DIP Episode 583 - 2025 USMLE Step 1 Free 120 Discussion Part 3 (Q21-30, super helpful for Step 2 and 3!)

Welcome, my name is Divine. This is episode 583 of the Divine Intervention Podcasts. In today's podcast, we're going to be continuing the series on the step one, three, one, twenty. Again, as I've said, this series is also very useful for people studying for step two and step three. The thing is the lines between step one, step two, seek and step three are becoming more and more blurred every single year. Alright, so if don't questions one to twenty, so let's jump to question twenty one. So it says, a 65 year old woman is brought to the ED because of a 10 minute history of chest tightness and severe pain of her left arm. Physical examination shows Joglevino's distension. Cracles are heard over the long fields and ECG shows ST segment elevation greater than one millimeter in leads V4 through V6 and new Q waves. Serum studies show an increase troponing eye concentration, which of the following labeled points in the graph best represents the changes in cardiac function that occurred during the first 10 seconds after the onset of chest of pain in this patient. So clearly this person has an MI and then we're giving a cardiac function curve. We see on the y axis, we have cardiac output on the x axis, we have endastolic volume. Right. I just feel like many times people end up making these stains harder than they need to be or sometimes resources make these stains harder than they need to be. But if you notice in this question, this person has an MI.

So just use very simple straightforward thinking. If you have an MI, your cardiac muscle is not getting enough oxygen on blood. So it's not going to be working, right? It's not going to contract as well. So your cardiac output should go down. That's number one. And then number two, if you really think about it from an endastolic volume perspective, that relates to preload. It just means, hey, how well is your heart feeling with blood? Well, the thing is your heart. And also your endastolic volume, I guess, is a function of how well your heart is able to get rid of. But really, it's more based on how well your heart is feeling with blood. Right. Because if you think about it, these people want their heart is not contracting. Right. So their cardiac output is down. But their heart is not feeling with blood actually. It's just that they cannot contract and send this blood out. So over time, blood is accumulating. So their preload is fine. It's just that their contractality is terrible. So blood will be coming back to the heart. It just has nowhere to go because you cannot pump it out very well. Right. And it makes sense. Right. It manifested as us being able to hear crackles in this person's lungs. So honestly, the only answer that makes sense here has to be an answer where cardiac output is going down. Right. So going from like W to X or Z, you know. So, but the thing is even going from W to X cannot be right.

Because if you're going from W to X, your endastolic volume is not changing. And that's not what's happening here. Right. These people literally, their hearts, the preload is fine. They can't contract well. So blood is accumulating in the heart. It has nowhere to go. So their endastolic volume actually. So look at EDV endastolic volume. Volume of blood left in the heart after the astaly after feeling. Right. It's going to be increasing and increasing and increasing because that blood is not leaving the heart because the heart is not contracting very well at all. Right. So it has to be some answer where the cardiac output is going down and the endastolic volume is increasing. And only if the only answer that really makes a lot of sense with that is going from W to Z. Because going from W to Z on the Y axis, you see that the cardiac output is plummeting and on the X axis, the endastolic volume is increasing. These changes from Y are not exactly possible because in going from Y to Z or X, your endastolic volume is going down. And that's not what is reflected in this question. Your endastolic volume should go up in this question. I mean, think about here, why would this person have crackles in the lungs? Right. Just something to kind of keep in mind. So I think I'm going to go with option C for this one. It really makes no sense to even consider the other ones. Right. Because the other ones going from X upwards to W, Y makes no sense.

Because that means all your cardiac output is rising. That's certainly not what is happening. And going from Z to W, Y also makes no sense because your cardiac output is not rising. Your cardiac output is actually falling here. All right. So we're going to go to question 22. Previously healthy 33 year old woman is brought to the emergency department by the secret service for stocking the president of the USA for two months. She claims to be married to the president's twin brother and states that the president just had a twinkid nap to avoid competition. She speaks rapidly and is difficult to interrupt. Her associations are often loose. She says, I haven't slept for a day. But I wouldn't even try to sleep until my husband is rescued. God has been instructing me to take over the White House. I can't wait to be reunited with my husband. I hear his voice telling me what to do. When asked about drug use, she says she only uses natural, she uses only natural substances. She refuses to permit blood or urine tests saying, I don't have time to wait for the results, which of the following is the most likely diagnosis. Right. So again, we see this person is having sleep problems. This person is having these grandiose delusions. Right. This person is very talkative. You can see that I'm kind of feeling in the blanks for a lot of these dig fast symptoms. Right. So what does dig fast stand for? Remember, the distance for destructibility, the I stands for. So let me go through the rest.

I remember the I so destructibility, the G stands for grandiosity, the F stands for flight of ideas, the A stands for like activity increase, the S stands for sleep problems, like lack of sleep, the T stands for talkativeness. I kind of wonder what the I stands for irritability. Yes, irritability. I think that's what it stands for. The dig fast pneumonic in people that have bipolar disorder. Right. People that have bipolar disorder. Right. So don't forget your dig fast pneumonic is something that's actually pretty high you to know for for exams. Right. So dig fast pneumonic very, very high you to know. Wait, I'm thinking irritability relates to generalize anxiety disorder. What does the I stand for? Oh, yeah, I think that I actually do stands for impulsivity because people that are borderline, I mean, sorry, that are bipolar, especially people that are manic, they tend to be very impulsive. So sorry, the I stands for impulsivity. Okay. So let's run through this again. D for this tractability, I for impulsivity, G for grandiosity, F for flight of ideas, F for activity increase, S for lack of sleep, and then T for talkativeness. Right. So this person clearly has bipolar disorder. This person is manic and she's having these psychosis, right. She's kind of having these weird beliefs that she's, she's married to the president's twin brother. So option A makes the most sense. Option B will be wrong because our symptoms have gone on for more than a month.

Pref psychotic disorder is when you have issues for less than a month, you know, schizophrenia like symptoms for less than a month. She's having this for like two months. The illusion of disorder is when you have this fixed false belief, you know, despite evidence to the contrary. But this person has a lot of other stuff going on, right. She clearly has psychosis. She clearly, you know, she, you see she has many other features of bipolar disorder. She doesn't just have this fixed false belief and then have no more functioning. This person does not have normal functioning. This person is extremely manic. And then option D says psychotic disorder due to a general medical condition. I don't see any general medical condition here. We don't see any abnormal labs or anything of that sort. And then schizophrenia are symptoms that have not been going on for six months. Remember, if you have symptoms for less than a month, these brief psychotic disorder want to six months is schizophrenia from the disorder and they're more than six months is schizophrenia. This person has not had symptoms for up to six months. So I'm going to go with option A here. This person is probably going to need some kind of anti psychotic to calm her down at first. And they need to add some kind of multiple like left. Theum of our prick acid or something of that. Nature. All right. Now question 23 says in an informal couple that their newborn has Down syndrome.

There is a specific relatively limited amount of information that the consulting physician should give immediately. The rest can be discussed at a later time, which of the following best explains the purpose of using this approach to disclosure. Right. This is pretty straightforward. Think about it. You're giving a very devastating diagnosis to a family. Right. You don't want to just like lay like just load them with tons of information. They may not be ready to receive it because emotionally these people are probably pretty drained. They're going to be very drained by the information you're giving to them. So it just makes sense to give only what is necessary. And then later you can, you know, in other visits, you can solve everything in one visit in other visits. You can give some more information. So let's look at the answers here. Psyne A says, allowing the couples primary care physician to discuss most of the information with them. That's no why we're doing that. Option B says, allowing the parents time to tell all the family members. No, it's not that the family, all the family members are not necessarily a problem where we're focused on the people that actually have the issue. Option C says, delay in parental distress until the information is completely disclosed. No. Option D says disclosing the most important information so that it can be understood as fully as possible. Yeah, makes sense, right.

Because again, when a person is emotionally down, they may not necessarily be here and what you're telling them. I like option D a lot. Option E says influencing the parents course of action about what is medically most appropriate. No, you're not trying to influence them. You're supposed to be truthful with your patients, right? So ultimately, every piece of information they need, you should give them. You may just not give all of it at one visit. I've noticed with many of these ethics style questions, you need to kind of go through every single answer. You cannot just settle on one answer and you've kind of seen everything. So I like option D a lot for this one. So again, remember option 21, we said the right answer was C, question 22. We said the right answer was a question 23. We said the right answer is D. All right, let's go to question number 24. A 62 year old man comes to the physician because of a six month history of urinary hesitancy and dribbling after your ination. He has to urinate two or three times nightly. Physical examination shows a diffusely enlarged firm and non tender prostate. Which of the following is most likely to have contributed to the development of this patient's condition, right? So again, let's work out what's going on here first. This is probably BPH. This person probably has BPH. Old guy with urinary problems, right? Don't don't overthink this thing. This is just good old BPH.

So he says what could have contributed to this patient's condition? Okay. We know that BPH can be managed with a seems like this is a pharmacology style question. We know that short term, your symptoms can be controlled by giving an alpha one blocker like Tamsulocin or Doxazocin or Prasocin. For long term, you need to shrink the prostate. You need to shrink the prostate. This person's prostate is big. That's why it's compressing on the bladder neck, right? So I want to shrink the prostate by giving an alpha alpha reductase inhibitor. Because remember testosterone is converted to DHT by alpha alpha reductase. And in that DHT is what encourages the prostate to grow, right? But if you give a alpha reductase inhibitor like Finasteride or Dutasteride, that's going to cause less DHT to be formed. It's going to resolve or reverse that prosthetic, uh, prosthetic problem. So option E says activation of the alpha one adrenovic receptor. Let's keep that. Let's keep that actually because we use alpha one blockers to treat BPH. So activation of the alpha one receptor, yeah, that may cause symptoms. Let's keep that. Option B says conversion of testosterone to DHT. Oh, yeah, because and that's actually like more directly related to what we're dealing with, right? We know that DHT is what makes the prostate and this is literally BPH. DHT is literally what makes the prostate grow. So that's a more direct answer. So B may actually be right here. But let's look at the other ones.

Option C says conversion of testosterone to estradiol. Uh, that's not what's going on here. That's like aroma taste. Excuse me. Option D says inhibition of the alpha one adrenovic receptor. That's wrong, right? That's literally how we treat BPH. Option E says production of PSA. That's ridiculous, so honestly for this one, it's between options NB, but I like B a lot because it's just more direct to the pathophysiology behind BPH. So option B is going to be the right answer. At least that's the one I'm going to pick. All right, question 25 says a 19 year old man who is in the US army is brought to the ED 45 minutes after he sustained a knife onto the right side of his chest during an altercation. He has no history of major medical illness and takes new meds. His temperature is fine. His stachycardic, his tecnic, his blood pressure is not too bad. Post-sox on room air shows an O2 side of 94%. On physical exam, the tricky appears to be shifted to the left. Poignant examination of the right chest is most likely to show which of the following findings, right? So what does this sound like? You see the trickier deviated, the person stachycardic tecnic has just been stabbed in the chest, right? This sounds an awful lot like a pneumothorax, so a lot of air is collecting in the plural cavity. A lot of air is collecting the plural cavity, right? So obviously because air is collecting the plural cavity, you've basically displaced the lungs on the right side.

So because you've displaced the lungs, those normal breath sounds will be decreased because you're literally not hearing the lungs because the lungs have literally been displaced. So the right answer has to be something that has decreased breath sound. So we can probably get rid of option C and D right off the bat. All right, so the answer is probably got me B between A, B and E. And then percussion. The thing is whenever supercution is something that is like, hey, if you tap on the patient's chest, like what do you, what do you hear, right? Whenever you have like a consolidation in the lungs, they'll be don't as supercution. But whenever you have air, like increase amounts of air in the lungs or in the plural cavity, so see for example, I present the has COPD or present the has a pneumothorax. You're actually going to have hyperresonance to percussion, hyperresonance to percussion. So just based on the strength of that, where we know that, oh, you're going to have decreased breath sounds and hyperresonance to percussion. Honestly, option B has to be the right answer. But let's look at this whole frame it as part, right? So frame it as is something where like you put your hands on the patient's chest, well, and say, you know, say something like 99 or say something like toy boat, right?

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Decreased breath sounds and hyperresonance to percussion on the affected side.

Testosterone.

Cardiac Output (CO) decreases, and End-Diastolic Volume (EDV) increases.

Grandiosity.

To ensure that the most important information is understood fully and to prevent overwhelming parental distress.

Decreased breath sounds, hyperresonance to percussion, and potential tracheal deviation.

Falling Cardiac Output (↓ CO) with rising End-Diastolic Volume (↑ EDV).

The conversion of testosterone into dihydrotestosterone (DHT), which stimulates prostate growth.

Grandiosity, Flight of Ideas, and Talkativeness (or any combination from D-I-G-F-A-S-T).

To prevent emotional overload and ensure that the critical information can be processed and understood by the parents.

Decreased breath sounds, hyperresonance to percussion, and potential tracheal deviation.

Falling Cardiac Output (↓ CO) with rising End-Diastolic Volume (↑ EDV).

The conversion of testosterone into dihydrotestosterone (DHT), which stimulates prostate growth.

Grandiosity, Flight of Ideas, and Talkativeness (or any combination from D-I-G-F-A-S-T).

To prevent emotional overload and ensure that the critical information can be processed and understood by the parents.