DIP Episode 555 - 2024 USMLE Step 3 Free 137 Discussion Part 3 (Q21-30, super helpful for Step 2!)

Welcome everybody, welcome to episode 555 of the Divine Intervention Podcasts. Into this podcast we're going to be a continuous series on the free 137 for step 3. This is going to be the discussion. This is going to be part 3. So I'm going to be going through questions 21 to question 30. And I know this is primarily intended for step 3 takers and level 3 takers. But this will also be abundantly useful for people taking step 2 CK or level 2. So we're going to pick up from question 21. And again if you missed the first two parts, check out episode 548 and 549. Just check those out. So questions 21 or 23 is pretty much talking about a drug add. And this drug add pretty much is examining because you know we see this drug add is about like zero system and a bunch of stuff. So what are some just pretty things to do when you encounter a drug add. Just basic things kind of skim it and make sure you're picking up on the important concepts and things you're talking about. So first you want to figure out what's the research question. So the research question here is that hey, if you're dealing with patients that have zero system acute bleeding is a huge of areas. You're comparing two things right either the sclerotherapy or the emergency protocol shunt. And they look at bleeding control of bleeding and survival. We know it's around a nice control trial. We know that there's blinding. We see the full up here in up to 17 years.

And then you always want to look at the patient characteristics. So there's 211 people that have been studied. And we see the criteria for them being included or excluded from the study. And then again, we see how many people the numbers always matter right like 166 people got sclerotherapy. 105 got a portable cable shunt. So again, those numbers are pretty pretty similar. And then you look at the outcomes, the measure. And then you look at the results always look at the results. Always look at the results. That's what we care about from a study right. Always look at the results. All these other things I talked about at the beginning, you know, we're kind of looking at like what are the characteristics of the study. Those characteristics generate questions. But then you want to look at the results because that also generates questions. So we see that, wow, okay, sclerotherapy seem to be not as good. 10 out of 106 people survived. But EPCS for it out of 105 survived right much, much better results. We see the confidence interval is, you know, it's great. We have the number in it to harm the confidence interval. And then they give us some other results in the table right. So they pretty much look at control of lead in 30 days, medium survival. Again, you're just generally scanning these things. Don't spend extensive amounts of time. And then they broke down by child's pure class, I believe. And then they look at medium survival.

And then they put a conclusion, which pretty much summarizes stuff. All right. So now let's go to question 21. But at least we've oriented ourselves. So we kind of know where things are. We kind of know what they did. So now we can try to start approaching this question. So question 21 says, a 52 year old man with hepatic zero says comes to the emergency department because of a three hour history of woman in blood. EGD confirms actively bleedingness of a geoversees. Based on the abstract shown, the physician is considering an emergency photo-civol shunt procedure rather than endoscopic sclerotherapy. According to the results shown in the abstract, approximately how many patients must be treated with EPCS rather than EST to prevent one case of recurrent portal systemic and cephalopathy. Well, before I start jumping into the drug, I ask myself what I'd even tested. This sounds like nominating at a treat. Remember, NNT just means how many people need to receive an intervention for one person to benefit? That's literally what NNT means. So now they're saying, how many patients must be treated with EPCS? That's the intervention rather than EST to prevent one case of recurrent portal systemic and cephalopathy. So let's go back to the study and look. All right. Recurrent portal systemic and cephalopathy. Recurrent portal systemic and cephalopathy. Well, we see the people that had EST, 35% of them had recurrent PSE. And then the EPCS people, 15% of them had recurrent PSE, right?

Portal systemic and cephalopathy. So it's like, hmm, how do we calculate number of data to treat? We take the risk difference first. So the risk difference between those two groups is 20%. Basically, like you have 20% more cases of recurrent portal systemic and cephalopathy. If you're a person that got a EST compared to getting EPCS, so the difference here is 20%. And then just to get the NNT divided into 100%. That risk difference, I calculated, is the absolute risk reduction. Right? Absolute risk reduction. So you then divide into 100%. 100% divided by 20% is five. Basically, if five people get EPCS, one person, is going to have a prevention of recurrent portal systemic and cephalopathy. That's literally what the number native treat is. So about 20% of the folks that, so, yeah, so one person will be saved. Sorry, one person will be saved from recurrent portal systemic and cephalopathy. So that means that, wow, for every five people that get this procedure, 20% of them are getting saved from having this badness happen to them. So I'm going to go to option C, the answer is going to be, it's going to be five. The answer is the making sense, right? So, all right, question 22, which of the following most strongly limits the generalizability of this study is finding? So again, remember, whenever you're talking about generalizability, it just pretty much means, hey, the results of this study, the results of this study, can I apply it to another population?

Can I apply to another population? So let's look at the answers here. Option A says the allocation was concealed. What does concealed allocation mean? It just pretty much means that, you know, the sorting of the participants into different groups, that information is going to keep private. That actually makes a study more rigorous, right? Because you're pretty much increasing the rigor of a study, the internal validity of a study. So the allocation was concealed. So that's just referring to the strength of the study itself, not how applicable are those results to some external population. Again, remember, that's what generalizability means. Option A is going to be wrong. Option B says, EPCS is available only at specialty centers. Okay, this looks like something that kind of talks about applicability of the study results to another population. But let's keep that for now. Option C says the study full of period was too short. Okay, let's see, what was the full of period here? Up to 17 years. 17 years seems like a really long time. You can become almost like a younger dog from birth in that period. So no, we're going to cross that off. The patients were not blinded. Well, that's certainly not true. We're told clearly the question that it was blinding of some sort. Right? Don't contract it with the NV Me say in a question step. That's usually not a wise exam strategy. And then option E says, on measure confounders, we're not controlled by the study design on measured confounders.

Okay. So in our original scheme of the data we had from the study, was there anything said about like confounders and whatnot? Not really, right? Again, it wasn't really mentioned. Again, that's the thing about these exams for many people. You see them, they grasp at straws. The thing is, the USM is many times. If something is not clearly stated, I'm not going to go after that thing. They didn't say much about confounders or they stand that kind of meme. We have made the study not ideal or whatever. So I'm going to skip that. So I think I'm going to go with option B here because it sounds like this study was done. At University of California San Diego Medical Center, UCSD. That's a pretty up there medical institution. And again, if you just relate to the question that's being tested, they say, oh, limits the generalizability. Hey, these results from this study. Can I just take it and apply it to any other population? Well, the thing is, the people that go to UCSD, they're probably going there for a reason, versus a person that goes to some community hospital. UCSD is probably not a community hospital. So again, it's just very important, right? Like, the data may not translate as well, because the patient characteristics presenting to those different kinds of institutions are different. So I'm going to go with option B in this case. All right. And then question 23 says, which of the following conclusions is most appropriate based on the results presented in the table? Okay.

So they say focus on the table. So I'm not even going to worry about looking at the rest of the study. I'm just going to look at that table. All right. Option A says that 95% confidence interval for the difference in survival between EPCS and EST for child's pu class A patients, child's pu class A patients include zero years. All right. So let's see. EPCS versus EST child's pu class A patients include zero years. All right. Let's go.

Okay. So the child's pu class A from this table. And we see that the survival is 4.62 for the EST folks, 10.43 for the EPCS folks. The p value 0.003. That's less than 0.05. That means it's significant. So if your results are significant, that means your confidence interval cannot contain, cannot contain the null value. It literally cannot contain the null value. It literally cannot contain the null value. So zero is a null value for this circumstance. Right. So that does not agree with the data from the study. The study shows us that the results are significant. Right. The study literally shows us that the results are significant. So if you are taking a difference in risk, right. Zero is the null value. Zero is the null value. Zero is the null value. Remember, if you're taking like two things, where you're taking a difference, that, oh, this one versus this or the one, well, if you're taking a risk difference, a risk difference, if zero is in the confidence intervals, your results are not significant. Because if it's zero, when you're taking the difference between two things, it means that, oh, difference between two things, but you're getting zero means those two things have to be the same. But that's not the case where we're told that the p value is 0.003. That's less than 0.05. So the results are significant. So it does not include that null value. So option A is definitely wrong.

Now, from P says, EPCS is more effective than EST in decreasing hospital readmissions for very still bleeding, requiring transfusion. Okay, let's go to the table. Very simply, you require transfusion. Number of readmissions. Well, EST 6.8. Minadmissions. EPCS is 0.4 minadmissions. So much, much less for EPCS. The p value is less than 0.001. That's significant, right? So that's probably the correct answer here. So we're going to keep that for now. Option C says the median survival after EPCS is statistically significantly less for child's pu-class C than for child's pu-class B. Okay, this option C illustrates a very common kind of error that people jump into with these bio-stats questions on the USM Ls. The USML is also applying an answer for something that was not studied. So if you notice here, the study for child's pu-class A, the study for child's pu-class B, the study for child's pu-class C separately. I don't see any column here where the study child's pu-class B versus C, like together. They didn't do any direct comparisons between both, right? So don't jump to those conclusions of something that was not studied. Option C is wrong. And then option D says the randomization procedure was ineffective in decreasing bias in this study. Okay, the randomization. Again, this was the randomized control trial. Is there any place in this study where the comment on randomization? Where you can start making those judgment calls that, guys, your randomization was not very great.

No, you can't really do that. You really cannot do that, right? So again, don't jump to those conclusions on things you're not sure about. Again, if they want you to answer a question, they're going to give you information for you to confidently answer that question. It's not there. So we're going to go ahead and skip that. So I think I'm going to go ahead and say option B is the right answer here. Now, we're going to go to question 24. So it says an 18-year-old woman with a five-year history of epilepsy comes to the office with her parents for a full-open hearing. She has sustained three seizures during the past six months. All of her seizures originated from the temporal lobe. Anti-convulsant therapy has not decreased the frequency of her seizures. The patient and her parents ask about the potential benefits of partial temporal obectomy. The physician performs a literature search and finds a published study conducted by a large surgical center. Evalucine outcomes of the operation. A total of 85 patients won the went-passional temporal obectomy. During a three-year-old patient's surgery, during a three-year period, we observed for 15 years to determine the number and frequency of seizure sustained post-op. Subgroup analyses were conducted of patients who reported no seizures one or two years post-op. A couple of minor plot of long-term outcomes is shown. The P-values provided, provided, represent subgroups compared with all other study patients.

Which of the following is the most appropriate conclusion to draw from these data regarding seizure recordings after the procedure? The most appropriate conclusion to draw from these data is the most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data is the most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data is the most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data is the most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. Again, let's go through the answer one by one. The most appropriate conclusion to draw from these data is the most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data.

The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data.

The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data.

The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data.

The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The most appropriate conclusion to draw from these data. The newborn was born at 37, which gestation to a 29-year-old woman. Gravita 2 Power 1. Upgrad scores were 4 at 1 minute and 8 at 5 minutes. The father is age 30 years.

The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years.

The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years.

The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years.

The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The father is age 30 years. The question is, what is the answer?

The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? The question is, what is the answer? Again, this child, we know what he has. We know his prognosis is extremely grim. This child really shouldn't be getting much done. This child needs his just like comfort care. The child is going to die soon. Sadly. Option C says EEG. I'm not going to pick that. Option D says, refer to a cardiologist. I'm not going to pick that. Option E says, ah-huh. Okay. Refer to a home hospital care. That seems like the answer we're going to pick. I'm going to pick that answer. We're going to move on. Did you see me sweating and agonizing over every single little detail from the question? No. What sadly does what a lot of people do on these exams. All right. We're going to go to question 26. So, a 79 year old retired executive schedules an urgent office visit. When you see him, he says that he had difficulty walking upon getting out of bed this morning because of disinness.

Which started last week and worsened last night. He has a 20 year history of hypertension, which he was treated. But for the past 10 years, his blood pressure has been normal without treatment. At his most recent visit, three weeks ago, his blood pressure was 150 over a million. And he was instructed to adhere to a low-salt diet. He drank a moderate amount of alcoholic beverages in the past and smoked about 16 cigarettes daily from each 20 years to each 50 years. He has no smoke secrets during the past 29 years. Good job, buddy. Okay. He's taking no medication at present. All his close relatives have lived to be at least in their 80s. This morning, Paul's is 70 per minute and a regular and blood pressure is 160 over 90. It's kind of high. Now, neurologic examination shows instability when the patient is turning. And horizontal and stag must be changed in position. From the scopic examination shows no abnormalities, which of the following is the most likely diagnosis. So, see this guy is old. And he's just having difficulty walking because he's feeling dizzy. And not just feeling dizzy. He's having this, you know, when he turns, he kind of feels unstable. As this horizontal and stag must be changed in position. So, seems like he has a lot of vertigo. Seems like he has a lot of vertigo. So, let's see what the answers here say. Okay. Option A says cardiac arrhythmia. Okay.

Again, when a person has a cardiac arrhythmia many times, you're going to see them kind of pass out very suddenly. And then they'll have this rapid return to baseline. And the thing is, most times when people have a lot of vertigo, most times when people have these cardiac arrhythmias as their cause of like syncopy or whatever, many times they will have like a really bad cardiac history. This guy doesn't have any extraordinary disease or aphab or am I in the past or anything like that. So, I'm going to go ahead and skip that answer actually. Then, option B says, serbility taxia due to alcohol abuse. This guy has no drunken. He has no drunken a long time, I think. Oh, he has no drunk at all. Let's see. Difficulty walking. In the past and smoked. Okay. Moderate amount of alcoholy beverages in the past. So, it doesn't seem like something's doing right now. Nah, that doesn't seem significant enough. So, I'm going to skip that as well. Option C says labyrinthitis. Well, labyrinthitis, you're going to have vertigo symptoms. Many times you have nice stagmas. You know, sometimes you get it after like a viral ur eye. And many times it's going to last for about three to six weeks. And then after that it's going to pass. Sure, it seems like it here. So, let's skip option C. Option D says orthostatic hypotension. Okay. Well, let me ask you this. Orthostasis is a decrease in systolic blood pressure by like 20 millimeters of mercury. And going from you being supine to standard.

Do we have that data giving to us in this question? Just ask, again, let's be black and white here. Do you have that data? We do not have that data. Again, don't pick answers on information that just magically is not there. We literally don't have that data to make that judgment call. So, I'm not going to pick option D at all. And then option E says stroke. Okay. So, this could be a stroke. I mean, it's an old person. Some strokes can cause these are dizzy symptoms, right? Dizzy, dizzy symptoms. But the thing is, it would make sense that if you have a stroke, you have all these kinds of neuro deficits. Right? This guy doesn't seem to have a ton of neuro deficits. And if you've had a stroke that has happened and it has lasted that long, you may start having signs of like increasing stroke, cranial pressure and things like that. Right? It doesn't really seem like that. So, honestly, I'll say the most likely answer here is going to be option C. I'm going to go with lab or enthides. Again, remember, sometimes on exams, they call this vestibular neuritis. It's kind of similar for the most part. Most times the USM is not going to put both as answer choices. And basically, you see these people, they either had like a viral URR or whatever. And you notice that they feel kind of dizzy. You know, they feel dizzy. Sometimes they'll have a nice stagmas. Sometimes they can have like some hearing loss. But again, all their symptoms are transient.

Within a few weeks, everything is going to get better. Everything is going to get better within a few weeks. And most times you don't have to do much of any treatment. Basically, what can happen? And it's like an inflammation, right? It's an inflammation of like the labyrinth, that fluid network in your ear. Most times you just maybe give them anti-histamines. Just something can I help with their symptoms. But most times you don't have to do anything. You know, let me try to trick you on your exam to pick in steroids. Don't pick steroids. It's usually not a good idea. Just support if care. They'll be fine. It sucks. But you'll be fine after a while. Or you can give them like an anti-emetic, you know, like progroperos, you know, something. But again, be careful of those extra-permital symptoms. All right. So I'm going to go to option C for question 26. All right. Question 27. Okay. So, 78-year-old woman who resides in a nursing care facility has had an increasing confusion. And draws in his during the past 10 days. Head nurse says the patient is usually alert, talkative and outgoing. But during the past several days, she has become increasingly confused and withdrawn. She drifts off to sleep even during activities that she enjoys. Vital signs have remained normal. She has been eating well. No change in her medication regimen, which includes preva statin for high lipids. I'm not even for high blood pressure. Dilead, 1 milligram aspirin.

And periodic sublingual nitroglycerin for stable angina. On interview, the patient says she does not have any symptoms, she identifies as white. Her vitals look pretty good to me. It appears to be drifting in and out of sleep during the physical exam. She's arazable and not in distress. She's oriented on you to present in place. There's a 5 centimeter echimosis without him at home on the right-paradol scop. Uh-oh. Okay. That's not good. Popules are equal around the reactive to light and accommodation. Oculomobins are intact. Optic discs are poorly visualized due to bilateral cataracts. The remainder of the exam, including neuro-exam, shows non-normalities. Results of lab studies are shown. Let's look at these labs. Honestly, let's see. Does anything stick out to me? Nope. Everything looks pretty good. Everything looks pretty good. So, which of the most likely explanation for the patient's worsening condition? One thing I actually tell people is this. It's usually a good idea to know what some of the classic labs look like. This is a very good smattering of like, hey, what are the normals like? The thing is, it kind of saves time on exams because you don't have to start looking up every single individual lab. So, you're fully in the most likely explanation for the patient's worsening condition. So, again, let's summarize this question. This is an old person. You see a gash on her head and she's going to act in out of it. What does this classically look like?

Again, many people always think that the USML is trying to make up some strange, bizarre situation.

Most of the time, if you know your concepts and you know the stories behind those concepts, these questions speak to you. You see an old person. They can act in bizarre. They have a gash on their head. You get a gash on your head. You probably fell down on your head, or person. Remember, as you get older, you bring shrinks. When you bring shrinks, it becomes a little more flimsy. It can whip around in your, in your cranium, in your skull. Then it causes a sub-dural. This looks an awful lot like a sub-dural. Not a pedural, because a pedural, you only for 10 days when a pedural, you belong dead. This is probably more of a sub-dural. Classically, I think people know this gash on their head. Option B, makes the most sense. Drug-jog interaction doesn't make any sense here. That drug-jog interaction doesn't explain this gash on their head. Hypothyroidism, do you have a TSH? Don't make up stuff you don't have. MDD, well, it's been going on for 10 days. I hope you're not saying a person has depression after 10 days of symptoms. Remember, it's going to be 14 days. Varylins of alitis, literally no fever, literally no leukocyte. Although, you don't need to have a fever to have varylins of alitis. You don't need to have a luchus like dosis, which is basically almost like no neurodeficits. So no, I'm not going to go with that. The more classic story here is a sub-dural. Himatoma, sub-dural, himatoma.

This person is probably going to need some kind of brain imaging, like a non-con CT scan. And they're going to need some kind of neurosurgical evaluation. Question 28 says, a 12-year-old girl with a seizure disorder is brought to the emergency department 40 minutes after her on founder unconscious in a backyard. The entrepreneur reports that the patient is visiting her for the summer. On arrival, the patient is awake for drowsy. She says she's embarrassed because she forgot to bring her anti-convulsive medication from home. She requests that you don't call her mother because she'll yell and get angry. A vital look completely fine. Physical exam shows no fucon neurodeficits. The patient requests that she received one dose of carbomisopein now. And that she be given a prescription to feel at the nearby pharmacy. Which one of the most appropriate next step? Alright, so she's saying, hey, I want to feel my script. Please give me some anti-pilipidics. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it.

The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it.

The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. The first thing I want to say is that the patient is not going to be able to do it. Okay, the episode results spontaneously and there was no associated eye pain. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes.

Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes.

Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Medical history is remarkable for hypertension on type 2 diabetes. Well, first things first the credit part is more common. So you should probably usually go more with those answers. The credit and bullet parts we're going to see in people that have had a recent M.I. or brought to have A.F.I. This guy has never had an M.I. This guy does not have A.F.I.

There is a reason why the M.B.A. means specifically state. Partic exam discloses a regular rhythm with no murmurs. They're telling you that this guy does not have A.F.I. This guy does not have a vavela problem. So I'm going to go with maybe this person probably has a corroded issue of some sort. And again, you see the M.B.A. M.E. They write these questions to be classic things. They write these questions to be classic things. So honestly, like so option A says for example, is in geography I'm not going to pick that. I'm not going to pick that. No, I'm not going to pick that. That doesn't really talk about dealing with here. Measurement of intracolor pressures that's glaucoma. This person does not have glaucoma. Option C says C-E-E. Again, that's what you'd be picking if you thought they had a cardio-embolic stroke. But I think I've made a pretty strong case that that's not what's going on here. So I'm going to skip that. Option D says ultrasound sonography. Well, you're going to evaluate the coordinates by doing that. So I'm going to go with option D. Go to go to option D. That seems like the right thing to do option E says no for the evaluation. You had a TIA and your doctor says no for the evaluation needed. You should get a different doctor. I think is what should happen there. All right. Let's go to question 30. I'll ask question for this podcast.

So it says a 55 year old man comes to the office because of a four to six week history of what he describes as chess pounding that worsens when he lies on his back. He also reports occasional episodes of non-exertional chess being lasting one to two minutes. He's unable to follow characterised the pain. He says that he has had moderate shortness of breath after working three blocks. But he has no heart nocturnal dyspnea. Medical history is remarkable for type 2 diabetes and gourd. Crane meds includes investatin, metformin, as some pepper's all on 81. 81 milligrams of aspirin again. Well, whatever. The patient has smoked one pack of cigarettes daily for the past 35 years. That's not very smart. Family history is remarkable for MI in his father at age 58. The patient is six foot tall with 200 pounds, PMI's 27. His vitals. Okay. Um, pulse is fine. Respirations are fine. Low pressure 165 over 55. Hmm. Gee, that's weird. The systolic is pretty high. The systolic is pretty low. That pulse pressure is through the roof. The difference between systolic and the systolic is like 110. Huh. That says something. There is no JVD. Cardi pulse is a brisk compounding. Ooh, brisk pulses. Okay. Oskitation of the lungs discloses mild diffuse weasers. Cardiac exam discloses PMI does this please louderly. Yep. If you have high blood pressure, um, or your heart's not, oh, well, actually I'm going to comment on that. Let me let it go for now. There is a softwaist one and S2.

Gryfria, the six-bluing murmur is audible at the lower left streonoid border. That extends through to thirds of the astrali. Okay, so if you listen to thirds of the astrali, that means that, ooh, this is a systolic murmur. Because most of the astrali is impacted. Sysolic and the systolic breweries are heard over both femoral arteries. Results of lab studies are shown. And then we look at his labs. Well, it's total cholesterol is pretty up there. This creatinine is not great, but it's not too bad either. Is hemoglobin white count is fine? Easy G shows normal sinus for the man. L'Eventure Lipertrophy, chest x ratios and enlarged cardiac silhouette. Permanente is sending the order, which will find the most appropriate additional diagnostics to the at this time. Right? There's way too many clues in this question. This is a very reasonable question. This person first things first is like, ooh, my chest is pounding. Everything seems to be pounding and blowing. And they keep using these fancy words, pounding, blowing. Right? So, you see these stains and they are talking about a murmur. It's probably going to be a yodic regurgert. Right? It's probably going to be a yodic regurgert. It just makes sense. And again, remember, a yodic regurgert. What does he do to your heart? Because it's a chronic volume overload, right? Because all this blood is regurgent to your left ventricle. So your left ventricle is like, man, I keep getting all this extra blood.

Because now your left ventricle is getting preloaded from two spots. It's getting from the left at your front and getting from the other. So the left ventricle is like, man, I always have to handle the increased volume. So maybe I should make my cavity size bigger. Right? So how is it going to do that? It's going to do that by adding sacrameres in a series. You're going to increase the cavity size of the left ventricle. You're going to get a dilithic cardiomyopathy. Literally a dilithic cardiomyopathy. Again, that's good because you can handle your volume. But now, when you have this dilithic cardiomyopathy, you don't have good systolic function anymore. That's not great. Right? So that's why this guy's point of maximal impulses is literally displaced. He has eccentric hypertrophy. He's going to develop systolic heart failure at some point in his life. Right? And then we also see the white pulse pressure. His systolic is very, very high. His systolic is pretty low. That's a white pulse pressure. Literally, many of those things that you see people memorize head, bow, and quenky pulse or whatever. Those are all white pulse pressure phenomena in people that have aortic regurg. This guy has classicortic regurg, blue and murmur. Right? And the lower left sternal border is a systolic murmur, because you feel those effects when the left ventricle should be feeling with blood. So it's a systolic murmur. And again, what causes the white pulse pressure?

What causes the high systolic and the low systolic? It actually makes sense. Remember, your systolic blood pressure is proportional to cardiac output. Okay. So I'm trying to defend that, hey, this person's cardiac output must be high for the systolic to be high. But why is the cardiac output high? Well, think about this. What places is this person getting a... Where is this person getting preloaded from? The left ventricle. It's getting preloaded from the left eater, which is the normal case of life. But it's also getting preloaded from the yorick, from the yorter, because of the regurg. So overall, the preload is increasing for the left ventricle. If your preload is increasing, according to the Frank Stalin principle, the cardiac output is going to go up. If your cardiac output goes up, your systolic pressure is going to go up. So that 165 systolic makes sense. Okay. Now, that's... That's 55. Remember, that stolic blood pressure is proportional to your systemic vascular resistance. Okay. So I'm going to defend you now that this person's SVR is actually low. Okay. So think about this. Your blood leaves your left ventricle, goes into your yorter. And then kind of relaxes into the other vessels of the body. So the thing is, normally, the yorter, the blood in it, can only relax into the vessels of the rest of the body. Blood flows from the yorter to all the systemic vessels. But the thing is, now, the blood in the yorter actually has two spots to relax into.

Some of that blood can go to the rest of the body, you know, systemic vessels. But some of that blood can also regurgitate back to the left ventricle. So it's almost like, wow, the blood in the yorter doesn't have to be all cramped up. Let me maybe use an analogy that makes sense to you. Let's see, you live in a place that has high levels of traffic like New York. You know, like, you know, mainstream New York, like Manhattan or whatever. And there's only one road that connects point E to point B. And there's always traffic there. Well, how can you reduce traffic? I don't know. Maybe make another road. If you make another road, you can offload some traffic from that singular road to another road. That's going to reduce the pressure of traffic between those two roads. That's clear what's happening here. Right? The yorter can only offload its blood to the rest of the body, normally. But now, it can offload it not just to the rest of the body, but back to the left ventricle. Right? The living room is a big, stout structure. Right? So that just offloading of some pressures is going to cause like a functional decrease in systemic vascular resistance. That's going to reduce your stonic blood pressure because systemic vascular resistance and that stonic blood pressure, they're proportional. So we see that the cardiac output is going up. So the SPP goes up. The SVR is going down. So the DBP goes down. So the post pressure, which is the spread between those two pressures is wider.

Right? So this is going to be a yorter regurged. So this is a yorter regurged. This is a valve-elow problem. The person clearly has symptoms. So honestly, I'm going to evaluate for this valve problem. Right? So what's the answer to the evaluation for the valve problem? Ocean E says, at your uncle, we kill index. Uh, no, this is not right. Again, this is what happens when you just concentrate on discrete parts of the question and don't look at the whole picture. You're going to get in trouble. Right? It's like, hmm, hmm, divine. He walks. He feels weird. No, this is not PD. This is literally not PD. Right? This is not, this is not, not PD. This is literally not PD. So no, ocean is wrong. Right? Option B says coronary angiography. Well, that's what you will pick in the person who has coronary artery disease. Uh, that's not, that's not the main focus of this question. So I'm going to skip that option. C says PF Ts. Uh, we worried about COPD here. Well, that's not the main point of the question. I didn't spend like three, four means discussing a yorter regurg for, for no good reason. So option C is wrong. Option D says renal ultrasound.

Again, if you focus on the discrete parts, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, who whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, wh

oo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo

, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo, whoo from divine, divine intervention broadcast and divine intervention life lessons, thank you.

Number Needed to Treat. It indicates how many people need an intervention for one person to benefit.

First, calculate the Absolute Risk Reduction (ARR) = |R1 - R2|. Then, NNT = 1 / ARR.

Wide pulse pressure, bounding pulses, and a loud, blowing systolic murmur heard best at the lower left sternal border radiating to the axilla.

Subdural hematoma, due to cerebral atrophy making bridging veins fragile.

Supportive care (anti-emetics), avoiding steroids, and recognizing that recovery is typically gradual over weeks without specific treatment.

Aortic regurgitation (AR). The high systolic pressure results from increased cardiac output, while the low diastolic pressure results from reduced systemic vascular resistance due to backflow into the ventricle.

The result is statistically significant; the intervention group is genuinely different from the control group.

Cerebral atrophy stretches the bridging veins, making them prone to tearing and slow bleeding under the dura mater.

Wide pulse pressure (high systolic/low diastolic) and a loud, blowing systolic murmur at the lower left sternal border radiating to the axilla.

Orthostatic hypotension (a drop in blood pressure upon changing position).

Aortic regurgitation (AR). The high systolic pressure results from increased cardiac output, while the low diastolic pressure results from reduced systemic vascular resistance due to backflow into the ventricle.

The result is statistically significant; the intervention group is genuinely different from the control group.

Cerebral atrophy stretches the bridging veins, making them prone to tearing and slow bleeding under the dura mater.

Wide pulse pressure (high systolic/low diastolic) and a loud, blowing systolic murmur at the lower left sternal border radiating to the axilla.

Orthostatic hypotension (a drop in blood pressure upon changing position).