DIP Episode 528 - 2024 USMLE Step 2CK Free 120 Discussion Part 9

Welcome to episode 528 of the Divine Intervention Podcast. My name is Divine. In this episode we're going to be continuing a series on the US Mily Step 2 CK Free 120. This is the most recent one on the US Mily website. And this is going to be part 9. This is going to be part 9. Again, I'm trying to give a fairly detailed discussion of every single question in this series. I've done 65 questions so far. So we're on question 66. So let's go ahead and power up here a little bit. Okay, so question 66. Let's just again, if you've missed any part of the series, I promise you this is a lot of very useful learning. But anyway, okay. So, when a five-year-old man is admitted to the hospital because of a 3 D history of fever, he has type 2 diabetes, malatrous, hypertension, and chronic obstructive coronary disease. One year ago, he had a stroke with residual, right? Lower extremity hemiparises. Medications are amlodipine, tiotropium, metformin, glibipride, lysinoprylonasperin. He does not drink alcoholic beverages and a smoked one pack of cigarettes daily for 50 years. The patient is widowed, lives alone and has three adult children. He is not in a acute distress. He has 178 centimeters, that's 5 foot 10 inches tall, and weighs 82 kilograms, that's 180 pounds. His BMI is 26 kilogram per meter squared. Temperature is 39.2 degrees Celsius, that's 102.6 degrees Fahrenheit. Bulse is 110 per minute, respirations are 22 per minute. And blood pressure is 150 over 90 millimeters of mercury.

Bulse oxygen room air shows an oxygen saturation of 96 percent. Scattered end expiratory whizzies are heard. There is dense hemiparises of the right lower extremity. Appropriate therapy is initiated, and three days later, the patient's condition has improved. He's awake, alert, and conversing with one of his sons about current events. Temperature is 37.2 degrees Celsius, that's 99.0 degrees Fahrenheit. Bulse is 72 per minute, and blood pressure is 130 over 82 millimeters of mercury. Distrash plans a discuss with the patient, his son, the physician, and a physical therapist. The physical therapy says the patient will be best cared for in a nursing care facility. The patient acknowledges that a nursing facility will provide better care for him. Bulse says he will prefer to remain at home with a visiting nurse. Once outside the patient's room, his son says, I have his power of attorney. Don't listen to him. He needs to be in a nursing home. Which of the following is the most appropriate next step? Option A says, inform the son that the decision is the patient's to make, regardless of the medical team's recommendation. Option B says, reassure the son that the patient will be admitted to a nursing care facility. And accordance with the physical therapist's recommendation. Option C says, refrain from making any decisions on telefamily meeting with the son and siblings is arranged to discuss the matter.

Option D says, request psychiatric evaluation of the patient's mental competency. Option C says, request to review the legal documentation, designating the son as having a power of attorney. So what do you think? So in this question, we can clearly see that this person, this patient seems to be pretty, pretty with it. And his voice, he's heard the physician's, the physical therapist's recommendations. And he is voiced his decision. So we got to respect that we have to respect patient autonomy. And it's not like this person is demented or they don't know what's going on. Yeah, yeah, yeah, yeah, yeah. Right. So option A is going to be the right answer. Pissions meet a decision. Yes, voice this decision. He wants to go home and be seen by visiting nurse. So I'm going to do that. So I'm going to go to option A. You know, option B, let's see, we're going to show the son that the patient will be admitted to a nursing care facility. And at court, it's no, you're not respecting patient's autonomy by doing option B. Option C says, refrain from making any decisions on telefamily meeting with the son and siblings is arranged to discuss the matter. You don't need a family meeting. This guy's got him better. He's only like his chicken into a hospice or whatever. Nah, that's wrong. This is a simple question. You got to respect patient autonomy. Option D says, request psychiatric evaluation. Nope, this person doesn't have any signs of being demented or having a mental health disorder.

And then option E says, request to review the legal documentation. Is this getting the son as having power for training? This is a very great, but very wrong answer. Because it may seem like, oh, let's check if the son is right. If the son is right, then, yeah, we got to let the son do what he got to do. But no, see, let me tell you this. There are very few times on the USME Ls where a patient you don't let them make their own decisions. Very, very few. Right. If a patient is with it, even if they've signed a power attorney or whatever, but they're still able to voice their own considerations, then you should always go to the patient's considerations. That is the honest, honest truth. That is what the honest, honest truth. Because I know someone may be like, wow, divine, what if the son was truly the power attorney? It does not matter. The only time where a power attorney is going to kick in is if the patient becomes incapacitated and is like, wow, the person is like out of it. Or the person is on a ventilator, is on a responsive, and they need a decision. Then the power attorney can kick in under those circumstances. That's a very subtle point, but it's a very, very important point to understand. Right. Even if you have a power attorney, even if you have a living will, blah, blah, blah, blah, blah. You, the patient, the decisions and stuff you see in real time, it's going to come more than anything. Right. Even option D is kind of a wrong answer. I mean, option D is wrong.

Right. He says the patient's mental competency. Competency is not something that is determined by a physician. A physician determines capacity. Competency is determined by the courts. Right. You're not a lawyer. You're a physician. Okay. All right. So just kind of make sure you see why 66 is clearly going to be correct. Okay. So let's go to question 67. So a 59 year old man is brought to the emergency department because of a one-on-hiss or weakness of his left arm and leg and mouth headache. All right. He says that when he was guarding with his wife, he suddenly became unable to hold his gardening tool, left his left arm or walk. Two weeks ago, he had a non-productive cough and nasal congestion that resolves spontaneously after one week. He has hypertension treated with lysinopril. On arrival, he is lethargic. He is 100 and 83 centimeters. So that's six foot tall. And weighs 97 kilograms. That's 215 pounds. BMI is 29 kilograms per meter squared. Temperatures 36.6 degrees Celsius. That's 97.90 degrees Fahrenheit. Post is 94 per minute. Respirations are 16 per minute. And blood pressure is 174 over 109. Makes sense. It's having a stroke. The popules measure three millimeters and are reactive to light. Muscle movement is decreased over the left lower aspect of the face. Muscle strength is zero out of five in the left left extremities. Deep tendon reflexes are absent in the left extremities and two plus in the right extremities.

CT scan of the head shows a large area of increase attenuation in the right putemin region, which also follows the most likely cause of the spacial condition. All right, let's look at the answers. Option E says amyloid angiopathy. Option B says embolism. Option C says small vessel disease. Option D says fasculitis. Option E says venos thrombosis. All right, so what do you think? Right? This is a very good example of knowing your concepts, being able to make integrations, understanding pathophysiology, and being a test-taker just all merged perfectly. And to help you in a person answer a question correctly. So like for example, we know this person has a stroke. That's a given. Now what kind of stroke is this? Is it a cortical stroke or a sub cortical stroke? This is a sub cortical stroke. And the way you know that this is a sub cortical stroke is that the persons, operand, and lower extremities are affected at the same time. Right? That's one of the dead giveaways to tell yourself that, oh gee wait, this is a sub cortical stroke versus a cortical stroke. A cortical stroke is a stroke in the cortex. When you have a cortical stroke, you're going to have, you're going to respect cerebral artery distributions. Then I say that again, whenever you have a cortical stroke, you're going to respect what cortical artery cerebral artery distributions. Right?

So like for example, if you're dealing with the middle cerebral artery, you're going to have issues with your upper, with your upper extremities and your face. If you're dealing with the anterior cerebral artery, you're going to be dealing with your lower extremities. Right? But this person has parlysis of the left upper extremities, the left lower extremities. Yeah, they have some face thing going on, whatever. Don't really care too much about that. But the left upper extremities, the left lower extremities are affected. Whenever you see the upper extremities and the lower extremities on the same side affected, that person does not have a cortical stroke. The person has a sub cortical stroke. Because the thing is once you dip below the cortex, the fibers for the upper and the lower extremities, the collocate, this type, the is almost like they're separated, is almost like being single before you get married. And the cortex, the ACA, you know, does lower extremities, MCA does upper extremities and face. They're single then. Once you go below the cortex, you've did it for a long while. Now it's time to get married. So since they've got it married, everything is kind of mixed together. Once you go below the cortex. So that's why you'll notice that, wow, when you have a sub cortical stroke, the upper extremities and the lower extremities on that side are going to be affected. Right? Usually it's going to be contralateral to the stroke. Right?

Because remember, those cortical spinal tract fibers cross. Right? So this person, and usually sub cortical strokes, we're going to find people that have a hypertension. We're going to find people that have hypertension. Right? We're going to find people that have hypertension. Remember, hypertension is the biggest risk factor for strokes. Right? Because when you have hypertension, you can develop these as charcoal, bushard, micro aneurysms. And those micro aneurysms, they can pop. And when you pop, right? That can cause a brain bleed. As we see on imaging in this patient, he says, large area of increase attenuation. When you think that increase attenuation is, that's blood. Right? When the right put him in region, that tells us again that this is what? This is a sub cortical stroke. This is a sub cortical stroke. So those charcoal bushard micro aneurysms, look at what micro. Right? It's usually from small vessels. So the answer is going to be option C. Option C. Well, let's look at the other answers, because I don't want people to just say, oh, divine. You're using option C is right. Let's look at the other answers. Option A. Aminoid angiopathy is wrong. Aminoid angiopathy, we're really finding people that have Alzheimer's or people that have Down syndrome. Right? They can get brain bleed as a result of that. Right? They can get brain bleed as a result of that. Because if you have excess amyloid, right? That amyloid can deposit in the walls of your cerebral vessels.

And when you deposit in those walls, it makes those vessel walls weaker. And when they're weaker, they're going to pop. When they pop, you're going to bleed in your brain. Right? But this person does not have Alzheimer's. This person doesn't have Down syndrome. Remember Down syndrome, you have a ton of amyloid because they have three copies of the gene that goes for anyloid precursor protein. Embellyzen, usually we're going to find that in a person that has a fib or a recent amy. Right? If you have a recent amy, and then because the heart is not contracting properly, they have bloodstasis. Remember, Verkos triad, Verkos triad, they have bloodstasis, and that bloodstasis is going to make them hyperquagulable. Right? And they're going to make an embolus in the heart and then it'll flick up to the brain. We don't see that here. So I'm not going to pick that. Option D says vasculitis. Vasculitis is going to be a chronic process. Right? That makes no sense here. Option E says venos thrombosis. Right? Again, it's highly unlikely that venos thrombosis will cause these kinds of things. You know, you can maybe think of Carvenous sinus thrombosis. That's like a very classic venos thrombosis. They love to test on the exams. But Carvenous sinus thrombosis is going to cause a lot of extrocolomosol problems because a lot of the cranial nerves that could for the extrocolomosols that supply the extrocolomosols may pass through the Carvenous sinus. We don't really see that here.

That's not going to be the right answer. Okay. Question 68 says, a 24-year-old preemigravied woman at 10 Wistia station comes to the office for a scheduled dilatation and suction cure attached. Boy, I hear when people use the word dilatation. It's dilation. But dilatation is right, but I don't know. It just kind of goes on my skin a little bit. But anyway, right? So for the scheduled dilation and suction cure attached. All right. Autosanography two days ago showed a fetus consisting in size with a nine-week gestation with absincardiac activity. Oh, that's not good. Two weeks ago, the patient had an operator-retract infection that results spontaneously. One year ago, she was diagnosed with herpes' simplex virus, too, HSV2. Halasdao Brego is six months ago. She has no other histrosyrosyonis. She's 163 centimeters. That's five foot four inches tall. She weighed 82 kilograms. That's 180 pounds prior to her pregnancy. BMI was 31 kilograms per meter squared. She has had a 3.6 kilogram. That's an eight-pound weight gain during her pregnancy. Vital size only, they normal limits. The over-arrange shavon. No lesions are noted. Examination shows a normal appearing cervix. The uterus is non-tender and consistent in size within eight-week gestation. A lot of stuff here seems pretty normal. But anyway, let's keep going. There's homogenous wide-gray vaginal discharge. The pH of the discharge is 5.5.

She undergoes dilation and suction cure attach with sterile instruments and povidone iodine vaginal clinsic. Which of the four inches the strongest predisposing risk factor for post-operative infection in this patient? All right. So option A says, history of operative retracting infection. Option B says, HSV2. Option C says, Obacillin. Option D says, type of vaginal discharge. Option E says, Vovar shaving. All right. So what do you think this is? These are the kinds of questions that cause people to scratch their heads, pull their hair out on the exam. You don't have to join any of those groups of people. Again, always just ask yourself. What is like really abnormal here? Because you probably heard me as those really questioned that, man, a lot of the stuff is normal. This person unfortunately had an intrauterine fetal demise. The baby is dead. We're bringing out the baby, right? But they're asking, which of course is the strongest predisposing risk factor for post-operative infection? So we just need to ask ourselves, is there anything that is really abnormal in this lady that can cause problems? Well, let's look at some of these things. History of operative retracting infection. Does not abnormal? She had this operative retracting infection two weeks ago. It's cleared. She doesn't have it now. That's not going to be causing problems. HSV2. How last outbreak was six months ago? It's not causing any issues now. So no. Option C says will be city.

Okay, will be city may raise her rate. So let's maybe keep that for now. Option D says type of vaginal discharge. Well, the pH of the discharge is five. Oh, okay. So that's not normal, right? So wait, hang on. So vaginal pH of 5.5 is not normal. It is not normal, honestly. It's not normal. Once your vaginal pH is that deepening to the fives, that is not normal. That is absolutely not normal. If I actually let's look at the discharge, she says, wide-gray vaginal discharge. I wonder what that is. Let's see if you're thinking along with me here. What do you think? Wide-gray vaginal discharge. And the pH is much greater than 4.5. What do you think that is? This one has bacterial vaginosis. All right. So she's got bacterial vaginosis. That's like an actual infection. Okay, so that's not normal. All right. So I'm kind of thinking, I like option D a lot. But let's look at option E. We'll overshave it. You should have a person's over. You've got to do surgery. You've got to keep the air clean. So that's ridiculous. So, you know, I'll come between option C and D, but option D makes sense. It's an actually, she literally has an infection going on. So I'm going to go to option D. Option C is kind of a, because obesity kind of raises your risk with many bad things, you know. But it's not as strong as like an actual infection going on right now. Right? So I'm going to go to option D here. All right. Oh, question 69. Oh, okay. There's a classic one.

A 74 year old woman comes to the clinic two days after the sodium onset of severe left foot pain. She has had difficulty walking during this time and has been using a cane. She has not sustained trauma to the foot. She has type 2 diabetes, malitis and hypertension. Medications are metforming, insulin blargin, hydrochlorothiocyanide, lysinoprylonatroverestatin. So occasionally, she typically wears support stockings because of lower legs swelling. But the foot pain has made it difficult for her to wear them recently. She's a traveling pastor and spends more than four hours leaving her car. She has been monogamous with her wife for the past 30 years. Blood pressure is 146 over 88 millimeters of mercury. All the vital signs are within normal limits. A photograph of the left great toys shown. Great tolle. I wonder what this is. No other abnormalities are noted. Himokyribin A1c7.4%. Serum crafting concentration is 1.4 mixed per deciliter. And serum uric acid concentration is 7.8 mixed per deciliter. It's not only a wonder in the divine, it's not normal or abnormal. I don't know. I guess I gotta look at the table of values. But honestly, I don't care about the table of values. This is a pretty classic case. You really should not be getting these kinds of questions wrong on the exam. Results of serum electrolyte concentrations are within the reference ranges. Which of the following is the most likely diagnosis?

Oceanases, cellulitis, B-sase, gout, C-sase, infected, muhoid-sase, D-sase, osteoarthritis, E-sase, pseudo-gout, F-sase, rheumatoid arthritis. Please don't tell me that you're picking anything other than gout here. Again, the picture is clearly gout. But even if you don't see the picture, great tolle suddenly is hurting. And we see this person is thinking of a thiazide diuretic. The thiazides, they compete for the same transporters that help you excrete uric acid. So the ex-contransporters used to excrete thiazides from your body. Also the same transporters that you insert straight uric acid. So guess what? When you're using thiazide diuretic, so look diuretic, it's not going to raise your uric acid levels. This is going to cause you to have gout. This person has gout. There's no point literally discussing any of the other answers. The answer is gout. Okay? Remember gout, we treated with NSAI Ds. That's it. Gout is treated with NSAI Ds, simplest dot. NSAI Ds, NSAI Ds, NSAI Ds. If NSAI Ds are not an answer, or the person has a contraindication, you can go ahead and put the person on like steroids. Let's do one last question here. So question 70 says, a 47 year old man comes to the office for a routine examination before beginning an exercise program. He feels well. He has a 25 year history of type 1 diabetes mellitus. A grade 1 out of 6 early peak in systolic ejection memories heard best at the left third intercostal space. Sensation to light touches mildly decreased over the toes.

The remainder of these examination shows no abnormalities. An exercise stress test shows three millimeter ST segment depression early in the test. The test does not produce any pain. Which of the following is the most likely diagnosis? So, option A says cardiomyopathy, option B says continental heart disease, option C says coronary artery disease, option D says vascular heart disease, option A says normal cardiac findings. All right, so let's look at this. What do you think is going on here? I mean, this person in this question, let's look through it. It seems to have a, you know, it's getting a stress test. And then this stress test shows an ST segment depression. Well, whenever stress test is positive, it means that coronary vessels are not great, right? So, we're going to go with option C here. So, we're going to go with option C, right? In option B, doesn't make any sense. Conjunctal heart disease, if you want to detect conjunctal heart disease, I don't know, maybe do like an natural structural imaging test of the heart, like an echocardiogram, a vascular heart disease. Again, if you're trying to work on vascular heart diseases, you're going to be doing an echocardiogram, not an exercise, not an EKG based stress test, right? He says, no more cardiac findings. No, STD versions are not no more cardiac findings. Again, he feels, suspect the cardiac myopathy, and I'm going to be doing an EKG for that, he's going to be doing an echocardiogram for that.

And this person also has diabetic neuropathy. So, this is probably looking to that as well. You know, all these diabetics, many times they'll have like this burning, pins and needle sensation in their, in their low extremities. But just something to kind of keep at the back of your mind for, for example. I think I'm going to go ahead and stop here. I would like to keep going on this, like right now. What I have so many responsibilities to do, so I think I'm going to pause on this. But again, the next one, I'll try to make it where I cover more questions. So again, if you love the way I teach, you love the way I make integrations, you love the way I explain my reasoning, you love the way I explain pathophysiology, then you'll be interested in the classes I offer. I have a series of classes that are super helpful for step one, to step three. For step one, to step three, I have a starting on the 18th of this month. I have an NV Me testing and strategy class. It's two and a half hours long. I have a biostat class that's four hours long. I have a social sciences and ethics, quality improvement and healthcare systems class. That's five hours long. These classes are not lectures. If you're expecting lectures, wrong class for you. These classes are based on me discussing clinical scenarios, NV Me style questions extensively. They're pretty much almost all scenarios. And then I'll have these useful charts that I discuss to really get some points across to you.

And I'll help you make a lot of integrations. And then the week after that starting on the 22nd, I have a 20 hours step two step three class. And then in the first week in May, from May 1st to May 5th, I have a 25 hours step one class. Again, I think these classes are going to be super, super helpful for a lot of people. Many people have taken my classes, don't extremely well on the exams. I've had people get, if only the high 270s, I believe I've actually had two 80s from my classes. So again, I think these classes are going to be super helpful to you. If you're interested, just shoot me an email through the website. I'll offer one or one to you, for all the USML and complex exams. Metzical exams and shelf exams. And I help with your applications, recommendation letters, personal statements, and things of that nature. And then I have these podcasts on Apple, Google, and Spotify. So check those out. I have a You Tube channel where I post the videos that I make. And then I would also say that I have another website called at dividinginterventionlifelessons.com. Every week, I post two podcasts, usually on Fridays and Sundays, where from a biblical perspective, I address a life lesson. The podcast about 10 minutes long, you really should check those out. So thank you for listening to me today. I will see you in a episode 529, I guess. Well, God bless you right for now. Thank you.

Patient autonomy. The patient's stated preference always takes precedence over family input or professional recommendations.

Only if the patient becomes incapacitated, unable to make decisions for themselves. It does not override current competence.

Competency is determined by the courts/legal system; Capacity is a determination made by the physician regarding the ability to understand information and make reasoned choices.

Paralysis affecting both upper and lower extremities on the same side (e.g., left arm and left leg affected). This indicates involvement below the cortex where tracts are mixed.

Rupture of Charcot-Bouchard microaneurysms, resulting from chronic small vessel damage.

White-gray discharge and a vaginal pH significantly greater than 4.5.

Patient autonomy.

Subcortical stroke (due to mixed tracts below the cortex).

Acute onset, severe monoarticular pain (podagra) combined with hyperuricemia.

A pH significantly greater than 4.5 (normal <4.5).

Cortical stroke.

Amyloid angiopathy.

Patient autonomy.

Subcortical stroke (due to mixed tracts below the cortex).

Acute onset, severe monoarticular pain (podagra) combined with hyperuricemia.

A pH significantly greater than 4.5 (normal <4.5).

Cortical stroke.

Amyloid angiopathy.