that is on dialysis, if they are under 65, or are also eligible for Medicare, a person that is under 65, if they're on dialysis, they are eligible for Medicare. So option E is wrong. B is wrong, right? That makes no sense on if you get dialysis or not. Option C, her histrov arthritis again, makes no difference on if you get dialysis or not. Option E, her willingness to move to the city, just to get dialysis move completely. That doesn't really make any sense, right? So if we can do home dialysis, we should try to set it up for this lady. All right, so question 28, a 60 year old man is brought to the hospital for management of acupuncturitis. Results of lab studies are shown, right? So his amelesis 1000, calcium is 8.4, BUN is 5, hematocritis 42%, white count is 14,000. Results of serum liver chemistry profiles are within the reference ranges.

After 48 hours of fluid therapy and observation, a poor prognosis will be indicated by which of the following lab studies, right? So option E says a serum LT of 106 B, serum amelesis of 2000, C, serum bilirium of 4.2 mix per deciliter, D, serum calcium of 6.6, and E, serum glucose of 200, right? So whenever you get a question involving prognosis or an acupuncturitis, go for the good old Ransin inscribed tier, right? The good old Ransin inscribed tier, right? You know, there's all these newer things that they use like the bisap score and all those things and those are great. But Ransin is where our friends at the MBM is typically come out on the exams, right? And remember, we have Ransin inscribed tier for admission, and then we have Ransin inscribed tier for 48 hours later, right? And it's a fairly decent predictor of your prognosis, right? Like for example, if you check, if you have like five or more of the Ransin inscribed tier being positive, your risk of dying from acupuncturitis is like 40% or more, right? So it's very helpful, right? So, you know, on admission, the criteria, if I'm remembering correctly, sorry, there's a bunch. Let's see if I can remember this, right? So age over 55 is part of it. Another one is white count over 16,000. Another one I believe is ASD greater than 250, I think. Another one, so ASD not LT. Another one on admission, I think is a common divine thing. I think LDH greater than 350, right? So I've talked about age, white count, ASD, LDH.

I mean, I feel like there's one more, but it's not coming to memory right now. So, but that's on admission. But 48 hours later, right? The things that are really worrisome are, if the person has required more than six liters of fluid within the 48 hours of admission. Another classic one is if their hematocrit has dropped by more than 10%. Right? Another classic one is if their calcium is less than 8 milligrams per deciliter. Right? Another classic one is, there's this thing with base deficit. I wouldn't wear about that for the exams. Right? But again, I know I'm probably missing out on like two or three. I guess the on admission, I think what I forgot is if their glucose is more than 200, right? Is either on admission of 48 hours, right? So you can look this up. Right? Again, I think I've tried to recall as much as I can. That's about as much as I can remember right now. But basically, right? So we see from all these criteria, right? So option A has to be wrong, right? LT is not part of Ransion's criteria. Option B has to be wrong. Amelies is not part of Ransion's criteria. Option C has to be wrong. Billior bin is not part of Ransion's criteria. Option D has to be right. Right? Serum calcium of 6.6, that's less than E. Right? That's really worrisome. Right? Option E, Serum glucose of 200. Remember, it's more than 200. Right? So option E is kind of wrong, right? But what option D is really worrisome? Right? I'm going to go to option D here and here's why.

The thing is, in pancreatitis, what's the pathophys behind acupunctitis? Right? So you have inflammation around the pancreas. And typically, you know, you will have this premature release of pancreatic enzymes like lipids. And that lipids, as is released from the inflamed pancreas, it can begin to digest. It can begin to, because lipids literally breaks down fat. Right? So it can begin to digest, it can begin to digest surrounding fat. Right? And lipids, right? As you digest surrounding fat, you're going to generate free fatty acids. Those free fatty acids can bind up calcium. Right? And that can sequester calcium. And lower your serum calcium levels. Right? So that can be indicative of a person having really severe pancreatitis. If lipids is now basically like being freely elaborated outside of the pancreas and, you know, not into the GI tract. Right? So that's why that calcium is kind of like a barometer for impending doom. All right? So I'm going to go to option D for that one. All right. So question 29 says, a 60-year-old white man comes to the office because of progressively worsening right-growing pain for the past month. He will also have a patient three months ago for preoperative assessment for a total right-heap replacement. For the past five years, he has been treated within Hill Bronco Dileaders from Fizima, resulting from an extensive history of smoking cigarettes. The patient is widowed and has lived alone in a mobile home since his wife died four years ago.

Vital signs to their temperature of 98.2 degrees Fahrenheit, pulse of 66, respiratory expressions of 18 per minute, and blood pressure of 110 over 82. This glistening examination shows an on-camped man who appears much older than his stated age. He has evidence of alcohol on his breath. Dentition is poor, with several broken loose teeth, and gingival pyrorea is present. Long sounds are distant and air entry is poor. Herd and abdomen are normal. There is no hernia present in the groin. With the exception of testicular atrophy, the patient's genitalia are normal. Each of the following is the most likely initial working diagnosis. Option E says, illegvintrumbosis. Option B says, infected heeperstesis. Option C says, occult up in the side. Option D says, occult hernia. Option E says, somatoform disorder. I think for this one personally, I'm going to go with option B. Infected heeperstesis. Why can I allow the others? Illegvintrumbosis. The patient is probably going to have more acute symptoms. This has been going on for a month. So that's probably wrong. Option C, occult up in the side. This abdomen is normal. Again, you probably shouldn't be having an appendicitis for a month. Occult hernia. I think there is no hernia present in the groin. Don't argue with the NBM Es. That's what they've said. Work with it. Option E says, somatoform disorder. Somatic symptom disorder is a newer term. In somatic symptom disorder, you have real symptoms, or you're blowing it out of proportion.

That doesn't seem to be happening here. This person seems to have an actual issue. I'm going to go with option B. You may be wondering, there is an infection, but the temperature is fine. Whenever you have, especially a chronic infection like this, sometimes you may have no fever at all. When a person has a prosthetic joint, they can have an acute infection, happening like a few hours or a few days after the surgery. Typically for that one, you just take them to the OR, wash out the joints. You don't have to remove it. Wash out the joints, and give them antibiotics and debris. But if it's this chronic, it's lasted for such a long time. That infected joint has to be removed. Then you have to give them tons of antibiotics. Sometimes there's this thing called a cement spacer you put that can deliver very high doses of antibiotics to that region. But you need to remove that joint. You need to debris. Then, after the infection resolves, you can then re-implant a new joint. You can re-implant a new joint. The right answer is going to be option B. Last question here. Question number 30. A 9-year-old boy is brought to the emergency department by his father because of lethargy. On physical examination, the boy is slightly lethargic and has deep respirations, which are 32 per minute. The father who is a single parent says he is always thirsty and he pays a lot. Results of lab studies are shown. The glucose is 850. Sodium is 132. Potassium is 4.1. Chlorides is 92. Bicarb is 6.

After admitting the boy to the hospital, which of the following is the most appropriate therapy? Right? A says. Admin is thrown almost silly in an ad potassium once urinary output is adequate. B says. Correct the acidosis with oral bicarb solution. C says. Correct the dehydration with hypotonic cellion solution. D says. Gift phenobarbidol to prevent hyponitremic seizures. E says. Institute intermediate-actin insulin to create the hyperaclycemia. Right? So what's your working diagnosis here? Right? Crazy high glucose. Crazy low bicarb. This is DKA. Right? And DKA management is very regimented on the exams. And if you do things out of order on your test, you're going to get in trouble. The first thing you're going to do is fluids, fluids, fluids. Okay? Fluids. After you give fluids like normal saline, you then go ahead and start an insulin infusion. Right? And also make sure you're paying attention to the hypotassium. Right? So this person needs fluids. Right? So I'm going to go to option A. Right? That's the answer that makes you do the right first thing. Right? Option, you know, the other options are not like, oh, credo, acidosis with bicarb. No. Many times try out fluids, fluids, insulin, potassium. Right? That usually will correct the persons of bicarb. Right? So option B is wrong option C, dehydration. We don't give hypotonic fluids for DKA or HHSNS management. We use normal saline for it. Gift phenobarbitol to prevent hyponitremic seizures. We're not there.

This person's sodium is 132. The person has some room to go. Yeah. So again, I think I'm going to go to option A here. Right? Intermediate acting insulin. No. We're going to be doing an insulin infusion for DKA. Right? So let's go ahead and stop here. Again, you like the way I teach you, like the way I make integrations. You're going to love my classes. I literally have a class today. It's a last mini review. It's a three hour class for step two and step three. And then starting on Saturday, I have a 20 hour class for step two, step three. Many people have taken these classes and done extremely well on their exams. And then also I have a 50 hour class taking place in the month of June, first step two and step three. And then I have all the classes like the test taking class, the biostatistics class, and the social sciences and ethics class. Again, these classes, you know, I teach the whole class. It's over Zoom. There's time for Q&A. Right? And you really learn the material deeply. Right? And you can see very integrated fashion that can really be helpful in terms of exam prep. So if you're interested in any of these classes, just shoot me an email. I also have these podcasts on the podcast apps, Apple Google Spotify, you know, and I have a website where, you know, every podcast you can access it there. And then also remember that I tutor one on one for all the US Million public exams. And I also tutor from Ed School exams.

And the ABIM internal medicine boards actually do tutor for those as well. Right? And then one other thing I want to say here is that I offer help with ERAS applications. The ERAS season is basically coming to an end. So things are going to start ramping up for the next season already. I'm actually studying getting inquiries already about this. Right? But like mock interviews, personal statements, rec letters, things like that. And then I have another website called divineinterventionlifelessons.com. Divineinterventionlifelessons.com. So I am a Christ follower. Right? So every week I post like one or two podcasts where from a build build co perspective, I discuss a life lesson, divineinterventionlifelessons.com. There's actually an Apple podcast associated with that called the divineinterventionlifelessons podcast. So check that out. I think it can really help you with just life growth and things like that. And then I also have a You Tube channel right where I post the videos that I make. So I just called a divineintervention, you are seemingly podcasts and videos. So thank you for listening to me today. I will see you God willing in the next podcast episode 642. But have a wonderful day. God bless you and bye for now. Thank you.

Antibiotic coverage must be broad and polymicrobial, typically involving a combination like ceftriaxone, doxycycline, and metronidazole to cover anaerobic organisms.

The condition is driven by the stimulation of TSH receptors on fibroblasts in the eye, causing them to lay down glycosaminoglycans; lowering T3/T4 does not stop this process.

Refer the patient immediately to a domestic violence program and help create a safety plan; do not attempt to act as legal counsel or marriage counselor.

Hypocalcemia, due to free fatty acids binding calcium levels.

Fluid resuscitation (Normal Saline) must be initiated first, followed by insulin infusion and potassium monitoring.

Due to premature ovarian failure (streak ovaries), natural conception is extremely difficult; adoption or assisted reproductive technology are more realistic options.

Ceftriaxone, Doxycycline, and Metronidazole.

Fibroblasts (which possess TSH receptors).

Surgical debridement and removal of the prosthetic joint.

The release of free fatty acids from inflamed tissue binding calcium (sequestration).

Home dialysis, due to geographical barriers and the need for sustainable care.

Papillary thyroid cancer; prior radiation therapy to the head and neck/chest.

Ceftriaxone, Doxycycline, and Metronidazole.

Fibroblasts (which possess TSH receptors).

Surgical debridement and removal of the prosthetic joint.

The release of free fatty acids from inflamed tissue binding calcium (sequestration).

Home dialysis, due to geographical barriers and the need for sustainable care.

Papillary thyroid cancer; prior radiation therapy to the head and neck/chest.