DIP Episode 518 - 2024 USMLE Step 2CK Free 120 Discussion Part 1

Welcome. My name is Divine. This is episode 518 of the Divine Intervention Podcasts. In today's podcast I'm going to be doing something a little bit unique. I'm going to be going through some of the free 120 questions for the USMLE Step 2 CK exam. I'm going to be going over the most recent ones. In fact, according to this document it says that it was updated very recently. It was updated in July of 2023. July of 2023. Basically if you go on the USMLE website and you look for practice step 2 CK questions, this is precisely what you're going to see. I'm going to walk through the first six questions. I think one is a very good learning experience. But two, you'll also teach you quite a bit about how to process and read MBME questions. That's a big focus for me with this podcast. I'm really hoping that I'll be able to make more podcasts like these in the future. Okay, so let's jump right into it. So I'm going to go with question one. It says, a 21 year old man comes to student health services because of a six month history of increasingly frequent episodes of moderate chess pain. The first episode occurred while he was sitting in traffic and feeling stressed because he was late for a college class. At that time he had the sudden onset of moderate chess pain, a rapid heartbeat, sweating and nausea. He says he felt as though he were going to die. The episode lasted approximately 10 minutes. He had a similar episode one month later while on a date.

The symptoms were so severe that he abruptly ended the date. During the past three weeks, he has experienced two to three episodes weekly. He says he fears having an episode while in public or an date. So he has decreased his participation in social activities and the amount of time he spends outside of his apartment. He has no history of serious illness and takes no medications. He does not drink alcohol or use other substances. Vital signs are within normal limits. Physical examination discloses no abnormalities. On mental studies examination, he has an anxious mood and full range of affect. Which of the following is the most likely diagnosis? Option A says agoraphobia. Option B says generalized anxiety disorder. Option C says illness anxiety disorder, which was called hypochondriosis, back in the day. Option D says social anxiety disorder, which we also call social phobia. Option E says somatic symptom disorder. What do you think the correct answer is? What do you think the correct answer is? We see this person, they have chest pain. We see that. This first episode happened while they were in traffic. Stress because it was liver class. Second episode happened while it was on a date. And then, we see that he had the same episodes. While he was either in public on a date, he is just afraid of all these things. What is the simple thing that comes to mind here? I hope you are seeing divine. This guy seems to be afraid of public spaces.

So this is going to sound an awful lot like agoraphobia. Personally, I think I will go with that answer as well. I will go with option A. Which I believe is the correct answer. But let's hold a little bit more of a discussion here. Let's look at the other answers. Option E says somatic symptom disorder. The thing is somatic symptom disorder is something that happens where you have a real symptom. Something that is real. You just have this habit of kind of blowing it out of proportion. For example, you see a person that has leg pain. That leg pain is saying, oh, it may just be leg pain because I don't know. Maybe they worked out too hard. I don't know. Just ran a marathon. Whatever. But they are like, doctor, I think this is osteosarcoma. That is a little ridiculous. They will tell you usually in the question that there has been a lot of medical evaluation. There has been a lot of imaging or whatever and no evidence for this person's claims have been found. In circumstances like that, you would want to think about somatic symptom disorder. Notice one thing I did in talking about somatic symptom disorder. I asked myself, divine, what is the classic history that is associated with somatic symptom disorder? Literally, what is the classic history as a sort of somatic symptom disorder? Look at all I numerated. Oh, this person, they have a real medical symptom, but they are blowing it out of proportion.

And they, a lot of evaluation has been done by multiple physicians and none of their worries have been seen to be founded worries. In those circumstances, right? You're like, wait, this is not somatic symptom disorder. Because think about this, the classic history that I have mentioned, we literally don't see it in this system. So you have no business picking option E. And I'll comment on some testing principles after I go through all the answers. And then option D says social anxiety disorder, aka social phobia. This one is an amazing instructor. It's an amazing instructor. This is how you create a tough USMD question. But again, what's the classic history for social anxiety disorder or social phobia? You're going to see a person where they get anxious in what in social situations. Situations where they have to speak to somebody or they have to, like for example, there is a performance subtype, sometimes they call it performance anxiety, where you have to give a presentation or whatever. But basically, these people are fine otherwise, but when there has to be some kind of human interaction, they freak out. They freak out. Well, if you look at this question, this person seems to have had at least one situation where they freak out in a social situation while on a date. But you would pick option D if you conveniently ignore all the other situations in the question where there was no social situation, but the person is still freaked out.

Basically, as long as the person was outside, they flipped out. They literally flipped out. And I know some of you may be like, but divine, but divine. You know, there is the social situation with the person freaked out. And there is also the being outside situation with the person freaked out. So how can you have the presence of mind to say, okay, it's going to be agoraphobia versus social anxiety disorder and to be discriminatory against social anxiety disorder? Well, let me ask you this. Let me literally ask you a simple question. Reading through this entire vignette between agoraphobia and social anxiety disorder, which pathology does the NBME seem to devote the most number of sentences to? Like just answer that question. Just be honest. Just be honest. Literally take your finger and ask yourself, okay, how many social situations did they put here? And then contrast that with how many situations I hear with the person is afraid of being outside. You'll notice that man, an overwhelming amount of the question is focused on his fears from being outside. So because they just seem to put more effort and energy into talking about those situations where he's outside and freaking out, like we see here. Ooh, he was stressed. It happened when he was in traffic. He was not in a social situation. He was just outside. You know, and you know, he also said that he had it on a date. But that's literally like the only, only, only thing on a social situation. Right?

But we see this person. This person is afraid of being in public. Right? Again, just ask yourself, how much, like, see, let me tell you something. This is a testing principle. Ask yourself, how much effort did the USMELIS put into talking about his social situations? Almost nothing. How much effort did they devote to talking about, huh, this person is afraid of situations where they are outside? A lot of effort. So the USMELIS will not be putting in a lot of effort to just conveniently sidestep agroaphobia as an answer. So it's very important when you're taking these exams. Ask yourself, when did this seem to have put in the most effort? Right? Now let's look at the other answers here. In honest, anxiety disorder or hypocontriosis? Well, in honest, anxiety disorder, these people, they literally have no problems at all. They don't have any problems at all. But again, they're going to imagine that they have so many problems. In fact, they will many times tell you that, oh, they've been evaluated by many physicians for these supposed medical problems and they have no. Well, guess what? Have created the high-yield history. Does this question encapsulate any of that? Well, I hope you're saying, uh, divine. No. So because the answer to that question is, no, we should not be picking that answer at all. And then option B generalize anxiety disorder. These people are going to be worried about so many life situations over more than six months. Right?

And the thing is the USML is they're not stupid. Right? You see, they put, ooh, a 21-year-old male comes to student health services because of a six-month history. Right? They know that some people that don't read the questions carefully or pick answers just because of something cool that they see somewhere. They would, of course, jump for generalize anxiety disorder. And guess what? You're going to land in some very hot water, making those kinds of decisions on your example. The thing is, if you notice, other than the six-month business, and you may say, oh, divine, I see this person is worried. I see this person is worried. But again, their worry is a small part of the question. Right? Look at here. He says, he fears having an episode while in public on a date. That's the thing. Like, when you take things out of context on the USM Ls, that's how you get in very significant amounts of trouble. That's the truth. I'm telling you this. When you take things out of context, that's where you get into significant amounts of trouble. In fact, let me tell you something I think if I use an analogy. So again, this is kind of an usual podcast that I'm discussing content, but I'm also just discussing testing considerations. I promise you, this is actually a very, very high-yield, very, very helpful podcast if you were just putting the time to listen to it. Right? Have you had this experience where this is a classic thing that is done pretty much all the time in news media these days?

A person will give a statement and they will literally pick a small section of what they said and use it to push out an agenda. And then they'll put that. They'll make that a major headline. I think that is literally all that the person said. When you read those kinds of articles or you watch those kinds of videos, you've lost out on everything that the person said. You're basically thinking according to the way someone wants you to think. And that's a very bad way to live your life. But contrast that with the person that says, hmm, this news media or social media says, this person said this. And before you start calling this person a bigot in this and that, how about you go and listen to their whole speech? People when you listen to their whole speech and get the whole context, you have a much better idea of what they were thinking or what was going through their minds when they made that statement that they made. But again, that's a little too much work for almost anyone to do. So people are not willing to do that. It's just much easier to call a person a bigot or this or that or this or that. Well, here's the thing. Many people adopt a very similar approach to the USMLA exams. They're taking the USMLA exam. There's this whole honking vignette in front of them. But they just focus on one amazing statement somewhere and they pick an answer based on that. You pick an answer based on that and then you're wondering, hmm, man, why am I doing so polio my exams? And I wonder why?

I literally wonder why. So just be careful, right? I think there are two major things to take away from this question. One, when you're reading, when you're considering an answer, just ask yourself, like, how does this answer use, what's the story behind this answer? Not what's the association? Because that's the thing as well that kind of kills people that just focus on Anki, Anki, Anki, Anki, Anki in preparing for the exams. Just no associations. They don't know the story behind the pathology. That's the thing that I try to do with many of my podcasts, many of my review courses. I try to focus on the story first. When you know the story, the other details about the pathology are much easier to learn. Because if you don't know the story, even if you don't know the story, you won't even recognize the pathology that they are testing in the first place. So know the story behind the pathology. Like what's the clinical presentation? That's a smart thing to do. That's a smart way to study. But the second thing I will say is, don't take questions out of context. Don't. When you take questions out of context, you will land in trouble on your exams. Okay. Oh wow. This is almost 15 minutes. Okay. Let's go to the second one. Alright. If 35-year-old man is brought to the emergency department by a friend, 30 minutes after the sudden onset of right-sided weakness and difficulty speaking, the symptoms began while he was lifting weights at the gym.

He has not had headache or changes in vision. He has no history of serious illness and takes no medications. He does not smoke cigarettes or drink alcohol. He exercises regularly. His speech is incoherent, but he can understand what others are saying. Vital signs are within normal limits. No bruises are heard over the corroded arteries. Cardiopulmonary examination shows no abnormalities. There is swelling and mouth tenderness of the right-low extremity. I wonder what that is. You have one extremity and magically swollen and mildly tender. Okay. Let's continue. No chords are palpated. Neurologic examination shows a right-facial drop and right-operate extremity weakness. An MRI of the brain shows an acute stroke in the left-middle-cerebral artery, territory. Cardidolatrous sonography shows no abnormalities. Which of the following is the most appropriate next step in diagnosis? All right. Option A, a dental thin stress test. Option B, cardiac catheterization. Option C, cardiac MRI with gadolinium. Option D, CT and geography. Option E, echocardiography with a bubble study. Equal cardiography with a bubble study. So, let me ask you this. What do you think? Try to come up with an answer. What do you think? Right? And I want to take a slightly different approach with this question. I'm just trying to show you different ways of answering your semily questions. So this person in this question has a stroke. It's pretty clear. This person has a stroke.

I noticed I'm not making up anything here. I'm literally going with what is here. This person has a stroke. But again, you can see some elements here that don't make any sense. You're like, this guy is 35. And this does most sound like the classic human being that is a stroke person. You know, this person doesn't have, doesn't eat unhealthy, doesn't smoke, doesn't drink alcohol. This person exercises. So this person does not have the trappings of an unhealthy person. So that's one thing that's already weird to start. Right? Because that's one thing people don't understand. You always want to try to figure out like what's going on here. Right? Because many times people just jump to the answer choices and start like gesticulating through them. And they wonder again, what am I not doing well on my exams? Right? They start gesticulating, gesticulating, gesticulating through the answer choices. No. Try to figure out for goodness sake. What in the world is going on? This person has a stroke. We know that. Okay? But this person is not unhealthy. Right? And many times when people have strokes, typically we would notice that these people will have either corroded problems, many times when people have strokes is mostly from corroded problems or from a cardiac issue of some sort. Well, this person doesn't have any corroded problems. Literally, they tell you that carried out the sonography shows no abnormalities.

So you can pretty much sidestep that that's see, this is not a corroded problem. Or if we're thinking and they also say that there are no corroded breweries. So we know that this is not a corroded issue. Well, we say that in this question, this person has a DVT. Right? Why would a person have one extremity that is swollen and tender? That's a DVT. So in my mind, I'm like, okay, let me try to link all these things together. This person had a stroke. They don't seem to have many risk factors for a stroke. But this person has an active DVT going on right now. And this person doesn't have any corroded problems. Well, that makes me think that maybe this person has some kind of cryptogenic stroke. And not talking about stroke, you can get from doing a ton of stuff with Bitcoin. But I know that's not a good joke at all. But this person is in a situation where they literally have a DVT. They have a stroke. Well, what's the linker between those ideas? That's the thing. The USMLE exams are based on linkers. What's a linker? Linkers kind of like an integration. That's why you see me many times. Again, when I make podcasts, I try to say, okay, this concept, how can they go after it in many other ways? So that's exactly what I'm going after here. So what's the linker between a DVT and a stroke? Well, the linker is a PFO. That's why we call this thing as cryptogenic strokes. They don't make any sense because usually when you have a DVT, the thing you should have after that is a PE, right?

You know, the DVT will travel from the deep veins of your red extremities. So going to your red extremity, red extremity, logical between your pulmonary arteries, PE. But this person had a stroke in the MCA. So how did that thing get there? Well, you probably have some kind of VSD or PFO, P10 for a minute of valley, that that stroke that embolus passed through. And then it went left, HMLE ventricle, boom, a yodder, boom into your cerebral circulation and then boom, the person is in trouble. So we know that, okay, this person likely has a PFO. And many times the right answer is going to be dictated by the linker, by the integration that is given in the question. So I've decided all these things. And again, obviously, like in an exam, I'll be doing this in my brain. I'll be a lot faster than this. I'm not going to be spending all this time. So again, let's look at some of these answers here. I think it's very instructive. If you're the kind of person that reads this question with no context, absolutely option D sounding really good right now. CT and geography. CT and geography. CT and geography. That's from you basically having the wrong linker, thinking that you have a, they had a P or whatever craziness. What I'm going to pick that answer. And then option B says cardiac catheterization. Again, what's the classic situation where a person will get a cardiac cath? What's the classic situation? It's going to be if a person has an MI.

For person has an MI or if a person has really severe and general symptoms, right? They have like an acute coronary syndrome of some sort that you want to do cardiac catheterization. Well, let me ask you this. Does this question devote time, effort or energy to talking about M Is? No. Do you have any business picking option B? I would really hope not. That would be extremely disappointing if you picked option B. Okay, option A, a stress test. Well, why would you do a stress test? You do a stress test if a person has cardiac ischemia. If a person has an, if a person has angina, right, you try to do a stress test, right? You're trying to figure out like what's going on. And usually you're going to do an adenosine stress test if the person cannot exercise for whatever bizarre reason. Well, this person can exercise. This person is a pretty healthy individual. And this person doesn't seem to have any evidence of cardiac ischemia. They have a stroke. We're going to cross out option A as well. And then option C says cardiac MRI with gadolinium. Again, usually cardiac MRI. They are just certain things you want to recognize that man. This thing will almost certainly not be an answer on my exams, right? Like a classic example is consulting the ethics committee. You know that if you're reading an ethics question, a big answer that says consulting the ethics committee, you know you're going to be in order on your exams. You know that that's like a simple thing to keep in mind.

Well cardiac MRI, can I say that man, it will never be correct? No, I'm not going to open my mouth and see that. But how many times have you ever on an NBME question, not a Cuban question, an NBME question, ever seen cardiac MRI as an answer? You probably strongly answer that question for good reason, right? So I'm going to go ahead and cross that off. Usually we're going to do those when we're worried about like some kind of infiltrating disease of the heart. That's not what's going on here, right? So go to option E, option E, an echocardiogram with a bubble study. That will help us diagnose the PFO. That will help us diagnose what the patent for immunovale or whatever structural problem the person has. And it's causing these MRI to travel from the right side of the heart to the left side of the heart causing the person to have a struggle. All right. That was a little quicker. Okay, let's go to question three. A 65 year old man comes to the office because of a two year history of progress in the patient. Of progressive shotness of breath on exertion and a six month history of non productive cough. He now has shotness of breath when walking to his mailbox. He has not had fever, weight loss or chest pain. He has not had recent sick contacts, has had no occupational exposures and does not own any pets. He has difficult to control a fed hypertension, COPD and migraines. Medications are immune to run, warframe, lysinopril, tiotropio and proprylonal.

Temperature is 37 degrees Celsius, that's 98.6 degrees Fahrenheit. Both is 80 per minute and irregular. Okay, so it's got a fed. Respirations are 16 per minute and blood pressure is 110 over 70. There is no JVD. Ascultation of the lungs discloses fine crackles bilaterally, both anteriorly and posteriorly, but no egoffani. The remainder of the physical examination discloses no abnormalities. An adverse effect of which of the following medications is the most likely cause of these findings. Before you start jumping into the answers, do some question analysis. That's the smart way to take exams. This person is old. This has been going on for two years. Right? Okay. This person is old. It's been going on for two years. And we see this person has a lot of shotness or breath. So this seems to be a lot of long issues. Right? This person seems to have a lot of long problems. And then we're told he has all these issues. A-fib hypertension, COPD, migraines, takes all these drugs. No JVD. His blood pressure seems to be fine. And he'll find crackles. He'll find crackles. You're probably thinking of a fibrolytic lung disease. And physical exam rest of it doesn't show any abnormalities. So if we look at all of this, this person seems to have pulmonary fibrosis. Well, what's the drug here that causes pulmonary fibrosis? This is pretty easy. This is option A. These are mutorone. Right? Make sure you know the drugs that cause pulmonary fibrosis. They love to test these things on the exams.

You're not done with those because you've taken step one. Remember, bliumisin. That's an anti-cancer drug. Biosulfin. That's an anti-cancer drug. That's an anti-cancer drug. Methyltricsate. Sorry. Immuterine is not an anti-cancer drug. It's an anti-rhythmic. What do we use it for? We're going to use it for V-tack. For a person who has V-tack and they're hemodynamically stable. That's a wide complex regular attack here. The person that's hemodynamically stable, you would use amyotr. You would use amyotr. And then methyltricsate. That's an anti-cancer drug. Although the one thing the USML is love to do these days is they know that everyone knows that methyltricsate is an anti-cancer drug. Many people think of, they're taking an anti-cancer drug, they develop pulmonary fibrosis, methyltricsate. Of course, they will not be able to be as fun as an answer. Many people have memorized that. Many people have memorized that. That's the context that many people have learned it in. The USML is these days. One of the most common things they do is that they take classic situations that they test. But they put it with unusual associations. Let me explain what I mean. It's novel. So compare, consider two ways of testing the same pathology. Methyltricsate, interstitial lung disease pulmonary fibrosis. Imagine giving pulmonary fibrosis to a person that's on a cancer drug. And put it methyltricsate as an answer.

Versus giving pulmonary fibrosis to a person that has a history of, you know, elevated ESRCRP, chronic joint pain, and the anguish individual has been on pharmacotherapy, pressing and exercising the morning to feel well enough to go to work. That's rheumatoid arthritis. Right? The thing is, thinking of pulmonary fibrosis with rheumatoid arthritis therapy, is that something that is obvious now that I've described it? Absolutely. It's obvious. Well, is this something that people will routinely think about? Probably not. That's how the USML is set up questions these days. That's why when you read experiences of people that have taken the exam, recent, and they say, oh, you know, when I took the exam, I feel like everything I saw have never seen before. That is not true. That is not true. It's just that what you're used to, you did not see. It's the same pathologies they're testing. They're just testing them in more unusual fashions. Right? Like another classic example I love to give, especially during my review courses. I tell people this, that, oh, you know, when in case I know all of you have learned this with alcoholics, fine. But the thing is, the USML is these days, you know, alcoholic when it is, that's in every onky deck known to mankind. It doesn't, if you're really trying to see if people understand stuff, instead of having just memorized things, how can you see the truly understand stuff? Just give them that same concept.

In unusual ways, why don't you give warning keys to a person that has like high premises, gravity, dark? Why don't you give warning keys to a person that has had a gastric bypass? Why don't you give warning keys to a person that has an erection or voci? Literally, these are always when you can be very accurately tested. But it will select for individuals that have not just memorized associations, but truly understand exactly what is going on. So this is something that you want to keep at the back of your mind as you're prepping for your exams. And let's look at these other answers. So the answer is obviously A. Let's look at these other answers. Option B says, like Ceno-Priol, doesn't make any sense. Like Ceno-Priol, what do we know about it? Well, we know that it's an easy inhibitor, it can cause dry cough. That's a classic side effect. It has all these electrolytes, normally it causes hyperchilemia, it's really doesn't have any anti-dense of those. And we know that it shouldn't give it to a pregnant woman. So they gave you a pregnant woman, that the woman that delivers a child, and this child has oligohydram meals, and then the other person's biography doesn't show any kidney or whatever, or hypoplasty kidney. Okay, that's going to be the way they will test an acinibular and R. But we don't see any of those things here. We shouldn't be picking those answers. Preparal loll is a beta blocker.

It's going to cause bronchospasinin people that have reactive airway disease, which this person does not have. And Preparal loll, you know, it can cause bradycardia, but this person does not have bradycardia. I mean, this person doesn't have any issues with Preparal loll, and I'm going to pick that. Tyotropium. That's a drug used to treat COPD. And clearly, this guy has a COPD, it's a macramecan antagonist. But again, when I see any of these anti-cholinergic symptoms, I'm not going to pick that answer. Warframe is going to be bleeding, bleeding, bleeding. This person is clearly not bleeding. They've had this problem for two years. The person is not going to be bleeding for two years. That doesn't really make much of any sense, right? It doesn't make sense to pick up some edon. Don't do that when you're exempt. Don't make those kinds of life choices. Okay, let's go to option four. Probably going to stop at question five, and leave it at that. I think that's probably a good stopping point. Okay, so an 18 month old boy is brought to the emergency department by his mother. 30 minutes after he fell from his bed onto the floor. That's not good. Two months ago, he sustained the fracture of the right humerus when he fell while playing in the park. The fracture healed quickly with immobilization and casted. His mother sustained several bone fractures in early childhood. But she currently does not have any medical concerns. On arrival, the boy is crying. Paul's 162 per minute.

That's pretty high. Respirations of 40 per minute and blood pressure is 122 over 80 millimeters of mercury. Examination discloses bluish sclery and echinocides and tenderness over the right tibia. Extra of the right lower extremity confirms the fracture of the tibia. The right lower extremity is immobilized with a cast. Limitation of physical activities recommended to prevent future fractures. Giving this patient's condition, it is most appropriate for which of the following types of screening to be done regularly. I don't think it needs much massaging to make you understand that this is osteogenesis imperfector. You see the bluish sclery. But again, this is why, and honestly, as much as people hate the MBM Es, I really appreciate the thoughtfulness that goes into writing many of these questions. If you are pressing the right questions, which I do, I don't write questions for the MBM Es by the way, but I write questions. You will understand precisely why they do a good job. Because here's the thing. This is an osteogenesis imperfector question. The classic met students that has just memorized a bunch of associations. They are like, oh, bluish sclery, osteogenesis imperfector. A lot of fractures, osteogenesis imperfector. Then some people memorize that it's an old or a more dominant disorder. It's a problem with type 1 collagen. Okay, great. Guess what? All that knowledge is not going to do you much good with this question.

All that knowledge is not going to do you much good with this question. What do the USM Mes do here? They took a classic pathology, and then they just found something unusual related to that pathology. To see, hmm, okay, let's see what will happen with this person. Again, that's why you cannot just memorize the only the classic associations. You need to understand what's going on. The thing is in my experience, when you understand what's going on, you can many times whistle your way to the correct answer. Okay, so now let's look at the answer choices here. Serum calcium and vitamin D concentrations. Okay, so option A says, audiography. Let me read out the answers. Option A says, audiography, option B says, dexascan, option C says, eco-cardiography, option D says, retinal examination, option E says, serum calcium and vitamin D concentrations. All right, so let's kind of talk through this stuff. Let's talk through this stuff. So if we're looking at these answers, I feel like most people will probably, again, maybe let me discuss some testing concentrations here because I think that's probably actually the most valuable part of this podcast. Option D says, retinal exam. Well, if you just focused on the blues sclery and they just ignored, you know, everything in the question is just blues sclery, blues sclery, then that's how you're getting trouble. And then eco-cardiography is not really something you should be thinking about.

Option A says imperfector, can D have cardiac problems? Yeah, they can. They can have cardiac problems. They certainly can have cardiac problems. But is that like a main feature of OI? Not really. And if the, because obviously we can see that this is a genetic disease. If the USML Es were testing a genetic disease with cardiac manifestations, don't you think it makes more sense to test like morphans or homocystinuria, stuff like that? But they don't, right? Like this is not a morphine question. And then a dexascan is also a really good answer, right? Because you may be thinking osteoporosis, osteoporosis, osteoporosis, osteoporosis, you know, bone mineral density issues, right? And then option E says, audiography. And I would say that the correct answer to this question is audiography. Now, let me explain why. Ostrision is in perfector. We know that it's an issue with type one collagen. So no, no, no, no. It's a more dominant disorder type one collagen issue. Many of us know about the blue sclery. Well, either there's the blue sclery happen. Well, the thing is, if you understand where type one collagen is, then it will make more sense to you. Type one collagen, we find it in many places. We find it in bone, we find it in teeth, we find it on skin, we find it on the, we find it in the eye and all those things, right? So if you think about this, that's why they have blue sclery, because the, the, the sclerer gets very thin. It's not like the sclerer is colored blue.

No, but the vessels that run underneath the sclerer, the sclerer contains type one collagen. Well, if you have abnormal type one collagen, then your sclerer is going to be very thin. And then the stuff that is under the surface will become more easily visible. I just like to think of it this way. If you have a lot of distance between you and something you're trying to see, it'll be harder to see that thing. But if you get closer and closer and closer to that thing, you're trying to see, you have better visualization. Because you have type one collagen issues, your sclerer is not as thick as it should be. So the things that are literally underneath the sclerer, like the choroidal veins, you're able to see them better. Remember, the blood that flows in veins is the oxygenated. So that's why you see this because that blood is like hypoxic blood in a sense. So because you have a thin sclerer, it can see better. That's literally why they have the blue sclerer. But these people, they tend to have a lot of problems with their bones, bones, bones, bones, bones, bones. So because they have lots of issues with their bones, they tend to have a lot of fractures, they tend to have hearing loss, right? They tend to have hearing loss. That hearing loss is typically going to be, you know, more conductive in nature. Because remember, your malios and your incas and your stapes, your middle ear, ossecles. Those are bones. Those are bones. Those are bones.

So I would go with audiography as that answer. Because again, it's just the answer choice that relates a lot more strongly to the question. And I know some people may say, there are some calcium and vitamin D concentrations or dexascane. But the thing is, those are not the primary, like, osseogenesis imperfecta is not a calcium or a vitamin D metabolism problem. It's not. Right? So again, even if it's a bone question, that's where understanding the path of this comes in. Because if you really delve deep into osseogenesis imperfecta, the problem is that you have issues when you have this mutation. The primary issue at play here, is that they cannot hydroxylate lysine residues very well. So they cannot make pro collagen properly. So this is more of an issue of collagen. Like this has literally nothing to do with vitamin D or calcium. It doesn't. Right? So, but again, if you don't have the understanding of the pathophase, and you're like, ooh, this is osseogenesis imperfecta, bone problem, bone problem, bone problem, bone problem, bone problem. Ooh, I must speak the calcium or vitamin D answer. Well, that's how you're getting trouble. Okay? These people, the problem is not necessarily a bone mineral density. The problem is with the collagen that makes our bone. It's not anything about the density of the bones. So, option B is wrong, option D is wrong. Right? And the retinal examination, that blue clear is just a finding. It's just a finding of explain the pathophase behind it.

Option D is wrong. Option D, honestly, is wrong. Option C, a co-chardiography again. Cardiac problems are not a main feature of osseogenesis imperfecta. Right? But hearing loss is a main feature. And the thing is, you always want to chase down hearing loss in kids, because if you're hearing is poor, and you don't deal with it, those people can have long-term problems. They can literally have long-term problems. Because if you can't hear, then you will not be able to learn to be able to speak. That's why people would osseogenesis imperfecta. I mean, people, if I'm good at it, just came to my mind. But if you cannot hear, you have trouble learning language for you to speak and speak well enough. For you to speak and do what speak well enough. So, that's something you kind of want to keep at the back of your mind on your exams. Now, to be honest with you, our friends at the NBM is this is a classic example of a question they can write. They can literally write the same thing yet, but they will discuss a child that has language delay. And then, they will say, which of the following is the most likely mechanism behind this exam finding in this patient? And they will put something like a conductive here, it can be like a conductive hearing loss answer, or they can put this function of middle ear ossecles or something of that nature. Again, people will be like, what? Conductive hearing loss, dysfunction of middle ear ossecles, but that's what the USMEL is those days.

I'm telling you this, the USMEL exams, though, I'm going to say two testing things right now. Number one, the USMEL exams these days are written in ways where there are fewer and fewer questions that you'll be able to answer just from having memorization. Like bio starts, for example, many questions these days, it's not the formulas that are going to get you there. No, most times it's a reasoning based question. Like literally, the USMEL is, they can write a him-onc bio starts question. They can write a cardio, like I literally kid you not. There's a question in one of my review courses, it's a question about P Es, but it's a bio starts question. It's literally a bio starts question. So you're reading questions and you're like, oh, this is a PE question. And then you look at the answers and you see all these bio statistical terms and you're like, wait, where did that come from? That's the way the USMEL is are written these days. The USMEL is these days. They've kind of realized that a lot of people just kind of escape by on memorization. And I'm sure some of you are aware of quite a number of the Fiasco's that are going on out there these days. I'm not going to talk about that. But these days, the exams are written to reward people down the stamp path of this. They are written to reward people that I'm able to make integrations. So that's the first thing. I'm telling you, fewer and fewer questions. In fact, I can almost predict that we did the next two, three years.

Within the next two, three years. If you're a person that is just memorized, I'm just knowing the associations. Those people are going to start performing super, super poorly on the USME Ls. That's one. The second testing consideration I want to give here. This is more of a common sense principle. Whenever you see a problem in many family members on a USMEL exam, that question is a genetics question. That is something you can lock into your mind. They're literally some questions I've answered correctly in my life just by knowing that concept. Let's see. This question, like, we see this boy had this problem. He's more and more so had similar problems. That's a genetic question. Just something to keep in mind. Okay. Let's do one last question. And then we wrap this up. Okay. Again, I hope you're finding this to be helpful. I know that I'm discussing concepts, but I really want to repay an attention to the testing principles that I'm discussing with this podcast. I think you're going to find this to be incredibly helpful. Just really help the way you approach questions, the way you think through answer choices. Okay. A 70-year-old woman, so this question, five-hour-last question. A 70-year-old woman is admitted to the hospital. Because of a one-hour history of shortness or breath, she has long cancer and dementia, Alzheimer type. And has had a decline in mental status during the past month. She lives with a boyfriend of 20 years.

He has cared for her and has taken care of the homes in shows diagnosed with dementia two years ago. She has one adult son who lives out of state, but she speaks to him on the phone daily. The patient's neighbor, who is a nurse and a long-term friend, takes her to all medical appointments and ensures she takes her medications appropriately. The patient is unable to understand the proper prognosis of her condition. The proper diagnosis of her condition. She has not designated a health care power of attorney. Which of the following is the most appropriate person to make medical decisions for this patient? Option A says boyfriend, option B says neighbor, option C says patient, option D says physician, option E says son. So what do you think this is? Again, if we just jump in through the answers, just do a little conversation in your head. I'm telling you, when I take exams, I have these conversations that go on in my head. I'm like, okay, they're asking about a physical power of attorney. Who can make decisions for this person? Well, the simple thing to keep in mind whenever I see these questions, I think of two things. Number one, is this person in contact with your family? Do they have a close family member that can make these judgment calls for them? If they have a close family member that can make these judgment calls for them, always pretty much go to the family member. Simple as that. Another consideration for me is, okay, has this person selected somebody?

Obviously, if they've selected somebody, you want to go to the person that he selected. And then the third consideration for me is, if these people have not selected anyone, and they don't have any close family member, I then ask myself, do they have a close friend? Do they have a close friend? Do they have what? A close friend? Some that have known for a decent period of time, then I'll go with that person. I'll go with that person. So in this case, the first line thing, I just talked about three things. I always arranged them as first line, second line, third line. First line is someone that the person appointed. That's always going to be the first line answer. Second line is a close family member. Third line, if they don't have any of those two, is to go with someone that knows them very well. Well, first line doesn't really apply here, because this person has not made those choices. So that's off. So go for second line. The second line answer here is going to be a close family member. That she speaks to regularly. I mean, the question literally says, she has one adult son who lives out of state, but she speaks to him on the phone deal. So that's going to be the correct answer. And she's going to be the son. Now, what is one nice testing consideration to keep in mind here? A very simple testing, those decision keeping mind here is we see this person seems to have this very close friend that's a neighbor. Very boy friend, right? So very close friend there as well.

So we see all these things, but again, if you notice amongst all these people that are available to make decisions for this woman, who is the person that has some uniqueness about them? The person that has this uniqueness is the son, right? He's literally related to her by blood. That's going to be the right answer. So the thing is, I usually employ this principle when I'm dealing with questions where there are so many potentially good people that I could pick or good thing I could select from a list of things. I just try to ask myself which one has the most uniqueness and which one fits the bill of the question I just read. That's probably going to be the correct answer. So that's just something you want to keep at the back of your mind as you prepare. So I think I'm going to wrap up here. If you are interested in any of my review courses, I have a bunch of courses starting next week Thursday. I have a testing strategies class for step one to three. If you like the way that I kind of broke down questions, we're going to be doing that next week Thursday. So I'm going to have a class over Zoom and then I have a class on Friday, a bio-stats class and then I have a social sciences and ethics class on Saturday. The bio-stats class is four hours long, the social sciences class is a five hour class. And in the week after that, I have a, and those classes are all for step one to step three. The week after that, I have a 20 hour step two step three class.

Again, if you like the way I make integrations across topics, if you like the way I break down questions and I do question analysis, these are all things that you can learn across these different courses. So if you're interested, just shoot me an email, they all over Zoom, they're not lectures, they all based on like stories, clinical situations, right? And there's going to be a lot of focus on explaining pathophase and things like that. Then you probably want to attend these classes. And then I have a 50 hour class in the month of June. Literally for 10 days, I'm going to be going over 500 questions. So imagine if I just did this with five questions, imagine multiplying that by 100. Imagine how much you could learn from that. There are people that took this class last year and they found it to be extremely helpful. That class is also going to be over Zoom is literally 500 in the midst of questions that walk through over 50 hour period. And then I have this podcast on Apple, Google and Spotify. I offer one of one tutoring for all the USMLE exams and med school exams. And I also help with ER As applications and mock interviews and rec letters and all those things. And then finally, I have a You Tube channel that you can check out where I post the videos that I make. And then I guess finally, finally, finally, I also have a, I also have another website called Divine Intervention Life Lessons.com.

Most weeks, I post about two podcasts from a B-Rick or Perspective address our life lesson. There's actually an Apple podcast associated with that called the Divine Intervention Life Lessons Podcast. So thank you for listening to me today. If you found this podcast to be helpful, the one thing I'm going to say please, don't just take away the concepts from this podcast. Take away the testing considerations. Those testing considerations are very important. Knowledge alone will not make you do well on your exams. You need to have a deep understanding of test taking strategy and question analysis. Until next time, have a wonderful, wonderful rest of your day. God bless you and bye for now. Thank you.

Blue sclerae, due to thin collagen allowing visualization of underlying vascular structures.

Patent Foramen Ovale (PFO), which allows right-to-left shunting of venous emboli into the systemic circulation.

It is a cytotoxic agent that can induce interstitial pneumonitis, mimicking drug toxicity from other immunosuppressants.

First, someone explicitly appointed by the patient; second, a close family member; third, a close friend.

SAD involves fear/anxiety specifically triggered by social performance or interaction; Agoraphobia involves fear/avoidance related to being outside or in public places where escape might be difficult.

Because type I collagen defects affect all connective tissues, including the ossicles of the middle ear, leading to conductive hearing loss.

Blue sclerae and recurrent fractures due to defective Type I collagen.

Echocardiogram with a bubble study.

Immunosuppressants/Cytotoxic agents (e.g., MTX).

Close family members (blood relatives).

Type I collagen, which forms the thin layer of the sclera.

Immunosuppressants or anti-rheumatic agents (general concept for drug toxicity).

Blue sclerae and recurrent fractures due to defective Type I collagen.

Echocardiogram with a bubble study.

Immunosuppressants/Cytotoxic agents (e.g., MTX).

Close family members (blood relatives).

Type I collagen, which forms the thin layer of the sclera.

Immunosuppressants or anti-rheumatic agents (general concept for drug toxicity).