DIP Episode 526 - 2024 USMLE Step 2CK Free 120 Discussion Part 8

Welcome, this is episode 526 of the Devan intervention podcast. In today's podcast, we're going to be continuing the conversation on the USMLE step to seek everyone 20. There's going to be part 8. If you've missed the first seven parts in this series, you should listen to it a lot of learning to be had. I would pretty much want to know the first 60 questions. For the last few podcasts, I've been trying to knock out 10 questions per podcast, but 61 to 70 have pretty extensive discussions that I want to give. So I'm going to kind of split it up. So I'm going to do 61 to 65 in this one. So let's get right into it. So question 61 says, 67 year old man is evaluated in the intensive care unit. He has end-stitch pancreatic cancer and was hospitalized three days ago for treatment of pneumonia. Respirations are six per minute, pulse or semi-tranal 100% oxygen by face mask, shows an auto saturation of 78%. Respiratory stress shows fever respiratory efforts. He's using accessory muscles of respiration or mental status examination. The patient is oriented to person, but not to place or time. If the patient is not in the tricky lane to build a mechanical mechanically ventilated, he will die within hours. His wife says the parent recently told her, the patient recently told her that he would never want mechanical ventilation. But he never completed paperwork regarding his wishes.

His daughter insists that he be mechanically ventilated, which of the following is the most upper reduction for the physician to take. He says, performing the tricky lane to patient and begin mechanical ventilation. He says, performing the tricky lane to patient and then consult the hospital ethics committee regarding mechanical ventilation. Option C says, performing the tricky lane to patient only. Option D says, provide palliative therapy only. He says, seek a court order to assign a legal guardian. So this is a pretty simple question. Especially in hospital credit cancer. Again, we're possible always clarify, do we have wishes from the patient? That supersedes all things. If we don't have wishes from the patient, then we can go to a surrogate like the spouse. The spouse is kind of first line. We can ask the adult kids. We can ask the parents. We can ask the adult siblings in that order. So does this patient have wishes? Oh, absolutely. The Bible. No, I just made a divine intervention life lessons podcast. So the Bible. This question says, his wife says the patient recently told her that he would never want mechanical ventilation. That's the patient's wishes. So we're not going to do mechanical ventilation or intervention. So option D is the one that makes sense. Any sense, right? Provide palliative care therapy. That's it. All right. Let's go to question 62. So a 5-day old boy is brought to the office for an initial well-child exam.

He was born at 40 weeks just he should have discharged at 60 hours of life. On newborn screening, he moved to be an electro-ferrous, he should have an FS pattern. Oh, okay. We'll talk about all that. He is at the 50% half or length and weight. Temperature is 37.0 degrees Celsius. That's 90.6 degrees Fahrenheit. And pulse is 136 per minute. And the rest of the conditions are 34 per minute. He appears well. The combination shows no abnormalities, which of the following is the most appropriate next step in management? Option A says deferoxamine therapy. Option B says hydroxyure therapy. Option C says iron supplementation. Option D says monthly blood transfusions. Option E says benicillin perophylaxis. Then option F says vitamin B12 or cyanocobalamine supplementation. All right. So let's see. First things first, what does this child have? This child has sickle cell disease. And maybe like to know how do you know? So you talk about the hemoglobin electrophoresis results. Right. Basically, whatever you see as a result is what the person has. So we're told that this person has an FS pattern and FS pattern. So if you have an FS pattern, FS pattern, what do you think that means? It means that, oh, we see hemoglobin F. That's fellow hemoglobin. I see hemoglobin S, which is the mutated hemoglobin. So you may wonder a divine, couldn't this person have sickle cell trait? Remember, if we're pressing a sickle cell trait, they have one good hemoglobin and one bad one.

One good beta globin and one bad beta globin. So if you were to do hemoglobin electrophoresis, you'll see a, you'll see an FES pattern, right? You'll have some hemoglobin A, they'll have some hemoglobin S, and they'll have some hemoglobin F. So this person has an FS pattern. We don't see any hemoglobin A at all. So this child has a sickle cell disease for sure. So obviously we should own the option A because the thing is sometimes, you know, some people that have sickle cell disease, they can be transfusion dependent, blah, blah, blah, blah, blah, blah, right? So I could see why you're pressing me think, oh, maybe we should put them on ion, killator therapy, but this person is a newborn right now. It's not like they're getting a recurring transfusions where they need ion killators. So it's just not indicated right now, okay? Option B says hydroxyurea therapy. Let's keep that actually. Option C says iron supplementation. Again, this child doesn't currently have any ongoing anemia. We don't need to start supplementing iron. Option, you also kind of want to be careful about that because if they're going to be getting a lot of blood transfusions in the future, it won't them to develop iron overload. And D says monthly blood transfusion again. We don't really need to do that. The child is like asymptomatic right now. Option E says penicillin prophylaxis. That's actually something we're doing sickle cell disease. We're going to keep that for now.

And then option F says vitamin B12, that's cyanocobalamin supplementation. So let's examine this. We didn't really need B12. The thing that people that have sickle cell disease actually need is full eat because the thing is many of us have our bondant stores of B12. You have like a few years worth of B12 in your body. As you may be 18, like a normal diet and you're not a vegan or anything like that. But fully, you only have about 10 weeks to about three months worth. So people can run out of fully really quick. So people that have sickle cell disease, they tend to take quite a bit of fully it actually. And also, if you look at these answers, they are two answers that are also pretty good for sickle cell disease. They said drugs are rare. We know that. That literally increases hemoglobin F. So it's pretty good for sickle cell disease. And in addition to increasing hemoglobin F, it actually being shown to reduce the number of a visual-close-up episodes. But another thing that also helps is penicillin. Because remember, these kids, they tend to auto-digest their spleen very early in life. So they have a high risk of sepsis from encapsulated organisms, like strep pneumo, hemophilus, influenza, and isermin ingested. So you even wonder, man, divine, how do we know what to pick here for the big hydroxyarrhea or the big penicillin? Here's the thing. Hydroxyarrhea, I think it may be helpful to know the mechanism of action of hydroxyarrhea.

Believe it or not, hydroxyarrhea is a chemotherapy drug. The way it works is that it inhibits ribonucleothide reductase. It inhibits ribonucleothide reductase. So it's literally achymodrog. It's a chemotherapy drug. It's a chemotherapy drug actually. So the thing is, would you really feel comfortable right now, giving chemo to a 5 D old? That doesn't seem like a very solid idea, right? Because you know, it can cause bone marrow suppression on all these things. In fact, there is a reason why we generally don't give hydroxyarrhea to a pregnant woman. But is there any harm to giving penicillin to a 5 D old? I don't see any harm. I mean, women get penicillin into a problem. So again, there are some questions on your exams where you have to do like a risk-benefit analysis. So in this case, I'm actually going to go with us giving this child penicillin. Typically, kids that have sickle cell disease, we give them penicillin until about age five, just to reduce that risk of sepsis and infection with encapsulated organisms. Now by the way, hydroxyarrhea, I believe it or not, we don't start giving it immediately or boring if you have sickle cell disease. We wait until you've lived for a while, you know? Some people and the guidelines on that are not entirely clear, but for sure, you should not give it to a newborn and for sure, you should not give it to a pregnant woman. Hydroxyarrhea is something you usually give.

You know, there are some studies that say, oh, you can study this earlier as like, at least some readings I had. That say you can start as early as nine months, but usually people wait for a few years before starting people on hemoglobin F. I mean, sorry, on hydroxyarrhea. So I'm going to go with option E here. Okay, now question 63 says a one week old female newborn is brought to the office for a full-up examination after newborn screening showed a serum TSH concentration of 40 micro use per meal, right? And normally is one to 20. She has been breastfeeding well. She passes five to six tools and has multiple weight diapers daily. She has returned to her birth weight, vital signs, or within normal limits. Examination discloses no abnormalities. Serum studies today. So TSH concentration of 14 micro use per meal, normally 0.5 to 6.5 and free pyroxene. That's 34 concentration of 0.49 grams per desglitter and normally 0.92. Which of the following is the most appropriate next step in management? So option A says hydraulic hydroquadison therapy, option B says level pyroxene therapy, option C says monthly serial measurement of serum, thyroid, globulin concentration, option D says monthly serial measurement of serum TSH and free pyroxene. That's free T4 concentration. Option E says radioactive iodine optics scan, option F says ultrasoundography of the thyroid gland. So what do you think? So we see a child that has a high TSH and a low free T4, right?

So this child clearly is hypothyroid. The thing is hypothyroidism in a little child is not good because he can affect brain development. So want to start trading as quickly as possible. So we're going to go with option B. You're going to do thyroid hormone replacement therapy. If you look at the other answers, you don't really make much of any sense, right? Hydroquadison. Something we'll give to a person that has adrenaline, so efficiency, this child doesn't have that. Using these values monthly on a serial basis doesn't fix the problem. Radioactive iodine optics scan is something we do when we suspect the hot nodule. And ultrasoundography of the thyroid is what you do. If you're trying to look at like a cold nodule or thyroid nodule that you feel on exam, or if you're trying to do a finaly last version of the thyroid mass, you're going to usually do it on the ultrasound guidance. So again, this child is hypothyroid and what's the most common cause of hypothyroidism in a newborn? It's going to be thyroid is genesis, right? So the thyroid does not develop properly. So this child has hypothyroidism. Let's go ahead and trade it. Let me try to trick you on your exam and put Hashimoto's as the most common cause in a newborn. Don't do that. Hashimoto's right is an autoimmune disease. You should probably have left for a while before you start developing autoimmune disease. It's very rare to just be born with an autoimmune disease, at least on the USML. Okay.

Question 64 says an 18-year-old patient comes to the emergency department because of a two-day history of severe abdominal pain. The pain began in the middle of the abdomen after a large meal, but now his local lifestyle are right lower quadrant. The patient also has a two-month history of intermittent diarrhea. Three weeks ago, the patient had an operator in fact, trucked infection. The patient resorts spontaneously. The patient currently takes new medications. The patient identifies as non-binary and uses the-they-pronounce. Their signs say that birth was male. They do not smoke cigarettes or use other substances. Temperatures 37.8 degrees Celsius, that's 100.0 degrees Fahrenheit. Pulse is 80 per minute. Respirations are 20 per minute and blood pressure is 110 over 70 millimeters of mercury. Some examination shows fullness and tenderness to palpation of the red lower quadrant. Localsight count is 11,000 per millimeter cubed, which are the fullings the most appropriate next step in diagnosis. So, option E says abdominal ultrasound onography of the right lower quadrant. Option B says air contrast barium enema. Option C says CT scan of the abdomen. Option D says technician 99 M scan of the bowel. Option E says upper GI series with small bowel flow through. This question is kind of weird. But these weird questions definitely pop up on the USM at least. I call them weird questions because they are very non-descript, they are very non-specific.

You kind of wonder like, when, when, when, where am I going to go here? Because this person has CV abdominal pain. CV abdominal pain, that's the chief complaint. He studied in the middle of the abdomen, but now his look likes to the right lower quadrant. So, I guess it seems like appendicitis. And there are just many things here that don't make any sense. Like this patient has no fever. This patient, if I remember my white count, not well, this person's white count is normal. Well, they have a regular lower quadrant tenderness. So you know what? This seems like appendicitis. That's probably the thing that makes any logical sense. But again, it doesn't fit the classic presentation quite a way for appendicitis. So whenever the diagnosis is not clear, you want to do a CT scan with appendicitis. If you suspect it. So we're going to do option C here actually. Option E says ultrasound. Ultrasound is not as good as CT for evaluating. Cut up appendicitis. Option B says air contrast barium enema. That doesn't know how we diagnose appendicitis. Option D says the technician 99 M scan. That's how we diagnose mechols diverticulum. And then option E says upper GI series with small bowel follow through. That's how we diagnose biliosis in a newborn, you know, like my rotation, do a normal atrija, jajun, a normal atrija, can I deal? Okay. So yeah, for that, I think I'm going to go with option C. So let's go to the last question, question 65. Again, it's just more discussion with these.

So again, we're going to call it a question 65. So at 25 year old woman, gravity of three part to a 36 weeks gestation comes to the ED. Because of heavy vaginal bleeding, following sexual intercourse three hours ago. She has received no prenatal care. That's no lies. She has low history of serocelness or pretty procedures vital signs are within normal limits. Continuous external fetal heart monitoring shows a baseline of 155 per minute with no accelerations or decelerations. The uterus is consistent in size with a 36 week gestation. Tocodinamometer, dinamometer, yup monitoring, shows contractions every eight minutes, which of the following is the most appropriate next step in management. Option E says cesarean delivery now. Option B says, digital examination of the pelvic. Option C says, intravenous administration of magnesium sulfate. Option D says, intravenous administration of oxytocin. Option E says, transabuminal otrosymography. Let me ask you this. Do you know exactly what's going on in this question? No, you don't. So remember from one of the earlier podcasts in this series, I talked about the figure it out and then fix it approach to USMD questions. You got to figure out what's going on first before you start fixing it. So we've not figured it out. And this person, it doesn't seem like this person is like super unstable or dire right now. The vital signs are within normal limits. So you have time to figure it out.

So we should probably try to pick a diagnostic test first. So I'm not going to be doing option A, C section now. That doesn't make any sense. Option C and D. I mean, option C is something you're doing. Your just like a person has like a preclams, your claims here. This person doesn't have that. So that's wrong. Option D is what you do, you know, but again, yeah, you can get a dosage. You try to kind of get the pregnancy going, but we don't know what's going on for yet. Right. But we know that this person has third tremors to vaginal bleeding and it kind of seems painless. At least it doesn't seem like this person has any significant abdominal pain. So what are we going to do here? Well, we have two options. Option B says digital examination of the cervix. Option E says transabdominal ultrasound. So here's the thing. We know the causes of third tremors to vaginal bleeding. You know, if it's painless, things like visa, previous, plus interprevia, if it's being full, things like urine rupture or abruptuoplacente. But the thing is we don't know which of these things we're dealing with. So we probably want to look first because what if it's like visa-previa where it's fetal blood vessels that overlie the cervical loss? If you do a digital examination of the cervix, if you literally use your fingers to go into the cervix, you may inadvertently rupture those vessels with your fingers. So figure out what you're dealing with first before you start jumping in.

So I would say we should do a transabdominal ultrasound first. Option E before we go for a digital examination of the cervix. Right? Do something that is not invasive. Right? I mean, not inadvertently rupture some vessel or placental, whatever. So do that first before you then start using your hands. So not a good option E here. So I think I'm going to go ahead and stop here. Again, I offer review courses for step one, just step three. I have a bunch of courses running in the month of April. I meet podcasts on those. So just check those out. Well, I have this last minute review as well. That's taking place in April. I made a podcast on that. I also want to want you to infer all the USMEL Es, all the complex exams and medical exams. And I have these podcasts on Google, Apple and Spotify. And I have a You Tube channel where I post the videos that I make. And I also help with your applications and whatnot. So if you need it out there, should be an email through the website. And then finally, I have another website called Divine Intervention Life Lessons.com. Every week from a public or perspective, I try to address a life lesson twice. I usually post a podcast on Fridays and Sundays. I was just posted one this morning. So just check that out. There's actually a website, Divine Intervention Life Lessons.com. There's actually an Apple podcast associated with that called the Divine Intervention Life Lessons podcast. So thank you for joining me in this episode.

I will see you in the episode 527. Have a wonderful weekend. God bless you and bye for now. Thank you.

The patient's previously stated wishes (Advance Directive) supersede family desires.

A transabdominal ultrasound to rule out placental previa or other structural issues.

Thyroid dysgenesis (congenital thyroid gland underdevelopment).

Penicillin prophylaxis to prevent sepsis from encapsulated organisms (e.g., Streptococcus pneumoniae).

Sickle Cell Disease (presence of both Hb S and Hb F, with little or no normal Hb A).

To increase levels of fetal hemoglobin ($\text{HbF}$), which reduces sickling episodes.

High TSH and Low Free $T_4$.

Placenta previa or vasa previa (requiring ultrasound first).

Penicillin.

It stimulates the production of fetal hemoglobin ($\text{HbF}$).

Monitoring for anemia or potential need for $\text{B}_{12}$ supplementation.

High TSH and Low Free $T_4$.

Placenta previa or vasa previa (requiring ultrasound first).

Penicillin.

It stimulates the production of fetal hemoglobin ($\text{HbF}$).

Monitoring for anemia or potential need for $\text{B}_{12}$ supplementation.