DIP Episode 522 - 2024 USMLE Step 2CK Free 120 Discussion Part 5

Welcome, my name is Divine. This is episode 522 of the Divine Intervention Podcasts. To this podcast, we're going to be continuing the series on the 2024 Step 2 CK Free 1 20. This is going to be part 5. We've done the first 30 questions in the series. Again, it's a super educational series. So, I'll encourage you if you missed the first four parts. Go back and listen to it. Okay, so let's begin from question 31. A two-year-old girl has brought to the office by her parents for a well-child examination. She was adopted two months ago. She has no history of seriously all this and receives no medications. Vital signs are within normal limits. Examination shows no abnormalities. After the examination, the parents ask when they should tell their daughter about the adoption. Which of the following is the most appropriate advice regarding the best time to tell the patient. Option A says, after she turns 18 years of age, option B says as early as possible, even if she cannot process the whole experience. Option C says, once the seal on the adoption records has been lifted, option D says, right before she's eroding kindergarten, option E says, when she learns that she's not biologically related to her parents. Now, this is an example of a kind of question that you pretty much cannot prepare for. It's one of those things where you have to make judgment calls on you, except.

But the thing is when you see situations like this, the first thing you want to do is get rid of answers that make no sense, right? So, like option E doesn't make any sense. Or when she learns that she's not biologically related, that's pretty ridiculous. So we're going to get rid of that. Option C says, once the seal on the adoption records has been lifted, those are make sense. They're just certain things where if you've taken on off exams and baby-based exams, you know that yeah, these answers don't make any sense. So, option C and E, we're not going to worry about those. So we're kind of stuck between AB and D. A says, after she turns 18, B says as early as possible. D says, right before she's eroding kindergarten. So, the thing is, looking at questions like this, let's just ask ourselves which one seems to make the most logical sense. Do you think it's better? Logically, to wait till a child is really old before you tell them they're adopted? Or would you want them to know early? Well, I would say I would probably want them to know early. So personally, I'm going to go with option B in this case. The thing is, you may wonder like, man, it's just a USMLE concept, but I remember when I was I think studying for a step one back in the day, I learned that children have understanding of things like death, even if they're young. You know, they do understand, especially at certain early ages, that see this person may not, this person is never coming back again, kind of deal.

And again, just in my own personal experience, I just know that you may think that children don't know anything, but they actually know things. They can really pick up on many things very early in life. So I would say for this option B makes the most sense. I'm not going to go with option A after she turns 18, that's pretty late. Right? The child is probably going to feel pretty be treated that well, I've gone through all of life and you've not told me this because the thing is children can adjust to things that earlier you teach them something. I always think of this by booverers that says, train up a child in the way he should go when he grows up, he will not depart from it. So it sounds like that training should have come before the child grows up. So honestly, for me, I don't know how I can really connect this to any concept, but just logical reason I'll go be because I'm just asking myself between option B and option D. Option B just makes better sense. Option D says right before she's eroding in the garden. There's nothing special about in the garden that will affect anything. So I'm going to go with option B here. All right, let's continue. A surgical intensive care unit observes that the number of days that patients have central vinyl scathoders in place and the number of bloodstream infections have been increasing.

A multi-disciplinary team from the unit would like to decrease the number of days that central vinyl scathoders, those are central lines, are in place in order to improve performance in this area. Which of the following is the most appropriate next step? So it says, ask clinical providers in the units to identify what they believe to be the most common factors leading to non-removable of central vinyl scathoders. Option B says, change of central vinyl scathoders every five days. Option C says, place stickers on all intensive care unit doors, reminding staff to reassess the need for a central line. Option D says, plan around the mice control trial to test the effects of a reminder. To reassess the need for a central line on a daily goals sheet implemented during rounds. So what do you think is going on here? This is a classic health care systems question. And honestly, when people see questions like this, one principle that's honestly very helpful is just doing things in order. That's one thing I've figured out with many US semily questions. Just do things in order. Do things in order. Like they know they have a problem. The number of these central vinyl scathoders are in place is going up. The number of central line astrochetyl blaster infections is going up. Okay, we want to decrease the number of days that people on CV Cs want to decrease the number of infections.

Well, before you start doing any of those things, it probably makes sense to figure out why are we having these problems? That seems like the right first thing to do. Then after you figure out why you're having the problem, you then go ahead and create a plan for solving that problem. You then pretty much execute that plan. And then you reassess and see, okay, how's this plan doing? So it just seems like a smart thing to do. It seems like a simple PDSA cycle can a deal, right? Plan do study acts. So honestly, we don't know what's causing the problem. So let's figure out what's causing the problem. So option A makes the most sense, right? Option B, you start fixing a problem you don't fully understand. Does it make any sense? Option C, you start fixing a problem you don't fully understand. Does it make sense? Option D, you start fixing a problem. The randomized control trial is to kind of a way to figure out, but like, you don't have to do a, in fact, you don't have to do it under my control trial when you can just ask, right? Start with a, oh, maybe you want to do it under my control trial later, but like, it doesn't really make much of any sense. And honestly, a randomized control trial is going to have like a experimental group and a control group. Option D does seem to really seem to spell out much of a control group. I don't know how you're going to be able to do it under my control trial. How about a control group? So option A just makes the most sense.

Option A just makes the most sense, right? So I know you may be like, well, divine throughout the buzzword PDSA, but honestly, most of these things are conceptual. It's like a classic rule of healthcare systems and quality improvement and whatnot. Understand the problem first. After understanding the problem, collecting data, making metrics, make a plan. After that, execute set plan. After that, reassess, if it's a good plan, you had in the first place, keep doing what you're doing. That's it. That's like a classic mantra. So even if I did not know PDSA, cycle or whatever, this is a simple question that one could easily have answered. All right. Let's go to question 33. A 17 year old girl comes to the office because of a three-month history of daily moderate to gastric pain that is more severe after meals. So if you gastric pain three months, it kind of tells you something. Three weeks ago, she had water in her for two days, which results spontaneously. She has not had vomiting. She has no history of seroceros illness and takes no medications, vital signs are within normal limits. Examination including abdominal examination shows normalities, which of the fluen is most likely to confirm the diagnosis. Option A says cities can have the abdomen. Option B says endoscopy. Option C says examination of the stool for over-empower sites. Option D says stool culture. Option E says upper gastric intestinal series. Okay. So let's look at this question.

So we see a person having chronic epigastric pain more severe after meals. Right. After you eat a meal, your stomach is going to secret a little gastric acid. So it kind of tells you something. And the location of the peanut epigastric, right? That's kind of stomach pancreas area. This girl is not an alcoholic, she's not pancreatitis. This is a stomach issue. It's probably peptic ulcer disease. Well, we know that peptic ulcer disease most common cause is going to be H by lorry. So now we just need to find the answer that is, we'll help us evaluate the stomach to detect H by lorry. Option A doesn't make any sense. Right. City scan of the abdomen. You can see H by lorry on a CT scan. Option C says examination of the stool for over-empower sites. Thinking of H by lorry, we should not be looking at the stool for over-empower sites. H by lorry is not really a parasite. It's more for bacteria. Option D says stool culture. Again, it doesn't seem like a wise idea. Option E says upper GI series. That's wrong. That's the answer you would select when you're dealing with bilio semis in a newborn. So like daughter of atreja, genital atreja, marotation, that's not the answer here. The answer here is endoscopy. Again, the thing is if the USML is put in so far, go gastrodoidotinoscopy, EGD has an answer. Everyone will get it right. But again, they clearly did not do that. Again, the USML is these days. They're very big on not putting straight answers.

They like to put answers that are kind of related, but not exactly what you expected. So again, make sure, I'm just throwing all this warning again. Make sure a lot of person is just memorizing. Make sure you actually understand what's going on. Right. So we can do an EGD, do biopsy, can detect H by lorry. Remember, H by lorry should have triple therapy. Right. Clarithromycin, amoxysin in a PPI. Or you can do quadruple therapy with metronidazole, bismuth, tetracycline, and a PPI. So there's something to keep in mind. All right. Let's go to question 34. So between three year old man comes to the emergency department because of a one-hour histroventrumithan coughing spasms that began suddenly while he was attempting to clean more from his garage, with a mixture of acidic acid and cleaning agents. The cough is not productive. He reports shortness or breath only during the coughing spasms. Medical history is unremarkable and it takes no medications. Young person, wheezing and all those things. You probably know what's going on here. He does not smoke cigarettes, drink alcoholic beverages or use other substances. He's 180 centimeters. That's 5'11 inches tall and we 75 kilograms. That's 165 pounds. His BMI is 23 kilograms per meter squared. Vital signs are within normal limits. Post-oxymetro and room air shows an oxygen saturation of 94%. The patient has periodic paroxysmal coughing during the examination or variances clear.

Oskotation of the lungs discloses bilateral weasest throughout our long fields. There is no use of assisted muscles of respiration. The remainder of the physical examination discloses no abnormalities. Chestics ratios, mild, hyper expansion of the lungs bilaterally. The results of a teroblogal gas analysis on the room air shown below. The PO2 is 72 millimeters of mercury. The PO2 is 38 millimeters of mercury. The pH is 7.41 and the Bicarbis 23, which is the most appropriate initial step in management. Option A says arbiteral therapy. Option B says bronchoscopy. Option C says CT is kind of the chest. Option D says intubation. Option A says methyl-prinysolone therapy. This person clearly has an asthma exacerbation. It's pretty straight forward. The patient has an asthma exacerbation. What's the first thing you start with? You want to start with maybe lysis to open up the airway. You can use arbiteral, which is a short actin beta-to-aginist. You can also give you partropial, which is a short actin most carinacantacanest. Many times people get both. I'm going to go to option A here. Remember after that, within the first hour of the person in the agnostic or whatever, getting to the hospital, you want to give IV steroids. You can give IV dixamethasone and stuff like that. Usually for most people, that's fine. Now, if that's not working, then you need to start considering other measures. Like magnesium, that's pretty helpful.

It has a pretty low number of needle treat in people that have asthma exacerbations. You see how I just kind of threw in a low number in the needle treat. That means that if intervention is pretty effective. It's just one of these things that the USML is love to do. Take a concept and just integrate it away somewhere. I mean, who will be expecting a bio-stats question out of asthma exacerbation question? Again, it's just a classic thing the USML is do. They can be trained. They can give your bio-stats question where a person has like an asthma exacerbation or something. Then they give you around a mice control trial, give you a bunch of number of needle treat. Then they ask you which one will be the most effective intervention for this person? You should probably pick the one that has the lowest number of needle treat. I'll let you make that simmering your mind for a bit. It's just kind of important to be able to make integrations and make sure you can see things in different ways. That's like a very simple question that many people will get wrong. Many people will waste so much time on because that's a pretty simple concept because obviously if you have a low number of needle treat, chances are that thing is pretty effective. If you have a high number of needle treat, that means very few people get clinical benefit from that intervention. Those are just things to kind of keep at the back of your mice for exams.

Remember also you can do C-PA by PAP, not invasive positive pressure of ventilation in asthma. If all these interventions and all work in, but if you notice a person that has asthma and asthma exacerbation and their CO2 was normal, because usually when people have an asthma exacerbation, the AP little ACO2 is low because they're hyperventilating. If you notice that it's asthma malizing or it's that's rising, that's a bad sign. Tell us if the person's respiratory muscles are getting tired. Those people need intubation as quickly as possible. If they're probably going to die. So you don't want that. So there's something to keep in mind. You know, in ICU circles, you may also hear of Heliox, like Helium. It increases like laminar flow. In a person's airway, that's something that we talked about in the future if we have the time for it, but they probably won't go that far on the exam. So I'm going to go to option A, option E is given IV steroids. Something should be left with giving the nebulizers. Nebulizers will act immediately and start helping the person. Stereo is going to take a while to kick in. Okay. The person doesn't need intubation. You've literally tried nothing and the person seems to be pretty with it. So I'm going to do intubating. CT is kind of the chest. That's for like a PE or whatever pneumonia. Don't do that. But I'm also going to be very ridiculous. Okay. Let's go to question 35.

So, and if you 70 year old man is admitted to the hospital because of a 40 history of moderate abdominal cramps, nausea and vomiting, he has not had a bowel movement or past gas in the past 24 hours. He asked colon cancer. He started to the lungs lever and peritoneum. He didn't want to go here and the winter low anterior reception for T3 and 2 rectal cancer. I know some people may see this and say, oh, divine. Do I need to memorize staging of? No. Just don't. Okay. Move it on. Six months ago, exploratory laparotomy showed diffuse carcinomatosis and bowel obstruction and an eliotransverse bypass was performed. The patient and his family was in were informed of the findings and advised that he would not be a candidate for laparotomy in the future because there were no there would be no surgical options to treat another obstruction. The patient has no other history of serosilness medications. A five-throw-year cell and beta-vacizumab, five-fufurite. That's a family-dilixin case inhibitor. Beta-vacizumab is a vegetin inhibitor. Temperature is 37.2 degrees Celsius. That's 99.0 degrees Fahrenheit. Pulse is 100 per minute. Transpiration is a 20 per minute and blood pressure is 130 over 80 millimeters of mercury. The abdomen is distended and mildly tender to bowel patient. The anopyrotoninol-sciencities kind of the abdomen shows a mild geogonal, small bowel obstruction, multiple intraperitonial tumor deposits and assidies.

The physician recommends insertion of nasal gastric and percutaneous endoscopic gastroastomy tubes. The patient and his family request that the patient on the gorilla laparotomy and intestinal bypass, which of the following is the the patient's family request, the patient on the gorilla laparotomy and intestinal bypass, which of the following is the most appropriate next step in management? This is a classic ethics question. You're clearly told in the question that hey we're going to do this procedure for you now, but if you have any future cases like these, there's nothing where we're not going to be able to do a laparotomy. The USML in this question has told you the medical guideline. They said hey, can't get a laparotomy now. The family is like hey we want a laparotomy. You're going to be like hey, we talked about this back in the day. We cannot do this. I'm sorry for your your grandpa or whatever that's not feeling well, but he just cannot do it. Basically with ethics questions, if something is not does not meet medical guidelines, don't pick that answer. It's not going to be a good choice. Let's see the answer that basically makes us not to do what the family is requesting. The option A says abide by the wishes of the patient on the family. That's wrong. Option B says alter the chemo regimen. That's wrong. Option C says explain the futility of the oppression to the patient and his family. Sounds like a really good answer. I'm going to go with option C.

But let's look at the others. Option D says offer to transfer the patient to another facility. No, try to talk things over to people first if you can. Option E says suggest external being radiation therapy. No, that's wrong. So the answer is going to be C. Simple as that. No overthinking needed there. No. Question 36 is 62 year old woman comes to the office because of a three month history of anxiety, insomnia and frequent bowel movements. She has had a 9 kg that's a 20 pound weight loss during the spirit. Paul says 90 per minute and irregularly irregular. All right, respirations are 22 per minute and blood pressure is 150 over 65 millimeters of mercury. She's restless. The thyroid gland is diffusally enlarged. A bruise heard over the thyroid. Examination shows pulmonary themus. Some of her fingernails are separated from the nail beds. There's widening of the peripheral fissures of the poppybrile fissures and thickening of the skin over the dorsum of the feet with a pulled orange appearance. Pulled orange doesn't always mean inflammatory breast cancer as you can clearly see here. There's a fine tremor which of the feelings the most likely diagnosis. Right. So let's look at this. Option A says addison's disease. Option B says cross-noid syndrome. Option D says option C says cushion syndrome. Option D says fiochromocytoma. Option E says thyrotoxicosis. Let's look at these answers one by one. Option E says addison's disease.

Addison's disease is people are going to be pretty pretty hypotensive because they have like an outdoch-steroend efficiency and a cortisol deficiency. They'll be hypotensive. They'll have skin hyperpigmentation because they're not making cortisol so there's no negative feedback so the ACT shoots up. Remember whenever your ACT shoots up your MSH melanocystine-relation hormone is going to shoot up as well because both of them come from the compound POMC. The person is going to have skin hyperpigmentation. They'll have all these electrode abnormalities like again all from our dorsum deficiency like hyponitremia, hypercalemia, normal melanoma and get metabolic acidosis. Literally look at all of said about addison's disease. It's not here in this question. Option A is wrong. Option B says cross-noid syndrome. Remember cross-noid syndrome you're going to see bronchospasia. You're going to see flushing. You're going to see diarrhea. You're going to see right-sided heart problems especially when it's metastasized to the liver. Again the only thing we see here is diarrhea. We're pretty much everything about carcinoid is not here. It doesn't make any sense to be carcinoid. We're going to get rid of that. Option C says scushing syndrome. You're going to see a person that is obese. A person that has buffalo, hum, moon face, and a lot of not. We don't see that here. We're not going to pick that. Furechromocytoma.

These people will symptoms tend to be episodic, episodic headache hypertension. I'm a person who has hypertension but again we don't even see any MEN association here. Like MEN2 or 2 B. We just don't see any of that. That's wrong. I'm going to go to Option E here. This person probably has graves disease. The most common cause of hyperthyroidism in the US. But this person has thyrotoxicosis. We can see many pieces of evidence here. Friends at the MEN2, they like to occasionally test the hyperthyroidism as anxiety. If you have a lot of thyroid hormone, you're going to feel like an anxious person. Frequent bowel movements that's common in people that have hyperthyroidism. Weight loss because your viso metabolic rate is going to increase. Your viso metabolic rate increases. You're going to be bringing up a lot of calories. You're going to lose weight. This person has e-fib. You're regularly regularly. Remember the most common arrhythmia. That's actually pretty high yield. The most common arrhythmia in people that have hyperthyroidism is e-fib. This person's got e-fib. You can hear a broo over the thyroid. The thyroid is diffusely enlarged. This probably groups disease. Palmerarthema, fingernails, lifting of the nail bed. Those are again all pretty common findings in people that have criss disease. This person has criss disease. We're going to treat the person for criss disease. Remember the T3, T4 will be high. The TSH will be low. This person should get PTU on methymosol.

Probably get methymosol since they're not pregnant. PTU is something we love to use in the first trimester. Although you can also use a trough pregnant, it's not a big deal. PTU is something we use in hyperthyroid like a thyroid storm because it inhibits the peripheral five-prone diogenes that converts T4 to T3. Use PTU can use methymosol. This person should probably get definitive treatment with I-131 therapy. It seems like the best thing to do. Option is the right answer here. Let's go to question 37. Oh, it's a HPI question. Again, for these questions, people kind of sweat over them. You should probably do them on your second pass through a block. But honestly, most times you just gloss over it. Many times it tends to be on the easier end of the spectrum. This is a guy that's 20 years old, coming to the clinic. There's probably nothing emergent. This person was coming for follow-up after colonoscopy shoulder because of a three-month after-after undergoing colonoscopy. Because he had a three-month history of hemaruquizia or inefficiency anemia. So like pooping blood, well, that's not good. My young person is probably one of these IB Ds, but let's keep going. So he has a three-month history of three-lose bowel movements daily. Okay, so chronic diarrhea. And I really like IBD a lot. No fever abdominal pain since colonoscopy, no brain red blood perrector. Reports known use symptoms today.

Passes through GAD, his own systolic parameters, and this is our first GAD, no allergies, more than father or fine. He is smoked. It's not a good idea. I mean, your young person, your 28, he's already smoked for 10 years. So he has a 20-pack of year history of 28. Sounds like COP Ds in this person's future. Okay, let's look at the vitals. Again, you're just looking off for anything that really stands out, and it's really bad. So the vitals, nothing crazy stands out. Well, the abdomen, scaphoid, normal active bowel sounds, liver spines, lying centimeters, biprocution, maltintinistopal patient of the regular quadrant without rebalancing or guardian. That's like the terminal elion area, right? This is IBD. No hepatosplenomagely. Dagnostic studies. So colonoscopy. Heirs of coalesced ulcers with normal appearing, you go through between involving the elion. Yeah, that's definitely, that's definitely, uh, IBD. What kind of IBD does the person have? This is Crohn's disease, right? See, skip lesions. Like, literally they're describing, again, the USM is another not come out and say colonoscopy shows skip lesions. That's ridiculous. Now, if they did that, everyone will get a 270 on their exam. No, they don't do that. Again, they're very descriptive these days, right? So what did they do? Oh, ears of coalesced ulcers with not all appearing, you go through between involving the elion. Basically, with that sentence, I'm telling you, this patient has Crohn's disease, all right?

So now, let's, let's answer the question. So which of the following is the most appropriate recommendation for this patient concentrating condition? Option A says, and also screening for lymphoproliferative disorders. Option B says, discontinuation of citadel-prone therapy. Option C says, prophylactic collectum. Option D says, smoking says, satial. All right. So let's look at the answers. I'm not screening for lymphoproliferative disorders. That doesn't really make any sense. People that have Crohn's disease, the big screening that's done in them is about eight to ten years after their diagnosis with Crohn's. They should be getting colonoscopies every one to five years because they have an elevated risk of colon cancer. Same thing applies for all three of colitis. Although, remember, the rule is kind of different if you have PSC. If you have primary sclerosis in colongitis, then you're going to start getting screened for colorectal cancer literally right after you've been diagnosed with primary sclerosis in colongitis. So I'm not going to pick option A. Option B says, discontinuation of citadel-prone. So necessary is anxiety. What I'm going to be doing for is anxiety for stopy is SSRI. That's wrong. Option C says, prophylactic collectum. That's something we'll do for all three of colitis, okay? Not for Crohn's disease. Because remember, on three of colitis, look at the name, alternative colitis. It kind of sticks to the colon. So it's the colon's going to mess up.

So to reduce these people's risk of colorectal cancer, we would have on three of colitis. We can be a prophylactic collectum. But this person does not have UC. UC does not cause skip lesions. It's Crohn's that causes skip lesions. So that's wrong. Option D says smoking cessation. I like that answer a lot because it's going to help his Crohn's, but it's also going to help him not get COPD and just dying the future from like the many other things that smoking causes in a person's life. So I'm going to go with option D. Remember smoking actually were since Crohn's disease. But people that start smoking, they are UC tends to improve. That should not be used as carfiblage to tell a patient or that has UC keep smoking. But certainly for a person has a ulcerative colitis, I mean, Crohn's disease. Stopping smoking is actually a helpful thing to do. So don't forget that factor. It is kind of high you to know for exams. Crohn's disease improves when you quit smoking. Option D for colitis improves when you smoke. So I'm going to keep in mind. Okay. Now, 19 year old man is brought to the ED by ambulance 15 minutes after he was stabbed in the chest during a fight. The stab wound is located immediately to the left, Nepal. At the scene, Paul was 105 per minute. Respirations were 18 per minute and blood pressure was 120 over 80. Paul sucks on room air should an oxygen saturation of 96%.

Two large bore intravenous catheters were placed on the routes to the ED and a lactated ringer solution was initiated. On arrival in the trauma bay, the patient develops a pulse of 130 per minute and blood pressure of 80 over 40 kilometers of mercury. There's GVD. Results of focused assessment with sonography for trauma fast and most likely to lead to which of the following next steps for the patient. Option E says CT is kind of the chest and abdomen with contrast. Option B says exploratory laparotomy. Option C says needle decompression and chest replacement. Option D says pericardial isis. Option E says peritoneolova. All right. So what are we thinking about here? So let's look at these answers. So CT is kind of the chest and abdomen with contrast. So CT is kind of the chest and abdomen with contrast is something that's reasonable to do. Typically, after you do a fast scan, depend on how do I put this. The CT is kind of the chest and abdomen with contrast. It just doesn't seem like a good idea in a person that is not stable. This person is definitely not stable. Person is tiny cardiac. They're super hypotensive. They've got in fluids and they're still like that. Person has a GVD. CT is kind of the chest and abdomen with contrast. It doesn't seem like a good idea in a person that is that unstable. I'm not going to pick that answer. Option B says exploratory laparotomy. Well, I will think of exploratory laparotomy.

If a person has a peritoneal sign, you know, rebound, garden, blah, blah, blah, blah, blah, blah, or stabbing drifts of the abdomen. This question is talking about the chest and the abdomen. I'm not going to pick up from B at all. Option E says peritoneal lavage. Again, that's something you worry about if you're dealing with abdominal issues. This person will stabbing the chest not in the belly. I'm not going to worry about that. Option C and D are great answers. Option C, obviously, is what you're going to be thinking of attention in your thorax. Option D is what you're going to be thinking of a pericardial effusion, you know, like basically a cardiac tamponat. So which one do we pick? Well, let's just go back to the question. If you go back to the question, you can pick out the answer. Just ask yourself, where did you gain this most efforts in? Option C, I would pick up. The question was talking about like, you know, decrease breath sounds subcutaneous and fizzy, something like that. Although that's usually more with us over your rupture. But decrease breath sounds and all those things. The question will focus a lot on the lungs. Option D, now pick up, if the person has like Bix triad, you know, hypertension, GVD, more foot heart sounds. This person is definitely hypotensive. This person definitely has GVD. We don't see anything about the more foot heart sounds. But under thing is also, let's go back to step one.

If you stop immediately to your left, Nepal, remember your left, Nepal is your point of maximum impulse. It's like the almost like the fifth intercostal space in the mid-clavicular line. That's your point of maximum impulse. That's where your left ventricle is. So if you were stopping immediately to the left, Nepal, chances are you probably start the person's left ventricle. So it's just more stuff here. That kind of goes with the heart. So I would go with option D here, pericardial synthesis. Yeah, it's kind of hard to differentiate that from option C, but I like option D better. If I were in an exam situation, that's a better idea. So I'm going to go to option D. All right, I'm pretty sure this person has cardiac tamponaut because that's just the one we have information for. Okay, question 39. A 47-year-old woman is scheduled to undergo a right knee arthroscopy and partial medial meniskeleton. Medical histories of the Lyzon remarkable. At her pre-op examination, two weeks ago, her surgeon discussed the risks and benefits of the procedure and both parties signed the operative consent form. On the patient's arrival at the hospital, the paperwork is reviewed, she's taken into the operating room and sedated, and the anesthesiology team starts a spimer on aesthetic. After the patient's regular extremities spread for the procedure, the surgical pause is taking to review the patient's name and consent form and to confirm the site of the surgery.

The pre-openeding room team is unable to locate the consent form for review. No markings are present on the patient's extremities to indicate the site of the procedure. The surgeon says that he remembers reviewing the consent form with a patient and seeing her sign it. The patient's husband is in the waiting room, which of the following is the most appropriate course of action? Option A says, ask the patient if she recalls, sign the consent form, and if so proceed with the operation. Option B says, ask the patient to sign a new consent form and proceed with the operation. Option C says, do not proceed and remove the patient from the operating room. Option D says, obtain verbal consent from the patient's husband before proceeding with the operation. Option E says, proceed with the operative procedures planned. Okay, here's the thing. If you don't have a consent form, you cannot do non-emergent surgery. Simple as that. Is this emergency surgery with the person die if you don't do the surgery right now? No, so this is non-emergent. Okay? Do we have a consent form? We don't. Do we have something in writing? We don't. Should we do the surgery? No. Option C, move along. That's it. Option C is the best answer here. Right? You sure are call signing the form if so. No, you don't have a physical evidence. Right? That's the thing. When you do things in haste without complete information, that's how people get in trouble many times in life.

Think of that as your life less than for today. So that's that's wrong. Right? Option B says, ask the patient to sign a new consent form. But again, usually you want to try to obtain consent under like non-stressful circumstances, if possible. Obviously, if it's emergency surgery, you got to get consent quick. But this is not emergency surgery. So, option B, no. Right? Because there are just so many things that can go wrong here. It's not just the consent, but like, okay, what side are we doing the surgery? You don't want to do wrong limb surgery. That'll be bad. Right? So, option C, do not proceed or remove the patient from the operating room. One, do work things out well. That's a better thing. Option D says, verbal consent from the patient's husband. No, I should get it from the patient. If you can get a consent from the person that's getting the procedure, that's usually a better idea. Option E says, proceed with your previous procedure as planned. Don't do that. That's not a smart idea. All right, you literally have no consent, physical or routine evidence. Don't do that. Okay. If we'll do question 40 again, I guess let's jump into question 40. Then I'll see a few things at the end. So, 30-year-old man comes to the physician because he and his wife have been unable to conceive during the past two years. Previous evolution of his wife should not have normalities. He has not been exposed to pesticides, heavy metals, radiation, or testicle overheating.

Wow, but USML Is and varicosell. Testicle overheated. I wonder, what do you mean by varicosell with testicle overheating? That's actually a great way for our friends at the NBM needs to describe a varicosell. Ouch! You think you've heard it all and then you read a question and you're like, wow, these people are already getting up there. But remember, when you have a varicosell, your pump-informed plexus is dilated. So, it's not draining the testicles well. So, blood is going to hang around in the testicles. When blood hangs around in the testicles, it's going to basically make the testicles at body temperature, which is not good because usually the testicles, we try to keep it at two degrees below core body temperature. That's the optimal temperature for sperm production. So, that's where the scrotum is outside the body. But if blood is kind of chilling in your testicle, that blood, remember blood carries heat. It's going to keep that heating in your testicle. So, sperm is not going to be produced. But and also, you know, people that sit on horseback and stuff, you know, all that pressure and stuff on the testicle is probably not very helpful for a person's reproductive potential. Okay, now, physical examination shows no abnormalities. Serum studies show a testosterone concentration. Within the lower reference range, a diagnosis of a legal sperm is made. Which of the most appropriate initial action by the physician? All right.

Option E says, ask the patient about his alcohol intake, smoking and stress level. Option B says, educate the patient about declining sperm count will increase the age. Option C says, prescriber, phosphodisteries, inhibitor. Option D says, provide a topical testosterone gel. Option E says, recommend, recommend, in vitro fertilization. All right. So, let's look at these answers. So, this prescience will go sperm. So, will it go sperm? It just means that, you know, what? Check a semen sample. It's not much sperm in it. Probably like under 15 million. I think that's like the cut off under 15 million per meal. On the 15 million sperm per meal of semen or something like that. So, let's look at the answers. Let's talk about option E. As the patient about his alcohol intake, smoking and stress level. Yeah, alcoholism, smoking and stress can kill a person's semen production, I mean sperm production. So, let's keep that for now. Option B says, educate the patient about declining sperm count will increase the age. This guy's 30. He should still have good reproductive potential. And honestly, that seems like not a good idea. Okay. Remember that concept I said of figuring out what a problem is before you start fixing it. If a problem has not been figured out, you should probably try to figure it out before you start fixing it. So, option B is like you're trying to fix or with no figured out. Let's not do that. Option C says, prescriber, first for diastereism inhibitor.

This is probably like the answer that many people pick that will be wrong. This person does not have erectile dysfunction. You got to figure out exactly what's going on. The person has oligospermia, not erectile dysfunction. I'm going to be giving them some dental feel for oligospermia. That's wrong. Option D says, prescriber, topical testosterone gel. That's not a good idea. That's not a good idea actually. Can you be careful about that? Topical testosterone gel. You do that so people have like lowly bidon and whatnot testosterone. You can give people testosterone if they have many formulations I imagine of testosterone. But people that have lowly bidon and stuff, I don't know if a gel is the best way to accomplish that goal. I don't know much about that. So, I'm not going to speak on what I don't know about. But this person doesn't have lowly bidon. They just don't know making an oligosper. Option E says, in vitro fertilization. No. Again, in vitro fertilization is something we do when there's infertility, usually from the female side of things. For the male side of things like this guy that has oligospermia, the way you would likely fix the problem is doing an intra-utering in dissemination. So, you pretty much put cement in the uterus. That's not the same thing as IVF. IVF you're literally doing stuff like in the lab. Something you want to keep out the back of your mind. Again, read your questions carefully.

And if you notice options B through E, we're trying to fix what we don't know about. We don't know what's going on first. Why does the person have oligospermia? Because if you can figure out the organic cost, then you can fix it better. So, option A seems like training clarify what's going on. So, I like option A a lot. Just like a testing principle of discourse now right there. So, let's go ahead and stop there. This is more than 40 minutes already. But again, I have review courses that can help you many of these subjects. If you like the way I teach, the way I make integrations, the way it's being pathophysed, you'll like the review courses I have. I have classes for Step 1 to Step 3 starting tomorrow. So, that's Thursday, the 21st of March. So, Thursday, Friday, Saturday. Thursday, we have the NV Me testing and strategy courses, 24 hours long. Friday, we have the forward bio stats classes. Saturday, we have the social sciences, quality improvement, healthcare systems and ethics class. Offer Step 1 to Step 3. And then it's not in next week on Monday, on the 25th. We have the 20 hours Step 2, Step 3 class. Again, if you're expecting a lecture, you shouldn't come to the class. That's not where you're going to be getting. The classes are going to be those clinical situations, exam style questions and everything. Then I'll use those to show you how the material is presented. Help you make integrations, help you understand pathophys.

Again, many people have taken these courses and found them to be profoundly helpful. So, if you're interested, the all over Zoom should be an email through the website and give you some more information. And then I also offer one on one tutoring for all the USML and complex exams. I have this podcast on Apple, Google and Spotify. I have a You Tube channel where I make videos you can check out. I also help with the residency application process, rec letters, personal statements and all those things. And then I also have another website called Divine Interventional Life Lessons.com. Every week I try to post two podcasts, usually about 10 minutes long, where from a biblical perspective I address a life lesson. There's actually an Apple podcast that's related with that. It's called the Divine Interventional Life Lessons podcast. And the website again is Divine Interventional Life Lessons.com. So, thank you for joining me today. I'll see in episode 523. I wonder if you're interested of your day. God bless you. Bye for now. Thank you.

Endoscopy (EGD) with biopsy to rule out peptic ulcer disease and test for H. pylori.

Plan, Do, Study, Act—a continuous cycle used to implement and refine changes in healthcare processes.

Atrial fibrillation (A-fib).

Smoking cessation, as smoking is linked to increased risk and worsening of IBD.

Hypotension and tachycardia (Beck's triad components).

First, investigate the underlying cause (lifestyle factors like alcohol/smoking) before initiating treatment.

Crohn's disease.

Hypotension, muffled heart sounds, and jugular venous distention (JVD).

Graves' disease.

Explaining the futility of the proposed intervention (Non-maleficence).

Alcohol intake, smoking status, and stress levels.

Prophylactic colectomy (due to continuous inflammation limited to the colon).

Crohn's disease.

Hypotension, muffled heart sounds, and jugular venous distention (JVD).

Graves' disease.

Explaining the futility of the proposed intervention (Non-maleficence).

Alcohol intake, smoking status, and stress levels.

Prophylactic colectomy (due to continuous inflammation limited to the colon).