DIP Episode 548 - 2024 USMLE Step 3 Free 137 Discussion Part 1 (Q1-10, super helpful for Step 2!)

Welcome to episode 548 of the Divine Intervention Podcast. Into this podcast I'm gonna begin a series on the free 137 for step 3. This is the 2024 version. I'll just see two things real quick before we get started. Number one, this series is gonna be very helpful to you if you're taking step 2 as well. So I know you may be like, ah, divine, these are gonna be spoilers. If I do these questions now, before I take step, ah, I mean, you need to take step 3 in the future, but there's a pretty decent chance that by the time you're ready to take step 3, the questions would have changed. So I would encourage you to use them. So if you're taking step 20 time soon, you should probably listen to this. Because again, the MBA Ms have just really changed in flavor over the last few weeks and months. And you want to be prepared with the most up-to-date information as to how the present material. I think you'd find this to be helpful. Obviously, if you're taking step 3, you're gonna find this to be super-amely helpful. You should certainly listen to this before your exams. So the second thing I'm gonna say is, if you're taking step 2 or step 3, if I'm step 1 or level 1 to 3, I have a series of classes that start tomorrow. I have a test-taking class that starts tomorrow. It's in the evening tomorrow from 8 to 10, 30 p.m. I mean, from 7, 45 p.m. Eastern. I have a podcast I meet recently on all the classes I have. I think you're gonna find them to be really helpful.

I think one thing you're gonna learn very quickly as we go through this series is that test-taking acumen is extremely important these days on the USMELIS. It doesn't matter how much you've studied. So if you want to be really prepared and be an excellent test-taker, you really want to consider this class. And I revamped it recently to really reflect many of the changing modes of the MBA Ms. Okay, without further ado, let's jump into this. So I'm gonna do the first 10 questions. I'm gonna encourage you if you're like, oh, let me do this. These questions before I go through this series. Do the PDF first. Do it with the PDF. Because if you do it with your online interface, the questions may not be in the order that I discussed them. Just FYI. All right. Question 1. 75-year-old man has brought to the emergency department by his son. Two hours after the sudden onset of fever, chills, pluridic chest pain, and cough productive of a roscolored sputum. He rates his chest pain as an 8 on a 10-point scale. Temperature is 38.9 degrees Celsius. That's 102 degrees Fahrenheit. Pulse is 106 per minute. Respirations are 22 per minute, and blood pressure is 130 over 80. Oxygen saturation is 94% on room air. The patient appears to be in moderate respiratory distress. Physical examination shows splinting on the left side. There's donays to per caution and engulfing over the left lower lobe. Abdominal examination shows no abnormalities. Results of lab studies are shown. So look at these labs.

What are the things that kind of stick out to me? Well, the creatinine looks a little bit high. His sodium is a little bit low. His chloride, well, not to read about those. His white count though really sticks out. The white count is 21,000. A lot of neutral fuel. So there's some bacterial thing going on. And then we'll look at the ABG. The PL2 is pretty low, right? 62 is not a great number. And then your analysis shows no abnormalities, and ECG shows sinus-tactic cardio. A chest x-reshows consolidation in the left-heural lobe and no cardio-megaly. Introvinal antibiotics are administered, and the patient receives oxygen via anisocannula. Three hours later, he's lying on his left side and has increased dyspnea. He's rolled to his right side and he symptoms improved within minutes. Which of the flu investigs explains this improvement? So, you know, there's options A, B, C, D, and E. So what do you think here? Again, what do you think is going on here first and first? So this guy sounds like he has a pneumonia. Sounds like he has a pneumonia. And if we look at the answer choices here with the ocean ACS, so why did he symptoms improve when he was rolled to his right side? So option A says positionally apparent PE, option B says positionally decreased AA gradient, C says positionally impeded filling of the left ventricle D says positionally impeded movement of the diaphragm, A says positionally increased left pleural effusion. So let's kind of walk through this.

So this guy appears to have some kind of pneumonia with any fusion. I remember pneumonia is they love to test those stains, pleural effusions, they love to test those stains. So the pneumonia we can clearly see is on the left. So presumably when he kind of moved to the right side, it kind of felt better. It kind of felt kind of felt better. So why did he feel better? So I'm going to venture that the answer here is going to be option B. Because if you think about it, when it's lying on his left side, he's like super, super disnic. Right? But when he rose to his right side, you know, because pleural effusions have the ability to move. Pleural effusions have the ability to move when you're rolling to his right side. At least you can move away some of that fluid. And if you move away some of that fluid, you're going to make the fusion more efficient. And if the fusion is more efficient, then oxygen in the air, you'll like and get into his pulmonary vessels and he can oxygen in better. So that's why this guy symptoms improve. So I'm going to go to option B, a positionally decreased of your arterial gradient. And I know you may be like, well, the way the word decrease sounds really negative. No, it's actually a good thing here. It's actually a good thing here. You don't want your e-gradient to be to be to be high. Right? Because if your e-gradient is high again, look at what does it literally mean.

E-gradient literally means the spread, the difference between your arterial, sorry, between your viola, oxygen tension. That's your PBGAL2 and your arterial oxygen tension. That's your P-little A-l2. If that spread is increased, it means that the oxygen in your viola is not able to make it to into your arteries very well. So it's going to be increased. So the guy, when he was on his left side, his e-gradient was pretty high. So it was really hard for him to breathe. It was really hard for him to oxygenate. It was really hard for oxygen from his alveolus to get into his pulmonary vessels. So it was hypoxic. But now that we've moved into his right side, then things improved. You basically, like, if you have a cause, this is very high yield. If you have a cause of hypoxemia, that's a sociable and increased e-gradient. The trend you want in the resolution of your symptoms is a decrement, is a decrease in that e-gradient. Because as that spread narrows, as the gradient narrows, it means that oxygen is more effectively able to diffuse from your, of your line to your pulmonary capillaries, which will obviously help you oxygenate better. Now, the thing is, option E is a very, I'm sure many people probably picked option E. Or, it's an amazing distractor here. Option E says, positionally increased left plural effusion. No, no. It sounds really good. But if you really dig deep into that sentence, it's pretty wrong, right? It's pretty wrong.

So, if you think about it, you know, by moving him to his right side, we're moving the plural effusion around. If anything, we're actually decreasing the plural effusion on the left, not increasing it. So option E is definitely wrong. And then remember, you know, option A, positionally apparent PE. That doesn't really make any sense, right? This guy just doesn't seem to have many risk factors for PE. They're really spending a lot of time on pneumonia. Let's, let's kind of stick with that put in here. And, positionally impeded feeling of the left ventricle. I'm not really going to buy that. This guy, no, just not what's going on here. And, positionally impeded movement of the diaphragm. No, I'm not going to go with that here. Remember the things that kind of mess up your diaphragm, I think, are muscular diseases, you know, the umbrae, my stenogravis, stuff like that. All right. So, let's go ahead and go to question number two. So, question number two. And again, if you notice with these labs, I kind of just glossed through them. I just focused on the things that really, really wear, wear abnormal. Okay. Question two. So, a 55-year-old woman, 55-year-old woman, grabbing a four-power-four, comes to the office because of vaginal spotting that has occurred once monthly for the past two months. Menopause occurred one year ago, and this is the patient's first monoposal examination. Postmenoposal examination.

Medical history is significant for elevated blood pressure readings during the past two years, and diabetes militaries, for which she follows an 1800-calorie diet. She takes no medications. Her most recent cervical cytology and mammography obtained one year ago. Dislose not normalities. Family history is significant for hypertension in her mother, who died at age 58 years from an unknown cancer. The patient has smoked one pack of cigarettes daily for the past 30 years, and drinks be irrigationally. BMI is 42. Temperature is 36.7 degrees Celsius, as 90 degrees Fahrenheit, post-us 90 per minute, rescriptions are 16 per minute, and blood pressure is 136 over 84. Bimonol examination discloses a firm, smooth, mobile, non-tender readers that is consistent in size with a six-week gestation. The remainder of the physical examination discloses not normalities. Results of dip-sticular analysis are within the reference ranges. Fingastic hematocritus 35%, and two-hour post-prondial, Serum glucose concentration is 188, which are the following is the most appropriate diagnostic study at this time. Again, so let's kind of frame this question. That's one thing I find to be very helpful on the US Emily exams. Just kind of frame the question, like what's going on here. This is a post-menopausal female with vaginal bleeding. Simple as that. Again, I know some people want to dig into the weeds and start saying, let's be careful with the sentence and that sentence. No, that's not smart.

That's not smart. We do take exams. I'll tell you that right now. On your exams, basically, look at how long this vineyard is. Your job is to just frame, frame it in your mind. The thing is, I would hope at this point, you have studied quite significantly. So most of the quick, high-yield presentations stick out in your mind now. So I will encourage you, instead of kind of dealing with all the weeds, just frame things, literally frame things. And you're going to be good to go. Like this is a simple question about a post-menopausal female that has vaginal bleeding. Obviously, if a post-menopausal female has vaginal bleeding, what kind of word about cancer in the metrocancer? I mean, the most common cause of vaginal bleeding in the post-menopausal female is, you know, vaginal atrophy. But we still got to run out of cancer. So we're worried about intometrocancer. Right? So our frame, I've got it in a bearing. Okay, so now, let's find the right answer here. You know, option A says CBC, option B says CT of the pelvis, mix no sense. Option C says endometrobiopsy. Option D says hysterosalpingography. Option A serums C125. Again, I'm worried about intometrocancer. I'm going to go with option C in the metrobiopsy. Right? Again, post-menopausal female vaginal bleeding. We don't care, you know, we're worried about intometrocancer. The answer that hits that is option C. You know, one answer I'm going to comment on here that, you know, me related a little bit is, hysterosalpingography.

What do we use it for an exam? We basically use it in women that have maybe had like recurring abortions, women that have had a lot of miscarriages. It's a very nice way to look at the potency of the uterus and the UV duct, which we also call the fallopian tubes. Right? C125, again, that's more of an ovarian cancer answer. CBC, two non-specific. It's not going to help us with anything here, right? Again, non-specific cancers are usually like on wise choices on the USM at least. I'm just going to leave it at that. All right. Question three, a 28 year old woman comes to the health center for an initial visit. The patient appears somewhat anxious. After introduction, she says, Dr, something has been happening to me for the past six weeks or so. That has me a bit scared. But once or twice a week and out of nowhere for no reason I have the sudden feeling of anxiety. It really gets severe. And I get short of breath. I just don't know what's going on. She has recently divorced a husband of seven years, giving the evidence at this time which of the following is the most likely diagnosis. All right? So we see a person just had a very big life stressor. Divorced a husband of seven years. That's a long time to be married, right? Even if you've been married for a month, it's tough, it's rough. And then now you see that she's having these panic-like symptoms. Of course, our friends at the MV me as well. This is nice of them. They didn't put panic attack as an answer.

That's an amazing destructive. I totally put that as an answer if I were with the one right in this case, then what different story. But basically, right? This person had a recent stressor. And then in addition to the recent stressor, we see cyclic symptoms. You know, that I've been going on for a few weeks. That really doesn't really meet the definition of an odysseyiatric disorder. This is an amazing way to think of what of adjustment disorder. That's the way I like to think of adjustment disorder on the USML Is. It's going to present basically in a very classic fashion. You're going to see a recent stressor in the person's life. Stressor probably happened within the last few days, last few weeks. And the person has cyclic symptoms for a few days, few weeks. That really doesn't meet the definition of an odysseyiatric disorder. You see that that's adjustment disorder. If you meet the definition for an odysseyiatric disorder, it cannot be adjustment disorder. So I'm going to go with option A here. That's the only adjustment disorder sounding answer. If you look at the other answer choices here, you know, this time, option C, you know, these days they call it persistent depressive disorder. Basically, you're going to see a person that has had depressive like symptoms for more than two years, two or more years, or more than a year, if you didn't know the person that is under EGT.

Generalized anxiety disorder option D cannot be the answer because you got to be worried about many different domains of life for a month and for at least six months. This has been going on for six weeks. Doesn't fit the criteria. Again, psych, remember the name of the game? Those are criteria. PTSD, right? I can see how a person will also pick PTSD here. Don't pick PTSD. PTSD is going to be something that's been, you know, more than a month ago. You'll be having your symptoms for a month or more. But, and I know you'd be like, wow, divine, this is six weeks. That's about an a month, but hey, calm down. Typically, PTSD, you're going to see an inciting traumatic event. More of equal accident, child abuse, domestic violence, warfare. You're going to see something like that. We don't really see any real traumatic event here, like no real trauma, right? Yeah, the person is having emotional trauma from the divorce, but this is not like a traumatic event. And one thing I'm going to say here is, I guess, I guess a side point for you to know PTSD that you should know for your exams. People tend to get PTSD more commonly from interpersonal events, interpersonal events, right? Like child abuse, domestic violence. Those people have a high risk of PTSD versus something that is like a motor vehicle accident, for example. You may be like, divine, why are you emphasizing this? This seems super low yield until you see it on your exam and your mild drops.

And remember that people that have PTSD, they have a very high risk of suicide. Right? They have a very, very high risk of suicide. And again, the class equilibrium, you're going to be, you know, the PTSD question is, the person is going to avoid that event. They don't want to talk about it. They don't want to experience it again. They're going to have dissociative amnesia for that event. So you notice that key parts of that event, they just seem to just not remember. They'll have a lot of flashbacks. They'll have a lot of flashbacks. And one thing I want to say about PTSD that is super, super high yield to know as some neural anatomical associations, somewhat some neural anatomical associations. What are those associations? Number one, people that have PTSD have a suppressed HPA access. The accord is all is low. They have a suppressed HPA access. The accord is all is low. Again, see, what am I talking about this? This is something that people could screw up on an exam. Because think about it. Classic reason, if you were using, if you were trying to use common sense. The reason I'm talking about these common sense was really work here. So let me think that a person that has PTSD stressed, right? So obviously if you're stressed, your accord is always going to be through the roof. No, these people's accord is always actually low.

There's actually studies that have shown a suppression of the HPA access in people that have, so the hypothalamic pituitary adrenal access in people that have PTSD. Right? But the acaricolamines are super, super, super, super high. So they have high acaricolamines that have a suppressed HPA access. They have low cortisol. Please keep those neural anatomical associations in mind with PTSD. I think I've said enough here, but we can clearly see that this question doesn't really fit PTSD. All right. Let's go to question number four. So 71 year old woman with a 15 year history of severe COPD submitted to the ICU for treatment of an acute COPD exacerbation. The patient has been receiving home oxygen therapy for the past three years. FF1, a year ago, was 27%. She has a DNR order stating that she does not want cardioponular resuscitation with no specific comment on intubation. Her daughter, who is not present, has power of returning for the patient's health care decisions. Although the patient has made all decisions in the past, medical history also is significant for hypertension. Medications are like synovrilo and HCTZ, as well as in health, triotropium, abiturol and flutica zone. The patient is intubated and mechanical ventilation has begun. She is treated with antibiotics, steroids and nebulized bronchordial leaders. Her condition gradually improves and she is extubated for these leaders.

Within two hours of extubation, within two hours of extubation, the patient becomes short of breath and has difficulty clearing her secretions. She is not using a system of also respiration. Temperature is 37 degrees Celsius, so honestly, her vitals are fine. Although the pulse is 98, that's kind of high. The pulse of respiration is 25 per minute, blood pressure is high, 168 over 98, 168 over 98. And then oxygen saturation is 89% on six leaders, that's not very great. The patient is alert fully oriented and converse, and results of ebg is shown. So PO2 is 61, that's pretty low. PCO2 is 55, that's high. Pg7.32, she's in the acidotic range. An attempt is made to manage the patient with non-invasive positive pressure of ventilation, but the patient reports this comfort caused by the mask, a request that it be removed. When initially acts, the patient declines to be re-intubated. Which of the following is the most appropriate next step in management? It is a clear social science question. It's a clear social science question. So one thing I'm going to say is this. Let's look at the answers first. Option A says, clearly states to the patient that if she gains declines in to be patient, when offered to her one more time, she will receive comfort care only. Option B says, contact the patient's daughter to request additional information regarding the patient's previous feelings, regarding intubation. Option C.

Exploring to the patient that because her advanced directive is confusing, discussing her options will be helpful. Option D. Proceed with her intubating the patient, option E. Request psychiatric evaluation of the patient's capacity to make healthcare decisions. All right, this is a pretty straightforward question. Although it also looks a little bit complicated, I can see why people may hate something like this, but here's the thing. What's the, again, what's the bearing here? What does this question really focus on? There's a lot of squabbles about intubation is like, hmm, should we intubate? Should we not intubate? Madam, what do you think about intubation? Do you want to get intubated? What do you want with your end of life care? We literally don't know any of these things, right? So we got to clarify. We got to clarify. We got to clarify. So honestly, for this one, I'm definitely going to go to option C. Let's figure out like, hey, woman, we need to know. We know that you don't want to be resuscitated, but what do you want from an intubation perspective? Option C will help us achieve that. Now, here's the thing. One thing I'm going to say here, because I know some of these answers. And I'm going to be like, wow, why can't we contact the power of attorney? Who's the daughter? Well, you got to be careful here. See, the current situation is that she has made all decisions so far. We know that, okay? Is she alert? Yeah, she's alert.

So she seems like she can make good quality decisions. Oh, absolutely. Right? So here's the thing. Be careful. Don't get it twisted with a power of attorney. They're supposed to decide things for you when you become incapacitated. Is this one incapacitated? No. No. If I get P.O. is an amazing destructor, I can see why many people will pick option B and get it wrong. So just be careful. Remember, in general, the NBM is they want you to focus on the individual first before it's not going to surrogate. This individual is conversing. She seems to be alert. She seems to be with it. There's no reason why you should start saying, hey, let's start asking the daughter. Let's start doing this P.O.A. whatever. No, there's no reason to do that. So I'm going to go to option C here. Okay, I'm going to go to option C. An option A is kind of root and forceful. That's not very humanistic. I would not do that. And option D, the patient says, hey, she declines wearing to be that you're going to be violating the patient's wishes if you did that. And then this one does not need psychiatric evaluation. She does not appear to have any signs of psychiatric disease. Again, and if you're struggling with social sciences, again, I have a class taking place on Thursday, five hour social science class, first step one to three and level one to three. We cover so many of these kinds of questions and scenarios more than 200 of them. So they are very prepared for your for your exams.

All right, question five says, a phase three trial is planned to investigate the use of a new medication for the prevention of type two diabetes melodies, which was a fully inclusion criteria should be selected to design the most efficient study. Well, you're trying to do a. Let's look at this first because again, the thing is many people are so quick to jump to answers. If this podcast can carry on one thing is don't be so quick to jump to answers like, you know, like just think of this question a little bit first. Do some mini analysis in your head before you start jumping into the answers. That's a smart way to take exams just just in general, literally just in general. So one or two of these three trial. Okay. And then want to investigate use of a new medication for the prevention of type two diabetes. So you obviously don't want to study people that already have diabetes, we're trying to do a study on preventing diabetes. It doesn't seem to make much of any kind of sense to say, let's get diabetes into the study. We also want to get in people into the study that maybe they have a high risk of developing diabetes. We want to prevent them from progressing all the way to having diabetes. So I will say that let's kind of be on the lookout for that kind of answer answers that need these particulars. So let's go one by one. So option A says patients aged 18 years and older who have a BMI of less than 23 and smokers. Option E is wrong, right?

Because type two diabetes usually develops in over people although with this obesity crisis we have in this country that is changing very rapidly. So 18 years and older people use tend to develop diabetes a little bit older in life, right? That's not a great population. There's good option B option. Peace is patients aged 18 years and older with no significant medical history. No, that sounds like a person that's pretty healthy. People that are pretty healthy probably don't have a great risk of developing type two diabetes. I'm not going to be trying to prevent type two diabetes in a person that is like extremely healthy. That doesn't make sense as an answer. Let's go to option C. Option C says patients aged 45 years and older with hyperlipidemia and central obesity. All right. Now we're talking, right? This looks like a person that is metabolically devastated. This person just seems to have the metabolic to benabolic badness that we know that kind of portends diabetes. So I like option C. Let's keep that. Let's look at option D first. Option D says patients aged 65 years and older with an A1 C of 6.5% or greater. These definitely wrong. These definitely wrong because think about this right? Like at this point, A1 C of 6.5% or greater, most people that should get diabetes have already gotten diabetes, right? I mean, literally if your A1 C is 6.5% you already have diabetes. This study is about diabetes prevention. That doesn't make any sense. So I'm going to go to option C.

Option C makes the most sense here. Option C literally makes the most sense here. Good age for people that are kind of like knocking on diabetes door. This hyperlipidemia central obesity risk factors for diabetes. So I like option C a lot. I'm going to go with that one there. All right. So I'm going to go to question number six. Ooh, this one is a long one. Okay. So and usually these long questions tend to be the easy ones. Just pro tip. Okay. So a 60 year old man is admitted to the hospital. Four hours after he awoke early this morning with shortness of breath. DZNS. I'm pretty chest pain. So it's pretty solid. Medical history is significant for coronary artery disease, hyperlipidemia, COPD. He takes a tovers statin, enteric acidity, 1 milligram aspirin, a tenolol, a bit of all, hypertropium and home oxygen at one liter per minute, via an isocannula. He has no hiding near is an LNS exposure to anyone known to be ill. Okay. All right. All right. He has smoked a pack of cigarettes daily for the past 40 years, drinks three to four quality beverages monthly. BMI is 21. His temp is fine. His pulse is high though 150 per minute. So he's very taggy, cardiac. He's the kipnic in our expressions of 36 per minute. His blood pressure is 105 over 72. It's kind of low. O2 sat is 84%. It appears uncomfortable speaking through a forward sentences. GV Ps 10 at 45 degrees.

Oscotation of the lungs, disclosies, poor air movement, diffuse hearted inspiratory, with his bilaterally, cardiac exam, disclosies of poppable parastronol lift. The abdomen is perturberant and a visible fluid wave and a, with a visible fluid wave and a poppable epigastric pulsation. The liver edge is pulpy, three centimeters below the right costo margin and the area's tender. Examination of the lower extremities disclosies two plus bilaterally, competing in the dima. Chestics for an e-gigia shown, which are the following is the most likely underlying explanation for this patient's condition. Okay, before we jump into the answers and start sweating, let's just analyze this question, right? This is a person that has a lot of medical problems, right? Coronary artery disease, high lipids, COPD. And this person has the sodium onset, pleuritic chest pain. Notice I'm trying to frame. I'm telling you this, if you've studied and you've done enough practice questions, you're going to be good at framing. Framing is a very good test in principle. Basically, what are you doing? You're boiling down a Q-stem to the high-yield essential that it is. I'm going to say that again. You're boiling down the Q-stem to the high-yield essential that it is, the high-yield what essential that it is. The high-yield essential here is that this person has a really bad medical history and has this sodium onset, pleuritic chest pain, very tacky cardiac. And we look at this chest x-ray.

Well, he's got COPD, so not a big surprise, right? That's a long hyperinflation right there. And this e-gigia, I don't see anything that again really jumps out at me. I don't see any craziness with the QRS. I don't see any ST elevations. I just see that this guy is just very tacky cardiac. The rate is like 150. It's pretty high. So again, what's like the high-yield essential that kind of matches up with what we've just framed this question as? Well, this sounds a lot like a PE. It sounds a lot like a PE. So let's ask ourselves, what answer choice goes with a PE? What answer choice goes with a PE? Well, let's look at them one by one option. He says, external compression of the SVC. No, PE does not compress your SVC. The things that compress your SVC, things like tension, you move thorax, air is kind of building up, right? You'll throsic cavity squishing your SVC. That's not what's going on here. Another one we may consider here is a SVC syndrome. But it's not a SVC syndrome. Remember, in SVC syndrome, the person's SVC can be compressed by like a lung cancer, like a pancus tumor, something like that. Or even a lymphoma. Believe it or not, a lymphoma can cause a SVC syndrome. Watch out for that presentation on your exams. I'm not going to pick up, Shen, A. Option B says, H by lower infection, which transmits oxygen, and peritoneal leaking. No. No. This question is focused so much on his lungs. I'm going to stick with his lungs. H by lower dosing cause lung issues. No.

Option C says, Lactic acidosis caused by systemic hypoperfusion. Hmm. His blood pressure is pretty decent. I think he's still perfusing his extremities well again. Let's focus on the lungs. Option D says, Poinari vasculature, Compromise, and Corpominali. All right. Now we're talking about what looks like a PE. I like Option D. Let's look at Option E. White spread hepatocelloid and Crosis and Prankhamalodema. Hmm. Yeah, he has this fluid wave. But again, this question, I'm just going to say, I'll talk about the shortness of breath and all these lung issues. Why do you want to focus on? Something that the question did not really spend a lot of time on. Nah. I'm not going to go with that. This guy may have, because remember, I guess some of you may be thinking that, wow, divine. Why does person have this fluid wave? Hey, remember, if you, if you have COPD, your lungs don't work, you're going to have Corpominali. Okay. So your right heart is going to fail. Because that pulmonary hypertension is going to cause your right heart to fail. If your right heart fails, what is the problem? Your right heart to fail. If your right heart fails, what do you think is going to happen to your liver? Your liver is not going to do well, because remember, your IVC basically becomes, sorry, your hepatic vein literally becomes your IVC. So, if your IVC, if your right heart is not working, your IVC is congested, your hepatic vein will be congested, you will develop porous hypertension from that.

Just want to keep that in mind. So I'm going to put up some D here, right? This person probably has a PE, bone-arvest culture is compromised, this person has Corpominali, right? So, I'm going to put things together. He's long as just the center of action in this question. All right. So I'm going to go with option D for question number six. All right. Let's go to question number seven. So question seven says, 67-year-old male US military veteran is admitted to the rehab facility three days after undergoing uncomplicated revision of his left trans-tabial amputation to a trans-femoral amputation, which was required because of the he-sense of the previous incision. Today, the patient reports been at the side of incision that he reads as a three on a 10 point scale. He reports phantom sensation, but no phantom pain. He also has a type 2 diabetes, maldi-divetic rethnopathy, hypertension, and severe peripheral vascular disease that required aortic to bilateral aliac, atrial bypass three years ago. Medications that have a gastron like xenoprilomethormin and metoprolol. His 5-foot-eage is tall, weighs 86 kilograms, BMI is 29, temperature is fine, spores is fine, respiration is fine, blood pressure is not too bad. It does not appear to be in distress, exemptions of well-healing incision. Fingers stick blood glucose is 120, which of the fluine findings on the further physical examination is most likely to inhibit the patient's long-term ability to amputate with a prosthesis.

All right, I love this question. Why do I love this question? Because it's something you can never prepare for. This is purely a test-taking strategy question. Again, I'm telling you this, test-taking, acumen, matters on the exam. This is an excellent example of a prognosis question, right? So this is a good example of a novel question never seen before. How are you going to prepare for stuff like this? Well, you need to deploy test-taking skills on common sense. Let's look at the answers here. Option E says a three-centimeter diameter blackened S-scar on the right heel. Option P says a five-degree left-hip flexion contracture. Option C says an irregular pulse. Option D says loss of perception in the right great toe. Just apply some common sense here. We're being asked which of the following findings on further physical exam is most likely to inhibit the spatial and long-term ability to ambolite with a prosthesis. Right? Abolite is to ambolite with a prosthesis. Ambolite with a prosthesis. So it's like, what is the thing here that may make us like, this guy may not be able to walk again. Just use common sense. You know, losing perception in a toe. That doesn't make any sense as why you may not be able to use a prosthesis. An irregular pulse. There are many people that are walking around with irregular pulses. Literally. There are many people that are walking around with irregular pulses. Does that prevent them from ambulating? No. A flexion contracture.

A flexion contracture is bad, but it's a hip problem. It's not going to, even if you may be limping along, cobbling along, it's not going to make you not be able to ambulate. No. Option E says three-centimeter diameter blackened S-scar. Man, where have I had a blackened S-scar before? Have we heard it in a bad light? It usually means you have some kind of ischemia that is going, or anthrax, or ectema gangrenosum with pseudomonas. Just look at this. Option A just looks bad. So maybe we should go with option A. And I like option A for this. Again, these are things you can prep for. But again, just common sense to get what the question is asking you about. Should be more than sufficient for questions like these. So I'm going to go with option A here. Right, again, I don't have any great theoretical basis. Although, you know, there's research that shows, basically here's the thing. There's research on this, but here's the thing. Essentially, if you have a black S-scar, provision is not good. If provision is not good, that limb may need to be res, this person has had a left limb gone. This person's right limb may have to go to, unfortunately. All right, so let's stop the link to all of that. I think I've discussed this, with a list of questions. Eight. Question eight says, researchers at a large health sciences center would like to evaluate the relationship between dental x-rays and risk for thyroid cancer.

They plan to enroll 300 participants with thyroid cancer and 400 participants without thyroid cancer. All participants will be asked to report past exposure to dental x-rays. The study will be federally funded. Since many of the participants may have received a dental x-rays at the institution, a member of the IRB is concerned about increased liability arising from the results of the study, especially if a positive association between dental x-rays and thyroid cancer is found. Which of the following is the most appropriate response by the IRB regarding this member's concern? Again, frame. Sounds like they're doing a case-control study. Oh, if we find something from this study, we don't want the people that participated in this study to come and start following us. That's the crux of the question. So, again, these are another example of... Tell me how much bio stats you're going to study to prepare for stuff like this. No. Or how much social science you're going to study. Again, these are questions that the MBA muses don't expect you to have prepared for. But they expect you to, again, use common sense, use critical thinking. There is an increasing number of these kinds of questions on the exam where you'll like, I've never seen this kind of thing before. Again, testing in scale comes in here. One thing I'm going to encourage you to do is, again, think of other similar scenarios, right? Literally build a model in your mind. Literally build a model in your mind.

Build a model in your mind, right? Let me think of other research studies I've done that have showed harmful things like, hey, I smoking causes lung cancer. Did those lung cancer patients go back and sue the people that did the study? No, they did not. Right? There are many studies that have shown very harmful outcomes with things. And, yeah, good people get sued or whatever. But are we going to say because we're afraid of what we see? Because we're literally afraid of the results we'll get from a study. Because it's like, oh, they may be really legal ramifications to this. We should not advance science. No, just use common sense. Right? So let's basically look for the answer that does not stop the study. This study should proceed, right? Like these people's concerns are really unfounded. Even if they get sued, that doesn't mean, like, why? Think about it. Should we because of fear of getting sued, not study things that may help us, save many more patients in the future? Common sense, right? So option A says approve the study. Probably option E that's the right answer. And B says don't approve the study. Definitely don't do that. option C says require language in the informed consent document advising participants of the right to sue. Should a positive association between dental x-rays and third cancer reform? Nah, don't do that. Option D says require language in the informed consent document releasing the decision from liability. No, no, right?

Just do the study and leave it at that. Do the study and leave it at that. All right. Good question number nine. 39 year old man, we're going to be wrapping up here soon. Come to the ED because of a 1 D history of progressively worsening generalize each and so of his skin. He also has had pain with your ination and blood in his urine during the past five days. He has not had fever, chills, nausea, vomiting, flunk, beenodaria. Two days ago, he was in the ED and diagnosed with renal calculi. Medical history of the wise is remarkable for psoriasis. His cream medications are oxycodone, ibuprofen, tamsolocin and topical clobetasol. Vital signs are temperature 36.7. So, temperature 36.7, so it has 90 degrees Fahrenheit. Pause is 76 per minute. Respirations of 12 per minute and blood pressure is 18 over 74. Examination of the skin shows multiple excoriations with a back and abdomen. No lesions are noted. The physical exam discloses no abnormalities. Results over your analysis are shown. Okay. What sticks out? Well, the billier means trace positive. Trace. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out. I'm not going to sweat out.

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You know, people think that basic science is just step one. No, step two and step three. From ecologies becoming extremely important. It's becoming extremely important. That's actually even with my review courses. It's becoming an increased point of emphasis from ecology. And as you'll see pathology, those two areas are becoming the increase areas of emphasis. Where if you don't have that knowledge, you're not going to do it on these, on these exams. Just just FYI. Just FYI. So, okay, going to go to option 10. Last question I've already done. So 72 year old man is admitted to the hospital. Through the ED, because of a 12-hour history of fever, chills, and increasingly severe abdominal pain, nausea, and vomiting. Medical history includes hypertension, hypercholesterol, lemia, and a thoracal erotic heart disease with a policeman of a coronary at least 10-3 years ago. Crane meds are at a total statin like synovial, he appears anxious and pale, so be my 30. He has a fever, temperature 104 is stagic, he's stachycardic, he's stachypnic, blood pressure is pretty low. 165, so two sets are kind of low. He's heard of the right coronary artery. Cardiac exam discloses no murmurs, S4 is present. It tells you that it's heart, he has like hypertrophic, he has like gastolic heart failure. Longs are cleared of scotation of abdominal exam shows decreased bowel sounds, diffuse tenderness with guarding that is most severe in the left upper quadrant.

Both lower, you'll see what I said, oh, in a bit. So, both lower extremities are called to touch with weak pito pulses. The mulexri shows dilation of the proximal colon. Results of serum lab studies are shown. Amalase, I don't know what normal amalase is, but 230 looks like a big number to me. Many times eyeballing is fine on the exams. What other lab looks bad here? Yeah, that bicarb is bad, 12. Glucos 180 is bad, but I think the glucose is the list of these guys' problems. So, search for a section of the colon is done. Which of the fluen histopathologic see this again? I said, what are we two subjects? I said to try to make sure you know for your exams, farm and pathology. Okay, search for fluen histopathologic changes. I'm not saying go deep for step two, step three, go deep, deep, deep, but you need to know the basics. Which of fluen histopathologic changes will most likely be identified on the resectal colon? So, what do you think is going on here? This is a very clear cut case of acute mesenteritis schemia. This person has a bad cardiac case tray, right? This person has had a coronary artery stand placed, you know, has high blood pressure, which makes sense. That's why he has the S-force systolic heart failure, right? Chronic pressure overload from the hypertension, hyperclosterolemia. And we'll see this sodium onset really bad abdominal pain. Why would you resect your colon if he did not die? We see this bad acidosis, probably a lactic acidosis.

See this diffuse abdominal pain with a rebound. Good thing they took him through X-lap, makes sense. Frame this question, right? Bad cardiac history, sodium onset, see if you have abdominal pain fever, dead bowel. That's a good mesenteritis schemia. We also see the location of the pain, the splinic fracture, the left collic fracture. That is the origin of the colon that's pretty susceptible to ischemia because it's at the tail end of blood flow from the superior and inferior mesenteric arteries, right? So, it's like the last one to the total bone. So, if I had to pick an answer, this person has acute mesenteritis schemia. So, we just need to find an answer choice that deals with the schemia of the mesenteri. All right, so let's go one by one. So, option A says, case hidden granulometeous inflammation is serous fiber satisfactions? No. Case hidden granulometeous equals infection, TB, fungi, stuff like that. This is not an infection. Scratch that. Option B says, quagulative necrosis. All right, quagulative necrosis is a kind of necrosis you see with the schemia. So, involving mucosa and sub-mucosa, let's keep that answer. Maybe right, actually. Option C says, neutrophilic infiltrating the mucosa with venous congestion and edema. Again, neutrophils tend to arise about 24 hours after an inflammatory process. Let's keep that. But I don't like C as much. Option D says, patchy mucoperilin to extrude it with exploding glandular crypts. Exploding crypts.

So, you see, exploding crypts, what are you thinking about? I hope you're seeing divine graversous host disease. Remember, graversous host disease, you're going to see a person with a rash, diarrhea, fever. After they've gotten like some kind of transplant, right? Sometimes the donor T cells can really start attacking the host organs. It can attack the GI tract and cause those kinds of things. So, you see, exploding crypts, that's graversous host disease. Then, option E says, transmural chronic inflammation with ulcerations extending to the sub-mucosa. Where have you heard the word transmural? That's Crohn's disease. This guy does not have Crohn's disease. It can get Crohn's in 12 hours. That doesn't make any sense, right? So, I'm going to go to option B, right? What kind of necrosis? Necrosis is something that happens when some like death has happened. So, I'm going to go to option B here, right? So, I'm going to go to option B. Again, I'm telling you this. Do not ignore B-sync sciences in preparing for your exams. I'm going to say that again. Do not ignore B-sync sciences in preparation for step two and step three and level two and level three. All right. So, I think I'm going to go ahead and stop here again. If you're interested in any of my classes, shoot me an email. It can give you some more information. Really, many of my classes address many of these topics very well. Testicking class is tomorrow. It's going to really help you in preparing for your exams.

Again, if you want to know what my classes until listen to the broadcast I made on my classes, you'll show you how my classes differ from my podcasts. And again, these classes are updated all the time. Because again, the USML Es don't stay as a static exam. They change so frequently. So, update these classes just to keep up with the changes on the USML Es and these complex exams. So, if you're interested, I have my podcast on Apple, Google on Spotify, have a You Tube channel you can check out. And again, if you're interested in one of my tutoring for all the USML Es and complex exams or help with your ERAS application, like just really every part of it, I can certainly help you with those. Just shoot me an email through the website or send me an email. Divine intervention podcasts. Podcasts with an SIVN, right? So, Divine, DIVIN, intervention, INTR, VEN, TIO, and intervention podcasts. P-O-D-C-A-S-T-S, at gmail.com. So, shoot me an email, give us more information and we can take things from there. So, thank you for listening to me today. I know this podcast is long, but I really made it a point to discuss a lot of testing principles. And there's just a lot of complex concepts here that I wanted to make sure I discuss. So, thank you for joining me today. I will see you in the next podcast. I will see you in episode 549. God bless you. Bye for now. Thank you.

Vaginal atrophy (though endometrial cancer must be ruled out).

Coagulative necrosis.

Adjustment disorder requires an identifiable stressor; GAD symptoms must persist for at least six months.

Suppressed HPA axis function (low cortisol) despite extremely high circulating adrenaline/noradrenaline levels.

Right heart failure (Cor Pulmonale), which causes increased pressure in the IVC, leading to hepatic vein congestion.

A blackened scar (suggesting severe ischemia/poor tissue viability).

Endometrial biopsy.

Portal hypertension (and potentially ascites/fluid wave).

Adjustment disorder requires a clear stressor; PTSD requires exposure to a traumatic event.

Coagulative necrosis.

A high P(A-a) gradient indicates impaired gas exchange (V/Q mismatch), which can be improved by repositioning or treating underlying causes.

Severe ischemia and poor tissue viability, potentially requiring further amputation.

Endometrial biopsy.

Portal hypertension (and potentially ascites/fluid wave).

Adjustment disorder requires a clear stressor; PTSD requires exposure to a traumatic event.

Coagulative necrosis.

A high P(A-a) gradient indicates impaired gas exchange (V/Q mismatch), which can be improved by repositioning or treating underlying causes.

Severe ischemia and poor tissue viability, potentially requiring further amputation.