DIP Episode 520 - 2024 USMLE Step 2CK Free 120 Discussion Part 3

Welcome to episode 520 of the Divine Intervention Podcasts. In today's podcast, we're going to be continuing the series on discussion of the free 120, the step to CK free 120. This is the most recent one. It's basically the one that you can see on the website now. Just check this date, you know, March 17, 2024. The one on the US Family website is the one I'm discussing. We've discussed the first 12 questions, so we're going to jump right to question 13. Okay. So, a 68-year-old man comes to the clinic because of a six-month history of frequent falls. He sustained the fracture of the left-right four weeks ago during a fall. He has not had lots of consciousness before or during the fall. He says that turning and pivoting often cause him to fall and he has a tendency to fall backward when walking. He has Parkinson's disease treated with carbidopa, levodopa and entakapun. Vital signs are within normal limits. Examination shows masked faces and a resting tremor of the right-up or extradite. Romburg sign is absent. When the patient stands still and is pulled backward, he is unable to maintain his posture. Which of the following is the most appropriate intervention to decrease this patient's risk for future falls? When A says biofeedback, option B says physical therapy, option C says primatexol therapy, option D says rupeinerole therapy, and option A says rotigotin therapy. So this is a very clear question about a person that has Parkinson's disease.

And the person seems to have this tendency to fall. And then he asks him, what can we do to decrease this person's risk for falling? To increase this person's risk of falling. And I know the first thought that may come to people's minds is, why don't we just give them maybe a different kind of Parkinson's disease therapy or change something on their therapy. But the thing is, that's a good thought. But the only problem here is, there are three treatments for Parkinson's disease that are answered choices here. So just none of them can be right. Primatexol believe it or not can be used for Parkinson's disease. Primatexol believe it or not can be used for Parkinson's disease. They are all dopamine receptor agonists. So because they all dopamine receptor agonists, they can't all be correct. So we can pre-more cross all of those off. And then option A, biofeedback. Biofeedback is like consulting the ethics committee on the USMM Es. You're not going to be right doing that. So the answer option B is going to be option B is going to be physical therapy. Actually, there are many people without Parkinson's disease. Actually, stories that have shown that physical therapy, regular exercise, has been shown to actually help these people. Reduce their risk for falls and help them with many different things. Okay, this one is a very simple testing principle. So question. Okay, so remember Parkinson's disease, you can treat it with a bunch of different drugs.

So you can use monamine oxidase B inhibitor like cellulogen or acetylene. You can use a Comtein inhibitor because MEOB, if you inhibit MEOB, you decrease dopamine breakdown, right? If you give a Comtein inhibitor, you'll also decrease dopamine breakdown. These are drugs like intacapone or tocaapone. I think another one is opicaapone. You can also use a mantidine, although to be honest with you, a mantidine has been pretty questionable benefits, so I don't hang my hat too much on that. And then also don't forget that Parkinson's can also be treated with dopamine agonist, right? I just give some examples. Primepexol, rupeinarol, rotigotine, cabregoline, bromo cryptine. Although remember, dopamine agonist will also use them a lot to treat prolactinomides. That's just a side point. And then the final thing I'll say is the mainstay of treatment of Parkinson's disease is carbidopa-livodopa. Carbidopa-livodopa. Carbidopa-livodopa, right? The levodopa is converted to dopamine, but if you want to increase its availability in the brain, you want to inhibit dopamine decarboxylase in the circulation because if you give a person carbidopa-livodopa, that levodopa can be broken down to dopamine in the circulation. That's not what you want. You want that levodopa to go to the brain and do its work in the brain because that's where you have the dopamine deficiency in Parkinson's. So you give carbidopa, you'll inhibit the peripheral dopadocryboxylic.

So you can have more dopamine to go to the brain to help. Just something you want to keep at the back of your mind for, for example. All right. So let's go to question 14. A six-year-old boy is brought to the office by his parents as a new patient. Three months ago, he and his three-year-old sister and four-year-old brother were adopted from a Russian orphanage where they had lived for two years. Their biological parents died in a motor vehicle collision. They have no other relatives. The adoptive parents say they were told that the children had stable caregivers, age appropriate stimulation and schooling at the orphanage. The children were shy initially on meeting them, but now same comfortable. They play well with each other. The patient is protective of his siblings. His medical and developmental history prior to two years ago is unknown. As being learned in English slowly, his parents hope he will learn enough by the end of the summer to begin kindergarten. A great below that of his peers. His peers. Although he can perform basic mathematics, he is unable to read even in Russian. Results of receptive language testing are consistent with an average IQ. His daily living skills are appropriate for age. He is at the 10th percentile for height and weight. During the examination, the patient's adoptive mother, who is fluent in Russian, translates for him. Physical examination shows no abnormalities.

On mental status examination, he is shy and maintains intermittent eye contact. He slowly answers questions with brief statements. He smiles and says he is excited and pleased about being adopted. Results of laboratory studies are within the reference ranges, which of the following is the most likely diagnosis. Okay. Option A says autism spectrum disorder. Option B says fetal alcohol syndrome. Option C says intellectual developmental disorder. Option D says learning disorder. Option E says post-traumatic stress disorder. Option F says reactive attachment disorder. So what do you think is going on here? I think again for the sake of time, I'm just going to talk through these. So option A, I would not think of option A. Autism spectrum disorder. Many times those people are going to have fixated interests. They're going to be focused on physical objects. And it's going to just be a little fixation on that. We don't see that here. So that's wrong. Option B says fetal alcohol syndrome. There's no evidence printed in the question that this children were exposed to alcohol in the year. So we're going to get rid of that. Option C says intellectual developmental disorder. This is pretty much going to be a person that in many domains of like the struggle with making judgment calls, planning, learning new skills. Many times these kids are going to be crawling or walking later than others.

They're going to have issues with things like bathing, putting on their clothes, interacting with other people. Just it's kind of pervasive in many years of your lives. They don't seem to be able to keep up. And usually the critical thing to know here is that these people are going to have a low IQ. The IQ is going to be less than 70. This child has an average IQ. So that's wrong. Option D says learning disorder. Certainly going to go with learning disorder. Maybe the way learning disorder is tested on the exam says they're going to give you a person that in one specific academic area, they're struggling. In one specific academic area, they're struggling. This person just cannot read. But pretty much every other thing he's okay for the most part. So I'm going to go with option D here. Option E says PTSD. This child did not have a tree. Yes, they lost their parents, right? But this is just not a classic PTSD question. PTSD questions are going to be first responders with an earthquake, military question kind of deal. We don't see that here. I'm going to get rid of that. And these children are not having intensified experiences. They're not having nightmares when they feel like that. This is not PTSD. Remember PTSD before you say a person has PTSD, they have 12 had symptoms for more than a month. And then option F says reactive attachment disorder. This is not reactive attachment disorder. Reactive attachment disorder basically. You see a lot of social interaction problems.

What do I mean by social interaction problems? You're going to notice that these kids, they seem to have either they have like unusual attachments to somebody. And they are, they may you may you may notice that man like to interact with other people. They're like so they just don't want to hang with other people. They cry. They just really go off the railings when stuff like that happens. And many times this is something that persists for a long period of time. When you see something like that, I want you to think of reactive attachment disorder. Many times in those questions, they will give you a person that has had like a lot of changes in their caregivers from when they were growing up or they didn't have consistent care given or they were abused the kids or they were neglected a lot of the kids. You're going to see those people having trouble attaching to others. That's, that's just a logical way of think of reactive attachment disorder. That's not what's going on here. So we're going to go ahead and cross off option F. So the answer is going to be D. Okay. Question 15 says a 17 year old boy is brought to the emergency department because of a one hour history of progressive difficulty breathing and a two hour history of an itchy red rash over his strong arms and legs. He has not used new soaps detergent solutions during the past week. 36 hours ago, he began a one week course of a moxissilin for an ear infection. He has taken four doses since that time.

He has no other history of serious illness and no, no allergies. He takes no other medications. Posts is a hundred per minute, respirations are twenty per minute and blood pressure is ninety over sixty millimeters of mercury. Posts oxymetral room air shows an oxygen saturation of 95%. He appears anxious and immodernies and moderate respiratory distress. Examination shows an aerothermados raised, demarcated rash over the trunk and all extremities, which of the following is the most appropriate next step in management. So option E says administration of our beautiful option B says administration of Diffin hydramine option C says administration of epinephrine option D says completely blocked count. That seems like a bad decision. Option E says observation only that certainly seems like a bad decision as well. So what's your diagnosis here? This person clearly clearly clearly is in an affelaxes. This person has an affelactic shock. This person has an affelactic shock. What is the drug of choice for an affelactic shock is going to be epinephrine? It's going to be epinephrine. So option C is going to be the correct answer. Remember our beautiful role we use that more for exacerbations, right? Like COPD exacerbations, asthma exacerbations and it's also the first one on the ladder of asthma, like long term asthma management is like a rescue inhaler. Option B says Diffin hydramine. Remember Diffin hydramine is an anti-histamine that has very powerful anti-colonurgic properties.

Most times on the USML Es the situation you're going to see Diffin hydramine tested with is either one for the management of acute dystonia. That's one of the problems you see with anticycotics. It's one of the acute symptoms you see when you see a new list of anti-psychotic. But two, you can also see it as a cause of delirium. Remember anti-colonurgic drugs are very, very good at causing delirium. And sometimes they will also just test it from an anti-colonurgic toxic from kind of deal. Alright, and then option D and E, right? That's not very smart. This person is actively dying in front of you. It doesn't seem like a very good idea to be observing them or doing a CBC. You want to do that in a life patient, not a person that's dead and gone. And another thing I think I'm going to emphasize here is that remember an aphylaxis is a kind of type 1 hypersensitivity reaction. And one thing that they love to test it with is with Ig deficiency. Especially when you see people have an aphylactic reaction to blood transfusions. Think of a person that has Ig deficiency. And again remember an aphylaxis is Ig imigrated. Basically you have something that attaches to Ig on the surface of my cells. It's going to cause those muscles to those are Ig's to cross link. It's going to cause muscle degranulation. It's going to cause muscle degranulation. So they're going to release things like histamine, heparin, bradykinein. That's going to cause a lot of those symptoms that they have.

Alright, let's go to question number 16. Two weeks after undergoing open-cholicesectomy for gangrenoscholicesitis. For the seven-year-old woman comes to the clinic for a removal of surgical staples. She was treated with oral vancomycin for close-treatoidies, difficile colitis during hospitalization. She has type 2 diabetes mellitus. Crime medications are met for men and pantopreson. She reports loose stores four times daily during the past two weeks. In addition to wearing a clean isolation gown, which of the following is the most appropriate precaution for the physician to take? Which of the following is the most appropriate precaution for the physician to take? Okay, option E says washing hands thoroughly with alcohol gel. Option B says washing hands thoroughly with soap and water. Option C says wearing a surgical mask. Option D says wearing sterile gloves and preparing the staple skin line with chlorhexidine. Option E says no additional precautions are necessary. This is a classic example of a healthcare systems question. And again, if you want to get good at healthcare systems, I have a review course coming up this coming Saturday. It's a five hour class. Step 1, 2, step 3. And it covers social sciences, quality improvement, healthcare systems, ethics and the works. It's a cover like 200 scenarios they're about in the course. We cover things like this. You're going to be very well prepared for questions like this with a course like that.

So basically, this person has C-Diff. Right? And they're saying, I mean, this person clearly is still having ongoing infection. Well, how do you prevent yourself from getting C-Diff if you're working with patients? I would really hope you're saying, oh, divine. I should be washing my hands with soap and water. You'll try to treat you with alcohol gel. Don't do that. Alcohol gel does not do deadly squat for C-Diff. For person, if you're working with a patient that has C-Diff, you need to wash your hands with soap and water. That's actually pretty high yield to know for the USMLE exams. Okay? That's pretty high yield to know for USMLE exams. All right. And that same rule applies to root of viruses. Well. All right. So we're going to go to, woo. Okay. We have a drug ad, question 17 to 19. I'm obviously not going to read this whole drug ad, but I'm going to try to give you some thoughts on this stuff. So basically, the research question is, in patients with opioid use disorder, what is the relative efficacy of buprenorphine and methodon maintenance therapy? And we see the scope of the study. We pretty much study people taking buprenorphine, maintenance. People taking methadone maintenance, people taking placebo. So basically, they compared buprenorphine and methadone, maintenance therapy, and they compared buprenorphine as well to placebo. Okay. And they also, you know, they did many doses. They did high dose, medium dose, low dose.

And then we see their review methods, looks like they use a bunch of databases to pull their study data from. And they used, this almost seems like it's like almost like a meta analysis and a sense. So they took 31 randomized control trials, N of 5,430. That seems like a lot of people. So it seems like they had a pretty good sample size here, ranging in size from 40 to 736 patients, met the selection criteria. Okay. And then the original study interventions, range from two weeks to 52 weeks. Okay. So they studied people that got interventions two weeks, all the way to 52 weeks. Okay. So they had a lot of trials, complete BMT with MMT, that's buprenorphine and methadone. And 11 complete BMT with placebo. All right. Let's see, do we have any exclusionary criteria? I think that's always a good thing to pay attention to with these questions. Okay. So they excluded pregnant women, okay. And they excluded those that we are assessing buprenorphine or methadone for detoxification. So that's like, you know, let's detox you, you know, let's get out of your system. Stop with no maintenance fees. Okay. And then what were the outcomes they studied? Whenever you're doing drug-at-questions, these are key things you kind of want to look at, right? So treatment retention. Okay. So people that basically continue with the program. And your analysis confirmed use of morphine, cocaine and benzoes. Okay. So now let's look at the results. Let's look at the results. Okay.

So it says, as shown in the table below, low, medium and high dose, buprenorphine, maintenance therapy, increase treatment retention, more than placebo. Okay. But BMT did not differ from equivalent doses of MMT for retention or had lower retention. Okay. And then high dose, but not medium or low dose BMT decrease morphine use more than placebo. Okay. So high dose buprenorphine helped with you not using morphine. Medium and flexible dose BMT and MMT did not differ from morphine use. Okay. So cocaine use BMT versus MMT and high dose BMT versus placebo did not differ from benzoes use. Right. So there are three things, right? They look that cocaine, I mean, they look that morphine, they look that morphine or cocaine and they look that benzoes. Okay. And then we see this table. We're going to talk about it. So let's look at the conclusion. You'll sort of should look at that. Right. So in patients with opioid use disorder, buprenorphine is more efficacious than placebo. Okay. That's a good statement to know. But less efficacious than method on therapy. Okay. So method is just a little better for treatment retention. Okay. For treatment retention. All right. So now let's look at the questions. Right. So 17 through 19. So 17 says 38 year old woman comes to the clinic for full-up examination. She has opioid use disorder and currently takes methadone, 40 milligrams daily as maintenance therapy. She says the method is causing mild sedation that is interfering with her job.

She would like to discontinue methadone maintenance therapy, but is concerned about her own relapse. That she also takes a friend's vellium when she's feeling stressed out. The physician discusses alternative maintenance therapy strategies with a patient. The physician discusses the pros and cons of medium or high dose buprenorphine maintenance therapy compared with medium or high dose methadone therapy with a patient. Based on this abstract, which of the following is the most appropriate information for the physician to convey to the patient? Okay. So whenever you're reading by your staff questions, you've got to be careful. So here, look at what they're trying to focus on. The physician discusses the pros and cons of medium or high dose buprenorphine maintenance therapy compared with medium or high dose methadone therapy with a patient. Okay. So what are they testing? Basically, they are asking you like, okay, if we compare high dose buprenorphine to high dose methadone or medium dose buprenorphine to medium dose methadone, what should we tell the patient based on this abstract? So once you've defined exactly what they're trying to test, literally go back to the drug add and read. Okay. So we see from the table, high dose buprenorphine maintenance therapy versus high dose MMT. We noticed that, huh? Okay. The results were not significant, right? So the number needed to harm was not significant.

And also if you compare medium dose BMT to medium dose MMT, the results were also not significant from a number needed to harm perspective. And then there's this thing that says relative benefit reduction. Oh, the USML Es. These guys are wonderful. So the thing is again, I think I've said this many times. The USML Es these days, they love this concept of derivatives. This is just a very great way to see about people that are memorizers from people that are under standards if those terms exist. But basically, this relative benefit reduction is just a nice way to mess a person up who does not understand what relative risk reduction means. To be honest with you, this RBR relative benefit reduction is literally almost identical to relative risk reduction. And remember, how do you complete relative risk reduction? It's basically one minus relative risk, one minus relative risk, right? One minus relative risk. Okay. All right. So we kind of know. Okay. Okay. And I mean, I can see, you know, high dose versus high dose BMT versus high dose MMT. The relative benefit reduction is 21%. But if you look at the confidence interval is minus 216 to 20. You'll see the medium dose BMT versus medium dose MMT. The confidence interval is minus 10 to 31. Hmm. Okay. Well, remember whenever you're dealing with things that we derive by ratios, whenever the confidence interval includes the number one, those results are not significant. So that's something we know. Okay.

Let's maybe go back to the question and take a look. Okay. So let's look at these answer choices in light of what we've abstracted from the drug. So option A says, buprenorphine is 13% and 21% less effective than methadone at medium and high doses respectively. I mean, the relative benefit reduction, yeah, we see those numbers 21 and 13%. But the results are not significant. So because the results are not significant, we cannot make that option H or main course. So that's going to be your wrong actually. Okay. And then option B says buprenorphine is a better maintenance strategy. And the patient is also regularly using benzodiazepines. That doesn't seem to much of what the question says. It says BMT versus MMT and high dose BMT versus placebo did not differ for benzodiazepine use. So we're going to scratch that off actually. Option C says methadone is statistically more likely to result in treatment retention. Again, remember, let's stick to what the question is asking is just looking at high dose BMT versus high dose MMT, medium dose BMT versus medium dose MMT. These two results we have explained precisely why they're not significant. So I'm not going to make that judgment call for method on that. Oh, statistically more likely. No, the results are not significant. So that's wrong. Option D says neither drug is more effective than placebo. That is absolutely wrong.

We're clearly told in the question that like clearing the conclusion, in patients with opioid use disorder, buprenorphine is more effective than placebo. So that option D is wrong. So option A probably has to be right. There is an unclear difference in efficacy between the two drugs at these doses. Yeah, because the results are not significant. So I'm going to go with option E here. I'm definitely going to go with option E here. All right. Now, let's look at question E. Teen says which of the following aspects of the study is most likely to limit confidence in the author's conclusions, which of the following aspects of the study is most likely to limit confidence in the author's conclusions? Okay. So let's look at these. Honestly, the process of elimination is kind of like a part of the course with bio-stats questions with these drug-ata questions. So option A says exclusion of patients using methadone for acute detoxification. Okay. So they excluded patients using methadone for acute detoxification. I don't think that's unreasonable. Because if you think about it, they just excluded people that were just using methadone for acute detoxification. The thing is the whole purpose of this drug-add is to study people that have opioid use the sorder and study maintenance therapy. So it makes sense if people did not go for any kind of maintenance therapy and all they went through was acute detoxification. Yeah. I think it's probably reasonable to exclude those people.

So we're going to get rid of that. Okay. Option B says exclusion of pregnant patients. So people that are pregnant excluding them. Is that going to, again, the thing is whenever you get questions like this, you always want to ask yourself. So this will this materially impact the results of this study. Excluding pregnant patients, I don't think is that huge of a deal. It's somewhat of a deal, but it's not that huge of a deal because pregnant women, they're just not representative of the entire drug use population. So by excluding them, it's probably not a big deal. But you know what? I don't feel super convenient excluding that. So let me keep option B for now. Option C says inclusion of randomized control trials only. No. RCT is one of the best kinds of evidence. So it's certainly not going to be limiting confidence. It's actually going to make me feel more confident with the results. Option C is definitely wrong. Option D says inclusion of trials that compared active drug with placebo. Okay. That's what's done in a randomized control trial. Like how's that going to limit my confidence? That's pretty ridiculous. I'm going to get rid of D. And in option E says inclusion of trials with an intervention duration of two weeks. Let's see what this drug has said. So it says under a few methods, second to the last sentence. It says version of study interventions rune from two weeks to 52 weeks. So including people that were studied for only two weeks, is that a problem?

That could be a problem actually. That could be a problem because you know maintenance therapy like people can quit many things for a week or two. But the people that stay the course for 52 weeks are probably more likely to have like just better long term outcomes than to put down liquid for a short period of time. Okay. So that means that things up. Okay. So B, I don't think we can exclude just yet. E, we can probably not exclude just yet. Option F says use of your analysis to determine treatment retention. No, I don't think I'm going to worry too much about that because most times, again, most times just ask yourself, is this the reason? What's the problem? Like most times when you're screening people for drug use, you're going to be checking their urine, right? It's been used for decades. Works pretty great. Was used in all study participants. It's not a big deal. So I'm going to get rid of F. So, okay. So we're pretty much between options B and E. So from B says exclusion of pregnant patients. Option E says inclusion of trials with an intervention duration of two weeks. Okay. So here's the thing. In considering these two answers, I'll ask myself which one just seems to be more significant, which will be more significantly, more adversely hamper the results of these studies. Honestly, between excluding pregnant people, because many pregnant people do use drugs. Don't get me wrong, they do some do, but don't many do.

And again, the pregnant population just represents a very small subset of all drug users, of people in maintenance therapy. So I think it's probably fair. Yeah, I don't think that's the big deal. So honestly, this is a judgment call kind of situation. Between option B and option E, I just feel better with option E. And I'm pretty sure that's the right answer. So I'm going to go with option E. Because if you're including very short study durations, right? Like, you can observe almost anything in two weeks if you serve. People can do the right thing for two weeks, but in the right thing for 52 weeks, that's a whole different ball game. That's a whole different ball game. Because I kind of wonder if they will get different results from this study. If they just used, if they kind of stratify things like, okay, people that did two weeks, people that did four weeks, people that did eight weeks, or whatever. So I think I'm going to go to option E. All right, question 19 says, which of the following is most likely to bias the results of the study? So they ask him for biases. Option E says earlier diagnosis of relapse in patients receiving method of maintenance therapy. Again, is there anything in the drug that comments on that? No, no, no, no, I'm not going to worry about that. Option B says exclusion criteria of studies used for the review. Exclusion criteria.

Again, we know that the excluded pregnant patients and the excluded people that used the for use method on for acute detoxification method of prenatal infarctured detoxification. If I think already discussed that those exclusion criteria are reasonable, so I'm going to get rid of that. Option C says likely to have more trials with positive results will be published. Likely who that more trials with positive results will be published. Um, any no one likes to publish bad data. Um, so let's keep that for now. Option D says, also funny. Let's see who give them money. Was this some pharmaceutical company that sells method on the upper and orphan? No, it was from the Australian government, right? The government is probably going to be working in the interest of the people. So I'm going to, I'm going to get rid of that. Option E says, variety of sample sizes of the included trials, variety of sample sizes. Hmm, variety of sample sizes. Hmm, I don't think that's that huge of a, again, that, that's maybe something we should keep. Uh, because again, if you use a smaller sample size, that can bias your results a bit. You, you, you can actually see, it can mess up your power. But the thing is, I just don't think he's going to cause that big of a deal because they use the wide variety of sample sizes and there are any is 5,430. That's a lot of people. That study has pretty good power. So I think I'm actually going to get rid of option E.

So the only answer that he had that seems to make any sense to me is going to be option C, right? Um, because this is like a kind of publication bias, right? Obviously, publications that show good results are going to be more likely to be published than publications that do not show good results. Okay. So I'll just see this. Biosat questions, leave them for the, like these drawgats. Don't do them on your first pass through a block. Does he make any sense? Leave them for the end of the, of the block. I think don't the quite oil, the other questions, then do these drawgats questions. And again, the best way to be good with drawgats is just to be good with bio statistics. It's just to be good with what? Bio statistics. If you're interested, this coming Friday, I have a four-hour bio stats class is for step 1, 2, step 3. And again, it's all clinical scenarios. It's all exam style questions. Um, it's not going to be a lecture because, and it's not going to be a formula regurgitation class. That's not very helpful, right? The USML is you're going to do a lot better if you understand. In fact, many bio stats questions these days are not answered by knowing the formula is answered by understanding. So if you want to pick up the tools to truly understand bio statistics that for a class and all these classes over Zoom is exactly what you, what you need. All right. One more question I think we'll call it for today. So, a 57 year, so this was on 20.

A 57 year old man is brought to the emergency department by ambulance. 30 minutes after he had loss of consciousness. His wife says he was making dinner when he fell on the kitchen floor. He has hypertension and his only medication is like Ceno Prile. He has no history of operative procedures. On route, his temperature was 37.2 degrees Celsius, which is 99 degrees Fahrenheit. This was 90 per minute. Transpiration were 10 per minute and labored. Blood pressure was 180 over 100 millimeters of mercury. Sounds like a stroke. Okay. Post-oxymetra and 40% oxygen by face masks should an O2 set of 99%. On arrival, he's on responsive. His glass-go-coma-skill score is three. He's intubated and mechanically ventilated. Temperature is 37.2, so same. Post is 90 per minute ventilator. It is 10 per minute and blood pressure is 180 over 100. He has this risk factor. The risk factor for hypertension is four stroke, sorry, is hypertension. Post-oxymetra and FIO2 of 0.4 should an O2 set of 90%. On examination, those eye, that's the oculocephalic manoeuvres, should absent eye movements. And the corneal reflex is absent. That's not good. On ice water color testing, there's no niestatmosidivation of the eyes toward the ear being irrigated. That's not good. See, this is kind of the head shows an ruptured serbal aneurysm. Ouch, okay. When the patient's wife is notified of the patient's condition, she says he wanted to be an organ donor, but does not have an advanced directive.

We should have learned the most appropriate next step in management. Okay, option E says, consult the host. No, no, no, no, no. Don't consult the ethics committee. You do that. You're going to be wrong on your exams. It's kind of like the biofeedback answer. When every select those answers, you know your heart. You're picking the wrong answers to that question. Option B says, contact the organ bank for potential donation. I don't see any problem with that. I mean, this person, I mean, she says wife. Yes, he doesn't have any advanced directive, but she says wife. She probably knows his wishes pretty well. So I'm going to, option B seems reasonable. Option C says, determine if there are any patients that we didn't organ donation in the hospital. No, no, the fact that no, right? There's an organ organ weakness for reason, right? It's done all over the country, not all like we only transplant within our hospital. That's ridiculous. C is wrong. Option T says, explain that the patient is not a candidate for organ donation because it doesn't have an advanced directive. That's pretty ridiculous. We've kind of talked about a similar question like this. I think either in part two or part one, the fact that you don't have an advanced directive doesn't mean that you cannot be an organ donor. We're just going to use a surrogate. We're going to start with your spouse and things like that.

Option E says, explain that the patient is not a candidate for organ donation because of his his for hypertension. If we rule out people that have hypertension and say, oh, you can be an organ donor, we're going to be really short on organs to give to people. That's ridiculous. The option E is not, is not correct, right? So the option is going to be option B, right? Again, remember, if a person doesn't have an advanced directive, you can ask their spouse, you can ask their adult children, you can ask their parents, you can ask their adult siblings in that order. If those are not available, then ask other people that know them pretty well. All right. I'm going to go ahead and stop here. Again, I offer review courses for step one, two, step three. Actually, they start this Thursday. I have a 20, half hour test taking strategies class on Thursday. I have a four hour bias test class on Friday. I have a five hour social sciences and ethics class on Saturday. I offer step one, two, step three. And in the week after that, I have a 20 hour course for step two and step three, or come next to one, three. Again, many people have taken these classes and found them to be very helpful. I also have these podcasts on Apple Google and Spotify, have a You Tube channel where I upload the podcasts that the videos that I make, you can check those out. And then I have on the website called divineinterventionlifelessons.com.

Every week from a biblical perspective, I try to upload about two podcasts that about 10 minutes long to address a life lesson. And there's actually an Apple podcast associated with that. And then also for one-on-one tutoring, and I help with ER As applications and the residency application process. So if you're interested in any of these things, just shoot me an email and I can give you some more information. And I also have a 500 multiple choice question costs coming up in June. It's 50 hours long. We just tear down many questions. They're pretty much all NV Me style. And again, we do like HPI questions and all these things. It's just, I mean, it's a significant time commitment. So it's going to only be held once this year. But again, I think if you're attending, you're going to find it to be profoundly helpful. So thank you for listening to me today. Please share this and I hope you find it to be beneficial. I will see you in the next episode. God bless you. Have a wonderful week.

Carbidopa-levodopa.

Washing thoroughly with soap and water (alcohol gel is ineffective against spores).

Epinephrine (Adrenaline), as it addresses both cardiovascular collapse and airway compromise.

IDD involves pervasive deficits across multiple domains (e.g., motor skills, self-care) and is associated with a low IQ (<70). A learning disorder affects only one specific academic area while other cognitive functions are intact.

The difference in efficacy between the two interventions is not statistically significant.

The spouse (or other close family members/surrogates) in order of priority.

Carbidopa (It prevents peripheral breakdown of L-DOPA).

Type I Hypersensitivity Reaction (mediated by IgE crosslinking).

Use soap and water handwashing, not alcohol gel.

The individual has average IQ but struggles only in one specific academic domain (e.g., reading).

The observed difference is not statistically significant, meaning no definitive conclusion can be drawn about superior efficacy.

Persistent social interaction problems, unusual attachments to specific people, and difficulty forming secure bonds due to early neglect or inconsistent caregiving.

Carbidopa (It prevents peripheral breakdown of L-DOPA).

Type I Hypersensitivity Reaction (mediated by IgE crosslinking).

Use soap and water handwashing, not alcohol gel.

The individual has average IQ but struggles only in one specific academic domain (e.g., reading).

The observed difference is not statistically significant, meaning no definitive conclusion can be drawn about superior efficacy.

Persistent social interaction problems, unusual attachments to specific people, and difficulty forming secure bonds due to early neglect or inconsistent caregiving.