DIP Episode 565 - 2024 USMLE Step 3 Free 137 Discussion Part 11b (Q105-110, super helpful for Step 2!)

Alright, welcome. My name is Divine. This is episode 565 of the Divine Intervention Podcast. Today we're going to be continuing the free 137 series. It's going to be part 11b. Alright, let's jump to 105 because we stopped at 104 last time. So we have this 44 year old female who's coming to the office. She says that Nick and Shorter Pin have come back again. So the HPI, she has a five year history of my official pain syndrome. 12 month history of race, I did Nick and Shorter Pin with no trauma. Rist the neck and Shorter Pin has six out of 10. The illustration of the neck and right shoulder and approximate therapy has not helped. Six months ago, she received a local anesthetic trigger point injection in the right trapezius muscle with complete resolution of pin for four months, four eight hours after she injected. She developed CVA H and redness symptoms results spontaneously. She was informed that she's allergic to local anesthetics but was not told which one was used. It was not very wise. Okay, so she has a history of depression hypothyroidism is on an SSRI thyroid replacement therapy and approximate. Has allergies to local anesthetics. Her mom has a history of fibromyalgia. Doesn't smoke cigarettes or drink alcoholic beverages. If you look at a vital signs, they're actually completely fine. Nothing wrong there. And then physical exam, pretty okay. But MSK exam, population of the right upper trapezius muscle triggers.

Discloses a trigger point within a top band of muscle that reproduces patient neck and shoulder pain. Okay, so the patient requests a repeat trigger point injection. That's reasonably worked last time. Which of the following is the most appropriate next step in management? All right, so. So this lady, right again, she has this myofascial pain syndrome has these trigger point pain or whatever. Again, these things, especially like also like fibromyalgia, which is another one. They tend to be associated with the heat stroke psychiatric problems, right? So, but we know this person has an allergy to local anesthetics, but is requested another trigger point injection. So let's, let's kind of re throw this first, right? So let's look at the answer. So option A says, administer the injection using phenol as the anesthetic. Huh. What she asked an allergic reaction to local anesthetics. Why would we do that? Okay. Option B says, administer the injection using prior looking as the anesthetic. C says, administer the injection using tetra cane as the anesthetic. I won't do any of those things. I just won't honestly. We don't know what the allergic reaction is. What if she has it again and becomes like an aphylaxis or something? I would not use any local anesthetic. So we need to find an answer. We're doing use a local anesthetic option. This has pre-treated with the patient or Laura to Dean then administer the injection using any local anesthetic.

I still would not do that because again, there are certain things that these are each one blockers will not see view from. You know, and you don't want to kill the patient. Option E says, refer the patient to analogies for full day evaluation. I like this answer a lot. Let's evaluate this thing. Let's see what's going on first. Let's figure it out before it's because this thing she has is not life threatening. She's not going to die because maybe we do a few days, you know, for a workup from an analogies. So I'm going to go to option E for this one. All right. So I'm going to go to question number one, oh, six. So we have a 62 year old male coming is in the hospital in the pack you. And he has postoperative knee pain four hours after undergoing total writing and throplasty. So his HPI has a two year history of severe right knee pain. He was extubed at post stop. Where is the right knee pain as nine out of 10? That's a that's a lot of pain right post stop. Pintens will be pretty severe. Is knee pain is difficult to control because the insertion of opioids causes sleepiness and episodes of apnea. Oh, that's not good. Okay. So he has a history of hypertension, GERD, high lipids, hypofironyzymoster arthritis, a ticslosarctan, HC Ts, you're meprosol, Livo thyroxin, Dini shaded hydromorphone, Kitoralakan, Tylenol in the pack you. He has no known drug allergies drinks two cocktails daily. Doesn't smoke cigarettes other use of the substances, certain school teacher.

Lips with his wife will look at his vital. So everything is fine, but man is BMI 39. That's kind of a lot of BMI. Let's live it at that. Oh, look at his respiratory rate. Whoa. While he's sleeping, he's two per minute. Okay. So this guy better don't give him opioids. That'll be a terrible idea. And when he sleeps, he just desaturates. Okay. This is really bad. This guy probably has like obesity, hypoventilation syndrome. Kind of throwing opioids in that makes kind of seems like not a very good idea. So his appearance is sleep people are also able to voice. He has decreased blood sounds at the basis. Um, extremities. He has a dress in rap and bracing mobilization applied to the neuro fully oriented. Okay. Says which of the following is the most appropriate next step to decrease his patients risk for post-stop respiratory events? Don't give him an up you. That'll be a horrible idea. Don't give him systemic opioids. That'll be really bad. Okay. Option A says, I mean, for oxygen fire, high flu, nasal cannula. You can do that. But G like this guy can breathe on his own. But opioids are just kind of doing a number on him. So I wouldn't do that. It doesn't really solve the problem. We need to help his pain. Given oxygen does not help his pain. We need to help his pain. But we need to not give him systemic opioids. Option B says you pick up you pick up a keen femuron nerve block. Okay. Let's keep that answer. Option C says chest wall impedance.

Monitoring that's not going to help with his pain. Option D says continuous pulse ox. That's not going to help with his pain. Option E says hydro morphing fire patient control. And how G'sia. No, don't do that. The literally said they initiated hydro morphing post stop. And this guy's like heavily desaturated and having a breath respiratory rate of two per minute while asleep. We shouldn't do that. I'm going to go with option B. Right. Remember, we tend to use nerve blocks when you want something that is as strong as IV pain medications. We've got a little stronger than IV pain medications, but you don't want systemic toxicities. This is why anesthesia, physical medicine and rehab, they have largely perfected these nerve blocks. So I like nerve blocks for this situation, right? Because remember, the knee is in the femuron nerve distribution. So if you do a femuron nerve block, that's going to help there. Right. Remember, if you have like a chest wall issue, this is another one you love to test a lot. You have like chest wall pain from like chest surgery. You can do like intercostal nerve block, right? Stuff like that. It usually just nerves around the general area of where you had your surgery. All right. I'm going to go to question 107. So we have a 52 year old female, that's Lebanese American coming to the office.

The patient presents because of pinning a left wrist, following a four one week ago, she's a diddry entry clerk, and you have been treating her for a couple tonal syndrome for the past year. Physical examination today discloses little swelling, but there is pain with attempts to flex or extend the wrist and fingers. Extras are shown. Which of the four is the most appropriate management? All right. Let's look at the X ring because they're not giving much information here. So the X-ray can't be helpful here. So the thing is whenever you're looking at an X-ray, especially at an extra of the hand, just look at the big picture things. Whatever but pathology they want you to see is going to be a big picture thing that's going to pop up. Right. So like for example, I look at like symmetry, you know, I look at symmetry. Look for anything that seems to be off to the side disconnected from the bone. That's going to be pretty classic for like some kind of fracture. Right. So we look at the, you know, the fingers. I don't really see anything terrible. You know, you can see like some erosive changes, which makes sense. You know, she's kind of old. She's 52. And then we look at the carpal bones. Right. And is there anything that again seems to kind of be hanging off on its own? And yeah, you can probably, and yeah, she has low bone marrow density here. We can see that the scaphoid. Right. This is actually a classic fracture. It should be able to identify on your exams.

The scaphoid is kind of like son in half almost. Right. That's a scaphoid fracture. That's usually pretty classic. Yeah. It's a pretty classic image. You should identify. And you may wonder, man, divine. How do you know it's scaphoid? Well, there's a nice nomonic. At least let me go to the med student level. There's a nice nomonic you probably remember from from med school, right? So long to pinky here comes the thumb. So long to pinky. Right. So like scaphoid, lunates, trapezoid or whatever it's called. No, trachecha, actually. And then I think it's like PC form. And then here comes the thumb. Right. So like you have hamid capitate. And then there's a tea. And then there is another tea. I can't remember that off the top of my head now. I'll probably have to think and I want to keep going with the spot cast. But this person literally has a fracture of the scaphoid. And the thing is scaphoid fractures. The scaphoid bone is many of you remember. It has a kind of a weird retrograde plot supply. So the risk of a vascular necrosis is very, very high. So these people want to put them in a thumb spike a cast as quickly as possible, a thumb spike a cast. Right. So that you can keep the bones lined up well. You can keep the vessels lined up well. So you don't have a vascular necrosis. So let's look for the answer that involves like thumb spike a cast of some sort. So option A says a plan a elastic risk band, wrist bandage. No. Right.

Option B says apply a plaster cast that incorporates the thumb. That sounds a lot like a thumb spike a cast. We're going to pick that answer. Let's go to option B. Option C says apply a plastic wrist splint. Again, you've got to do the thumb, the thumb, the thumb, right. C is wrong. The D says begin daily aspirin. Do not restrict use of the hand. I mean, if you want to cause a vascular necrosis, that seems like a good idea. Don't do that, right. Option E says refer to a higher tone of occupational therapists. No, that's not going to help. So this is a scaphoid fracture again. High risk of a vascular necrosis is a thumb spike a cast. So the answer is going to be option B. All right. Option 108. So 65 year old woman, who has been your patient for eight years, is being prepared for discharge from the hospital. After receiving a prosthetic hip joint, prosthetic hip, for inner hip fracture. All right. Post-op she received low dose heprin therapy and she has been able to move about with a walker. Okay. She has had diabetes melodies for 12 years, which has been controlled with glipesite. That's a sulfonyluria. A once a three months ago was 7.6%. Other than the diabetes, her health has been excellent and her weight has not changed in several years. She took estrogen for four years for hot flushes, but discontinuity because of vaginal bleeding. She does not smoke cigarettes. She drinks a glass of wine or a bottle of beer daily. She lives with her 62 year old sister. Who has?

CVS your arthritis when he's able to prepare meals and assist her with activities of daily living. During the hospitalization, the patient's blood glucose concentrations have reached from 220 to 280. For which she's being treated with insulin. She will continue insulin therapy at home. At this time, it is most appropriate to arrange for home services to do which of the following. All right. Again, these post-op questions, they kind of love them on the exams. Substantices are menstrual daily insulin. Now, this woman's blood glucose is pretty stable on the sulfonyluria. You know, when we get into the hospital, who loves being in the hospital is pretty stressful, so your glucose can go haywire. So, I'm not going to pick up some A. If we put her back on a home regimen for a while and her glucose is suddenly become like not well controlled, then yeah, we can maybe try to do that. I'm not going to do that. You want to try multiple oral hypoglycems before you just jump to insulin. Option B says, assist the patient in building an upper body strength. She had lower extremity surgery, prosthetic hip. Let's keep that. Option C says, assist the patient in strengthening and lower extremity muscles. She kind of looks a little better than D, but hey, let's keep it. Option D says, ensure the patient follows the diabetic diaper scribe for her. I mean, you can do that. But these patients seem to have been doing pretty well outside of the hospital.

Again, it's just surgery, stress, cortisol that can throw your glucose out of whack. I'm not going to pick that option. E says, measure the patient's blood glucose concentration daily. Do you really think that she's not doing that? Come on, that's ridiculous. So, I kind of stuck between B and C. Now, the thing is, when you have low extremity surgery like this, one concern, I mean, there's a reason they give her a walker. It's the risk of falling. So, we want to try to reduce that risk of falling. And you can reduce your risk of falling if you just beefed up in the lower extremities. So, I'm going to go to option C actually. It's not option B. It's just going to offer more benefit. And it's more directly related to what the question is talking about. All right. So, I'm going to go to question 109. So, 109, 101, 10, they are part of a sequential set. So, we have a 32-year-old man comes to the office because of mild eye irritation, running nose, nasal congestion and post-nizel drip. But I've occurred since he moved to his coronal apartment 10 months ago. He also reports occasional shortness of breath with wheezing and loss of his sense of smell. He has not had fever or cough. Medical history is unremarkable and he takes no meds. How many history is significant for nasal polyps in several family members who also have similar symptoms? The patient's vital signs are within normal limits. Physical examination discloses mildly injected conjunctivine.

Pale and swollen nasal tribunates and a slightly injected pharynx longs are clear to our school t-shirt. All right. The remainder of the examination discloses no abnormalities. All right. I just says which of the following factors in this patient's history most strongly predicts development of a more serious condition. Right. So again, this is a prognosis question. We've kind of talked about this, right? I visited this principle in an earlier question I think in this set. Where I said in this series, where I said that, hey, whenever they give me some of these things, just usually find the one that's like really bad. The one that's really bad is probably the one you'll be picking. Right? And then it says, as you get shortness of breath and wheezing, option B says, family history of similar symptoms. Option C says, what's the sense of smell? Option D says, perennial nature of symptoms. Well, let's think about this logically. Of this list, which one seems really bad? Which one is like, hmm, if you have this one, maybe indicative of something really sinister or, you know, maybe thing you could die or something bad, I'm going to argue that it's option A, right? Losing your sense of smell is not great. But many people walk around without a sense of smell. No nature of symptoms. It's not as bad, right? Yeah, you're having it on a recurring basis. But it's not as bad as, hmm, you're being short of breath and you're wheezing. Family history of similar symptoms.

Again, what if the family history is of something that's not really bad? Right? This person looks like they have like allergic rhinitis or whatever. Well, you've seen this allergic rhinitis with like, shortness or breath wheezing. This person may actually have asthma. Right? Person may actually have asthma. So, option E is just the worst of the list. So it's just the answer that makes the most sense too big. All right. Now, question 110 says, the patient is cancelled regarding allergen avoidance, including the use of hepa-elfie filters, a mattress cover, and frequent vacuuming with a dust removal. Here it turns to the office a month later with continued wheezing, a shortness or breath. Which of the following is the most appropriate for macotherapy at this time? Right? Again, you we know if we frame this question, this guy probably has allergic rhinitis. The best treatment for allergic rhinitis is in health steroids. It's just something you're supposed to know for your test, right? It's pretty classic. So let's look at the answer choices here. So option A says in health, you tick a zone. That's right. Option B says nasal cromoline. I will strongly encourage you not to pick cromoline as an answer on your exams. It's one of these mast cell stabilizers. It works. But I would not pick it on a USML exam. Almost nobody uses this or prescribes it anymore. All right. Option C says nasal oxymethazoline. That's not going to help here. Option D says oral effects of endodine.

Again, don't get me wrong. Oral H1 blockers can help. But they are not as effective. There are studies that have shown that in health steroids are the best treatment for allergic rhinitis. So I'm going to go with option A here. And that'll be it. Okay. So again, I just want to, I don't want to stop modding up the numbers for this. I want to be able to like, oh, jump to 111. Like the next podcast, I really hope to do 112, like 120 and stuff like that. So I'm going to go ahead and stop here. Again, if you're studying for the USML exams, I have a series of classes that are taking place this month and next month, especially for step two, step three, level two, level three. I have a 20 hour class that starts this evening at 5 p.m. Eastern on Zoom. You can still sign up. There's still a few seats left. So if you want to sign up, shoot me an email. I can give you some more information. And then I also offer all the classes like a test taking class, a bio stats class, social sciences and ethics class. A last minute review. The first three classes there, social sciences and ethics, bio stats and the test taking classes for step one, two, step three, level one, two, three. But the 20 hour review on the last minute review of first step two and step three specifically. So again, many people have taken these classes. I've had very recent people that have taken these classes as recently as like December, get like in the 250s, the 260s to 270s. Right?

So again, this class is pretty comprehensive and is heavily updated very regularly. So basically like you're in a situation where you're not getting still information. It's not like wow, the vine is still teaching the same stuff as like five, 10 years ago. No, obviously the USMLE is the change in flavor from year to year. Right? So I update this material. I update it just to keep up some time. I update it almost like every month just to keep up with the USML Es. Right? So and that's something that many people have found to be profoundly helpful. And then again, I also have these larger classes in the middle of the year that I think you'll find to be helpful again. I'm going to make a separate podcast on that. And just should be an email if you want some more information. I can give you some more information. And I'll follow on on one to learn from all the USMLE and complex exams. I also have these podcasts on Apple Google and Spotify. You can check out and I have a You Tube channel. You can check out as well. We're opposed to videos that I make. And then I also help with ERA's applications, personal statements, marketing reviews and things of that nature. And then finally, I have another website called, divininginternventionlifelessons.com, divininginternventionlifelessons.com. Every week I post like one to two podcasts from a biblical perspective address a life lesson. Actually, many people listen to that as well.

And if I need to be really helpful, there's actually an Apple podcast associated with that called the divininginternventionlifelessons podcast. So thank you for listening to me today. Again, I hope you'll find this podcast and this series to be helpful. So I'll see you in the next podcast. I'll see you in episode 566. God bless you. Sleep well. And bye for now. Thank you.

A thumb-spica cast/plaster cast that incorporates the thumb to maintain vascular alignment and prevent avascular necrosis.

Regional nerve blocks (e.g., femoral block) because they provide strong analgesia without causing respiratory depression.

Intranasal corticosteroids (steroids).

Assisting with strengthening lower extremity muscles and physical therapy.

Shortness of breath and wheezing (suggesting asthma).

High risk of vascular necrosis due to retrograde blood supply.

Because it has a retrograde blood supply, and improper casting/movement significantly increases the risk of avascular necrosis (AVN).

The presence of objective lower airway symptoms such as shortness of breath and wheezing.

Regional nerve blocks (e.g., femoral or adductor canal block).

Intranasal corticosteroids (steroids), as they are superior to oral antihistamines or mast cell stabilizers like cromolyn.

To strengthen lower extremity muscles and improve mobility/balance to reduce the risk of falls.

Because it has a retrograde blood supply, and improper casting/movement significantly increases the risk of avascular necrosis (AVN).

The presence of objective lower airway symptoms such as shortness of breath and wheezing.

Regional nerve blocks (e.g., femoral or adductor canal block).

Intranasal corticosteroids (steroids), as they are superior to oral antihistamines or mast cell stabilizers like cromolyn.

To strengthen lower extremity muscles and improve mobility/balance to reduce the risk of falls.