DIP Episode 647 - USMLE Free 86 Series 9 (Q77-86, for Step 2/3)

Alright, welcome. This is episode 647 of the Divine Intervention Podcasts. And into this podcast we're going to be finishing the series on the 386th, this is going to be series 9. Alright, so we're going to pick up from question 77. A 50 year old man comes to the office because of a lesion on his lower lip. That developed nine months ago. He has not seen a physician during the past five years and says, my wife made me come to see you today. Physical examination of the lips discloses the findings shown in the photograph. The lower lip is fixed to the entire aspect of the mandible, which of the following is the most likely diagnosis. Right? So we see this lesion, right? Looks like an ulcer. Looks like an ulcer, it's kind of around the lower lip, right? This looks like cancer, right? This looks like cancer. This is probably going to be a scrimal cell skin cancer. Right? So we're going to go with option E. It can be option A, B, cell cancer because we're not seeing like those telanget seizures and things like that that we see with B, cell cancer. And then this is not a carado, a canthoma. A carado, a canthoma typically is going to be a raised lesion with a central critter. Right? So it's like a raised lesion with a central critter. In fact, many times it's regarded as a kind of scrimal cell cancer. So that's wrong. Look up, Blakey. I remember we tend to find that in the middle compromised patients HIV patients.

It will be a lesion that is on the lateral tongue or on the tongue and it doesn't scrape off with a tongue depressor on like, on like a candidate. Right? And they may not know my tends to be a flat lesion. Right? So the right answer is going to be option E. Now a 10 year old boy, so 78, a 10 year old boy is brought to the ED by his father because of left flank pain and tenderness. About four hours ago, the boy was hit hard on the abdomen during a carate carate match abdominal CT scan shows a large splinic tear in the pediatric intensive care unit is blood pressure stabilized and is hematocritis 45%. Which of the following is the most appropriate immediate step? So option E says, so let's look at this. So this guy, this, this child has a splinic tear, right? A splinic laceration. But now he's blood pressure stabilized. His hematocritis fine. So what should you do? What should you do? Option E says continue, Paul some blood pressure monitoring. So this child is pretty stable. So I'm going to go with that option because the thing is, see, if you can avoid removing somebody's splin, try everything you can to not remove it. Because the splin has a very robust immune function, right? So if you can avoid removing a person's splin, especially if the person is stable, if a person is suffered spleen, can you drain their stable? Try not to remove their splin. So I'm going to go with option A. Option B says do silly, order me and splinectomy.

No, no, no, no, no, no, no, no, no, this child is stable. The hematocritis fine. Just watch him. So that's wrong. Option C says order diagnostic abdominal parasyntesis. Again, we do parasyntesis when we're worried about a person having like spontaneous bacterial parotonitis. So say for example, they have like, a sideys, right? But this child does not have a sideys. And then option D says order intravenous urography. Well, intravenous urography is something you use to analyze the kidneys, the urethers, the bladder, the urinary system. It's like a CT scan, right? Or an X-ray. It's basically a radiograph with contrast of the urinary system. This person doesn't seem to have any urinary system troubles. And then order radionuclides scan of the spleen. You don't really need to do that, right? radionuclides scans on the USME Lies tend to be like Raius scans for the thyroid. Or you can do a radionuclides scan for mechols diverticulum. Or you can do a radionuclides scan for, um, come on, divine. So I've talked about thyroid disease mechols diverticulum. Also for some cardiac stress tests, right? Like the, um, technician tests. Yes, those are those are radionuclides scans. All right. So we're going to go to question 79, uh, for the two-year-old woman with a history of MS comes to the office because she had a sudden loss of vision in one eye in the right eye, right? She has no history of diplopia.

External ocular movements are normal, but fondoscopic examination shows power of the optic disk. This patient's condition is most likely a result of demilination of which of the following, right? So we see painless sodium-on-cell vision loss in a person that has multiple sclerosis, right? This is going to be optic neuritis. It's a cranial two problem. It's a cranial two problem, right? So, uh, the problem is an optic nerve problem. The optic nerve is cranial two. So the right eye is just going to be C. Um, option A, the MLF, the medial longitudinal faciaculars, right? That's what causes interneucleophthalmoplesia. When you have it up, interneucleophthalmoplesia, you're going to have an adduction, ADD-Oction, ADD-Oction, nice stateness on horizontal conjugate gaze, right? You're not going to have vision loss, right? So this is not an MLF problem, right? The oculumodon nerve, that's wrong, right? That's cranial nerve three. Remember, uh, your oculumodon nerve is derived from the peripheral nervous system. It's not derived from the CNS. The only cranial nerve that's derived from the central nervous system is cranial two. It's the optic nerve. So it's the only cranial nerve that is generally affected in multiple sclerosis, right? So, um, so it's not the oculumodon nerve.

Remember, the optic nerve is an outgrowth of the diencephalon, but every other cranial nerve is derived from the, uh, from the neuro crest, but cranial two is derived from the diencephalon is derived from neuro tube. It's not a factoid many resources talk about was actually pretty high yield to know for you examples. And then the trigeminal nerve, that's wrong, right? It's not going to cause vision problems, option A visual cortex. That's going to be like cortical blindness. That's not what's going on here, right? So we're going to go to question number 80. We're going to go to question 80, right? So a 28 year old woman who is known to be HIV positive comes to the ED because of a one week history of increasing headaches, right side of weakness and this orientation. A generalized tonic clonic seizure occurs shortly after admission following the seizure vital signs are normal. There's no no core rigidity fundoscopic examination shows papilladema. There's also right hemiparosis and ephagia, which of the following is the most likely diagnosis, right? So we see a person that has HIV and this person seems to have a increased intracranial pressures, right? Increase intracranial pressures. This doesn't look like meningitis, right? This person doesn't have no core rigidity. This person seems to have increased ICP, right? So the person probably has some kind of space occupying lesion in the brain, some kind of space occupying lesion in the brain, right?

Space occupying lesions in the brain should make you think of a few things, right? Like what? Toxoplasmosis or what? A primary CNS lymphoma, right? So the thing is this space occupying lesion is kind of concerning, right? It's probably something that is like a mass or ring and hand solution or whatever. So I'm going to go for toxoplasmosis here. I'm going to go with option D, right? meningioma, right, is not, it's going to be more of a chronic mass, right? And it doesn't usually present with signs of increased ICP. I mean, go, go, meningitis. Again, the person is going to have fever. The person is going to have, you know, very high fevers. They're going to have no core rigidity. We don't see that here. On neurosophilus, right? We're going to see things like TB's dorsalis, right? We don't see that here. We don't see TB's dorsalis. We don't see many of those signs on neurosophilus. So that's wrong, right? Tobacco loss meningitis. Again, if you have meningitis, you have no core rigidity. You have high fevers. You have, you have abnormal vital signs meningitis is pretty deadly. So you're going to have abnormal vital signs. All right. So, so the answer is going to be option, option D, right? I remember we're going to treat that with Pyrametamine and the sulfa diasing, right? And we're going to give the person a local worry as well. So they don't develop a bone marrow suppression. All right. So question 81 says five year old girl with a lumber.

My lomeningosil is brought to the end. And remember, Pyrametamine sulfa diasing. Those are fully synthesis inhibitors, right? Again, please don't mess this up. The way we treat toxoplasmosis is with Pyrametamine and sulfa diasing. Okay. The way we treat it. But the way we prophylaxe against it, right? If your CD4 count is under 100 is with trimethyperum sulfur, ethoxazone. All right. So question 81. Five year old girl is with a lumber my lomeningosil is brought to the office by her mother for a priority health evaluation. The girl has little motor function and no sensation below the waist. She has a neurogenic bladder requiring intermittent catheterization. And she also requires daily suppositories to eating bowel movements. She does not have hydrocephalus but can walk only with the eat of braces and crutches. I am pleased with how well she is doing says the mother, but I'm so worried about what might happen to her later on. Which of the following is the most likely late complication in this patient? Right. So think about this. This person has a my lomeningosil. Right. So this person has bladder dysfunction. Right. When you have bladder dysfunction, think about it. You pretty much have like a functional obstruction, a functional obstructive neuropathy. Right. That's that obstructive neuropathy over time is going to cause problems with renal failure. Right. It's going to cause problems with renal failure. Right. Because you have obstruction. Right.

So you have like these increased pressures within your collecting system and whatnot that can ultimately lead to renal failure. Again, I know you may have never heard of this before, but it doesn't mean you cannot get this right. Right. All you literally need to do is ask yourself what's the answer that relates to what the question is talking about. The question clearly tells you that wait. This person requires daily suppositories. The question tells you that the person has a neurogenic bladder. Right. So it has to be linked to one of those things. Right. So, question. One of the bladder is wrong. Right. Remember the biggest risk factor for bladder cancer is smoking. COPD is wrong. She's not a smoker. Corpo monali is wrong. Right. Remember, corpo monali. Corpo monali typically happens when people have is basically like right heart failure because of a pulmonary cause. Right. It's typically a right heart failure because of a pulmonary cause, right heart failure because of pulmonary cause. Right. This person doesn't have like 65% so anything like that. Right. So that's that's not what's going on going on here. All right. And then endstatial disease is the correct answer option. He says, osteomyelitis of the femoral head. No. Right. We tend to find that in people that have like pushing syndrome, for example, right. Or people that are taking steroids. Sorry. Whoops. That's osteonecrosses of the femoral head. So osteomyelitis of the femoral head.

So the femoral head also my life is an actual infection. No, that's not what's going to this presence. There's no reason to develop that. So please whenever people have steroids access, they develop osteonecrosses of the femoral head. osteonecrosses of the femoral head. Please keep that in mind. All right. So 26 year old man is brought to the ED by his family because he has been telling them that he's been followed by gangsters and that they are going to kill him. He says that he has a history of drug abuse. His temperature is 100. Pulse is 110. Right. So he's tacky. Cardiac. Right. He's very hypertensive. His blood pressure is 160 over 95. His pupils are dilated. So the physical exam discloses no abnormalities, which of the following drugs most likely caused this reaction. So we see this person has public eye access. Right. So it's probably in a sympathetic state. We see the blood pressure is really, really high. Right. This is probably going to be cooking. Right. Remember, cooking increases the amount of kind of cool. It means you have adrenergic synapses. Right. So the answer has to be B. Right. This cannot be alcohol. Right. Alcohol. You know, you have like disinhibited behavior and things like that. It's not going to cause your blood pressure to rise. It's not going to cause public eye access. So that's wrong. The diazopamera is a benzoy, it's going to cause respiratory depression. It's going to cause respiratory depression. Right. Heroine, right, is an opioid. Right.

So it's going to cause respiratory depression and popularly meiosis and popularly meiosis. We don't see that here. Right. Right. And metacolone is actually kind of a is not about victory, but it works just like a barbiturate in modulids, gubbar receptors. You know, back in the day, believe it or not, this stuff was actually a prescription. I was called a quill, but the bandit because it has a pretty high abuse potential. Kind of works like a barbiturate in modulids, the gubbar ear receptors. So that's wrong. Right. So again, cocaine increases the amount of kind of cool. It means that the adrenergic synapse. So that can cause you to have things like. You know, very crazy high blood pressure because of alpha and mediative is a construction. It can raise your heart, so you can become tacky, because of middle one stimulation. Right. It can cause you to have my dryness is because there's alpha and receptors in the eyes. Well, right. Another thing that can cause a similar presentation is methamphetamine, but there is a reason why you didn't pull that as an answer as well. Right. So now question 83 says several patients with hypertension whom you have treated for many years have recently had strokes. You are frustrated by this outcome and review the literature on the efficacy of anti hypertensive treatments in preventing stroke. A large multi center randomized trial shows that a particular anti hypertensive medication lowers the five year risk for stroke. Right.

Lures the five year risk for stroke. From eight per thousand patients to six per thousand patients, right. Providing a relative risk reduction of 25% based on this study, the number of patients with hypertension, who must be treated to prevent one stroke is which of the following. Right. So this question is asking about the number needed to treat many people do you need to get give this anti hypertensive to prevent one stroke. Well, remember for you to calculate absolute risk, I mean to calculate number needed to treat first, you need to find the absolute risk reduction and then take the inverse of it. Find the absolute risk reduction and then take the inverse right and the absolute risk reduction is a difference in risk. Right. So it's like eight per thousand minus six per thousand. That's two per thousand. Right. That's the absolute risk reduction. And then just flip it stick the inverse 1000. The inverse 1000 divided by two is 500 right. So the NNT is 500. This drug has basically no clinical significance right. No clinical significance. The NNT is 500 right. Like literally to prevent one stroke 500 people have to get this drug. This drug has no clinical significance. Right. So remember, NNT is a very good way to gauge clinical significance on the USMLA exams. Right. Right. And also in the real world right now question 84 and 85 40 year old Native American construction worker who sustained a community fracture of his left TB and fibula four months ago.

He's transferred from the rehabilitation facility to the ED because of a three hour history of Disney and chess pain. Oh, during the past three months, he has recited in the rehabilitation facility with his left lower extremity fully mobilized. That's not good. He now describes and aching discomfort over the right superior and tier chest and the rights couple of posterior. That's not good. Family history is strongly positive for heart disease. All right. So we see a person that is like fully mobilized right for weeks. Come on. Right. This sounds an awful lot like a PE. All right. So let's look at 84. He says in questioning the patient father and important point in the history would be the relationship of the pain to which of the following. A says change of position. B says deep breathing. C says eating. D says swallowing. He says walking. Right. Remember, one common presentation. We find people that have to ease pulmonary embolus is a pleuritic chest pain. It's pleuritic chest pain. Right. So I'm going to go to option B for this. Right. Change of position. That's probably going to be more paradise. Right. Get worse when you lay back when you're supine gets better when you lean forward. Right. Eating that's probably going to be some kind of a so for Joe problem. Swallowing probably some kind of a so for Joe problem. Walking, maybe like, engine or something like that. Right.

So now the presence question 85 says the presence of a right plural of fusion right plural friction or op in this patient. We'll suggest which of the following right. So plural friction or op. Right. Again, this is probably a probably a PE right probably a PE. Right. So again, I'm not going to pick paradise. Right. Perkoditis is again gets worse when you lay back better when you lean forward. Not going to be pneumonia. Right. Numonia is cause it's going to cause chest pain, but you're going to have fever on all these things, right. Neumothorax. You're going to have decreased breath sounds. You're going to have decreased breath sounds and things like that. And the new motor axis pretty sodded pretty sodded. Right. PE with infarction. Yeah, I'm going to pick up some D right because remember when you have infarction infarction hurts. Infarction hurts in function hurts right. It's just kind of like when a person has an M.I. Their chest hurts. Right. So when there's an infarction. It is going to hurt in your plurip. Right. So option. ESP without infarction. That's that's probably not not as accurate. So I'm going to go to option D for this one. All right. So last question of the free 86. Woohoo. A 68 year old woman who underwent flexible sigmoidoscopy six hours ago in the office as part of routine screening returns to the office because of left lower quadrant abdominal pain. Fever nausea vomiting. Uh oh, that's not good.

Now during the procedure three centimeter polyp was found in the sigmoid colon and was removed vital signs or temperature of 100.6. So that's a fever. So 30.1 degrees Celsius. She's tacky cardiac. She's the Kipnic. A blood pressure is 120 over 60. Abdominal examination discloses bowel sounds and tenderness and guarding well in the left lower quadrant. So that those are signs of a periodionitis. Rectal examination shows no stool and tenderness only superior. Which of the following is the most appropriate next step. Right. This person has signs of periodionitis. That's an indication for exploratory laboratory. Right. So let's look for the X lap answer. Option A says obtain angiography to roll out in test. No, it's not X lap. That's wrong. Option B says obtain immediate consultation with the surgeon. Yeah, that's the person that can do X lap for you. I'm going to go to option B. Option C says pass a soft rubber rectal tube under fluoroscopy. When you have periodionitis, you've probably ruptured something. Do you think it's a good idea to pass a tube into a person where something has ruptured? That's not a smart idea. I'm not going to do that. Option D says repeat the flexible sigmoidoscopy to evaluate the operative site. No, again, when a person has potentially ruptured their bowel, you don't introduce tubes into the bowel because that can cause like very significant infection and death. Option E says start hydrochlorizone intravenously to decrease any inflammatory response.

No, don't do that. Right. Go and do exploratory laparotomy. All right. So that's it. Again, if you love the way I teach again, if you notice, I explain pathophysiology. I show you how things present on the exams. I make integrations. Right. Many people have taken my classes and don't extremely well on their exams. I really put everything I can into truly helping you understand the content into truly helping you understand the material. Right. And many people have run through my courses and don't extremely well on their test. So if you're interested, I have a last minute review for step two, step three taking place today and starting tomorrow, I have a 20 hour comprehensive step two, step three review. And then in the month of June, first two weeks, I have a 50 hours step two, step three class. And I also have a series of other classes I'm going to be teaching in the month of May. So if you're interested, shoot me an email. I can give you some more information. I also offer one on one to learn for all the USML and complex exams and medical exams. And I help with errors, applications, personal statements, more interviews and rec letters. And then this podcast on Apple Google on Spotify. So check those out. I also have a You Tube channel, divine intervention, USML podcast and videos where I post the videos that I make. And then I have another website called divine intervention life lessons.com divine intervention, life lessons.com.

Many of you that listen to this podcast, normal Christ follower. Right. So every week, I post one or two podcasts were from a biblical perspective, address a 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. Again, I think you listen to this podcast. You find them to be helpful. Share with your friends and your colleagues. And I will show the best on your exams. Have a wonderful day. Have a wonderful week. God bless you and bye for now. Thank you.

Fixed, ulcerative lesion that does not scrape off with a tongue depressor.

Non-operative management (observation/monitoring), as splenectomy should be avoided if possible.

Cranial Nerve II (Optic Nerve).

Pleuritic chest pain, which worsens with deep breathing.

Cocaine (or other sympathomimetics like methamphetamines).

Renal failure.

Tachycardia, hypertension (due to alpha/beta adrenergic stimulation), and mydriasis (pupil dilation).

NNT = 1 / Absolute Risk Reduction (ARR). It measures the number of people who must receive a treatment to prevent one adverse event.

Pulmonary Embolism (PE), as this type of pain worsens with deep inspiration.

Toxoplasmosis. Treatment involves Pyrimethamine and Sulfadiazine.

Functional obstruction leading to renal failure.

Tachycardia, hypertension (due to alpha/beta adrenergic stimulation), and mydriasis (pupil dilation).

NNT = 1 / Absolute Risk Reduction (ARR). It measures the number of people who must receive a treatment to prevent one adverse event.

Pulmonary Embolism (PE), as this type of pain worsens with deep inspiration.

Toxoplasmosis. Treatment involves Pyrimethamine and Sulfadiazine.

Functional obstruction leading to renal failure.