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DIP Episode 568 - 2024 USMLE Step 3 Free 137 Discussion Part 14 (Q131-137, super helpful for Step 2!) + A Comprehensive Life Lesson on Self Care

MixedMedium4 - HighHas Q&A

Step 2Step 3MedicineUSMLEStep 2Step 3

Topic

Aortic dissection; Wallenberg syndrome (lateral medulla stroke); Drug-induced neutropenia; Community-acquired pneumonia management; Cardiac tamponade...

Key Takeaway

The clinical presentation of a lateral medullary stroke (Wallenberg Syndrome) requires recognizing the constellation of cranial nerve deficits and sensory loss, while acute conditions like aortic dissection or cardiac tamponade demand immediate, life-saving interventions (e.g., beta-blockers, pericardiocentesis).

Runtime: 45 min

Published: 2025-02-03

Completed audio: Yes

Completed notes: Yes

Anki made: Yes

Section: —

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Episode Notes

Source / episode info

Episode: 568
Title: DIP Ep 568: 2024 USMLE Step 3 Free 137 Discussion Part 14 (Q131-137, super helpful for Step 2!) + A Comprehensive Life Lesson on Self Care
Published: 2025-02-03
Source: Episode page

One-liner

This episode integrates critical care management principles across multiple systems, covering the acute workup of aortic dissection and cardiac tamponade; neurological localization via Wallenberg syndrome; infectious disease diagnosis (CAP); hematology/pharmacology (drug-induced neutropenia); and chronic GI conditions (Crohn's).

High-yield summary

Aortic Dissection: The primary management goal is reducing shear stress on the aortic wall. This mandates immediate administration of a beta-blocker (e.g., esmolol) regardless of dissection type, followed by surgical repair for Type A dissections.
Wallenberg Syndrome: Lateral medullary syndrome results from occlusion of the PICA/inferior cerebellar artery and classically presents with ipsilateral Horner's syndrome, contralateral body sensory loss, CN IX/X deficits (dysphagia, hoarseness), and ataxia.
CAP Management: Bacterial pneumonia requires combination therapy: a cell wall inhibitor (e.g., Ceftriaxone) plus coverage for atypical organisms (Doxycycline or Azithromycin).
Cardiac Tamponade: The classic CXR finding is the "water bottle sign" (pericardial effusion), and diagnosis relies on Beck's Triad (hypotension, muffled heart sounds, JVD). Management is urgent pericardiocentesis.
Drug-Induced Neutropenia: Anti-thyroid drugs (Methimazole/PTU) are classic culprits; other agents include Carbamazepine and Sulfasalazine.

Learning objectives

Differentiate the clinical presentation and management of aortic dissection based on type and stability.
Localize brainstem strokes using classic syndromes (e.g., Wallenberg Syndrome).
Identify common drug causes of bone marrow suppression, specifically neutropenia.
Select appropriate empirical antibiotic regimens for community-acquired pneumonia (CAP) versus atypical pneumonias.
Recognize the signs and immediate management steps for cardiac tamponade.

Board exam buzzwords

Condition	Key Finding	Association	Board Exam Tip
Aortic Dissection	Diastolic murmur, widened mediastinum	Hypertension; Beta-blockers (mandatory)	Always remember to give a beta-blocker first to reduce shear stress before any definitive intervention.
Wallenberg Syndrome	Ipsilateral Horner's + Contralateral sensory loss	Lateral Medulla/PICA occlusion	Use the cranial nerves as a "GPS" for brainstem localization; this pattern is highly specific.
Cardiac Tamponade	Water bottle sign (CXR); Beck's Triad	Pericardial effusion; Hypotension	The immediate life-saving procedure is pericardiocentesis, not surgery or simply increasing PEEP.
Methimazole/PTU	Neutropenia, Thrombocytopenia	Anti-thyroid drugs	These are the most commonly tested drug causes of bone marrow suppression in endocrinology questions.

Rapid review table

Topic	Key Point	Context	Exam Relevance
Aortic Dissection	Beta-blockers reduce shear stress.	All types (A and B) require initial beta-blockade.	Critical step before surgery or definitive care; prevents catastrophic rupture.
Wallenberg Syndrome	Lateral Medulla involvement.	PICA occlusion/Posterior Inferior Cerebellar Artery infarct.	Classic exam pattern for localization questions; remember the specific deficits (CN IX, X).
CAP Antibiotics	Combination therapy required.	Bacterial pneumonia with potential atypical pathogens.	Must cover both typical (e.g., Ceftriaxone) and atypical (Doxycycline/Azithromycin) organisms.
Cardiac Tamponade	Beck's Triad: Hypotension, Muffled heart sounds, JVD.	Rapid accumulation of fluid in the pericardial space.	The diagnosis is clinical/radiological; management is urgent drainage (pericardiocentesis).

Board-speak -> diagnosis

Board-speak / Vignette phrase	Diagnosis / Concept	Why it fits
Patient presents with sudden, severe tearing chest/back pain, history of hypertension, and a new diastolic murmur.	Aortic Dissection (Type A)	Hypertension is the biggest risk factor; the aortic regurgitation murmur suggests dissection involving the ascending aorta.
CXR shows a "water bottle sign" in an unstable patient with hypotension and muffled heart sounds.	Cardiac Tamponade	The combination of these findings constitutes Beck's Triad, indicating fluid accumulation around the heart compromising filling.
A 75-year-old man presents with progressive fatigue and bruising, taking Methimazole for hyperthyroidism.	Drug-Induced Neutropenia	Anti-thyroid drugs (PTU/Methimazole) are classic causes of bone marrow suppression leading to neutropenia.
Patient has ipsilateral Horner's syndrome, contralateral body sensory loss, dysphagia, and ataxia following a stroke.	Wallenberg Syndrome (Lateral Medullary Syndrome)	This specific pattern localizes the lesion to the lateral medulla oblongata, typically due to PICA occlusion.
A 33-year-old woman presents with fever, cough, and localized lobar consolidation on CXR.	Bacterial Pneumonia (CAP)	The rapid onset, high fever, and localized infiltrate rule out "walking pneumonia" and require aggressive antibiotic coverage.
Chronic abdominal pain, bloody diarrhea, perianal fistulas, and enthesitis in a young patient.	Crohn's Disease (IBD)	This constellation of symptoms points to IBD; the presence of perianal disease strongly suggests Crohn's over Ulcerative Colitis.

Differential diagnosis / distinguishing features

Neurological Syndromes

Key Features	Distinguishing Findings	Next Step
Wallenberg Syndrome	Ipsilateral Horner's, contralateral body sensory loss, CN IX/X deficits (dysphagia).	Localizes the lesion to the lateral medulla; treat underlying cause (e.g., PICA occlusion).
Stroke (General)	Varies widely based on vascular territory.	Detailed neurological exam and imaging (CT/MRI) are required for localization.

Bone Marrow Suppression

Key Features	Distinguishing Findings	Next Step
Drug-Induced Neutropenia	Low WBC count, often associated with specific medications.	Discontinue the offending agent; monitor counts and consider supportive care/transfusion if severe.
Primary Bone Marrow Failure	Pancytopenia (low RB Cs, WB Cs, platelets) without clear drug cause.	Investigate underlying causes (e.g., autoimmune disease, nutritional deficiency).

Management pearls

Aortic Dissection: Always initiate aggressive blood pressure control with a beta-blocker first to reduce shear stress on the aortic wall.
Wallenberg Syndrome: The pattern of deficits is key; it points specifically to the lateral medulla oblongata (PICA territory).
CAP Antibiotics: Never treat CAP solely with a cell wall inhibitor if atypical pathogens are suspected; combination therapy is mandatory.
Cardiac Tamponade: If Beck's Triad is present, immediate pericardiocentesis is required for diagnosis and treatment.

Don't miss

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The "water bottle sign" on CXR is highly suggestive of cardiac tamponade due to massive pericardial effusion.

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Methimazole (and PTU) are the most common drug culprits causing neutropenia in board questions.

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Aortic dissection management must prioritize beta-blockers over vasodilators or pure pressors, as reducing heart contractility is paramount.

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The constellation of symptoms pointing to a lateral medullary stroke (Wallenberg) is a classic localization pattern that must be recognized quickly.

Integration & clinical reasoning

Cardiology/Neurosurgery: Aortic dissection requires coordination between aggressive medical management (beta-blockers) and potential surgical intervention, mirroring the urgency required in cardiac tamponade.
Infectious Disease/Pharmacology: The choice of CAP antibiotics is dictated by local epidemiology and the need to cover both typical bacterial pathogens and atypical organisms.
Endocrinology/Hematology: Anti-thyroid drugs are a critical link between endocrinological management (hyperthyroidism) and hematologic complications (neutropenia).

OMM / COMLEX integration

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For COMLEX: know these viscerosomatics / Chapman points, but don't let OMM distract from emergent diagnosis and management.

Aortic Dissection: In any unstable patient with suspected aortic pathology (e.g., severe pain, hypotension), standard emergency management takes priority. OMT/OMT principles are not applicable in the acute setting; stabilization and rapid surgical consultation are paramount.
Cardiac Tamponade: This is a mechanical circulatory failure requiring immediate drainage. The focus must remain on life support measures until definitive decompression (pericardiocentesis) can be performed.

Concept connections / cross-references

For detailed review of endocrine emergencies, see [ Episode 37 ] (Adrenal Crisis).
For comprehensive coverage of cardiac anatomy and MI workup, see [ Episode 12 ].
For general principles of infectious disease management and antibiotic stewardship, see [ Episode 45 ].

High-yield association table

Condition	Association	Mechanism	Clinical Significance
Aortic Dissection	Beta-blockers (Esmolol)	Reduces heart contractility/shear stress on the aortic wall.	Mandatory initial therapy to prevent rupture and stabilize the patient.
Wallenberg Syndrome	PICA occlusion / Lateral Medulla infarct	Damage to CN IX, X nuclei; sensory tract involvement.	Classic localization pattern for posterior circulation strokes.
Methimazole/PTU	Neutropenia (Bone Marrow Suppression)	Direct bone marrow toxicity or immune-mediated suppression.	Requires immediate discontinuation of the drug and monitoring of blood counts.
Cardiac Tamponade	Pericardial effusion; Beck's Triad	Fluid accumulation restricts diastolic filling of the heart chambers.	Diagnosis is clinical/radiological, requiring urgent pericardiocentesis for relief.

Key terms glossary

Term	Definition	Context	Example
Wallenberg Syndrome	Lateral medullary syndrome; stroke affecting the lateral medulla oblongata.	Posterior circulation stroke (PICA occlusion).	Presents with ipsilateral Horner's, contralateral body sensory loss, and dysphagia.
Cardiac Tamponade	Compression of the heart due to fluid accumulation in the pericardial sac.	CXR "water bottle sign"; Beck's Triad.	Requires immediate pericardiocentesis; causes profound hypotension.
Methimazole/PTU	Anti-thyroid drugs (Propylthiouracil).	Hyperthyroidism management.	Classic cause of drug-induced neutropenia and hepatotoxicity.
Lobar Pneumonia	Bacterial pneumonia localized to a specific lobe or segment of the lung.	CAP diagnosis; CXR shows distinct, dense consolidation.	Requires combination antibiotics (e.g., Ceftriaxone + Doxycycline).

Study optimization

Topic	Study Approach	Priority	Resources
Acute Vascular Emergencies	Focus on pathophysiology and immediate stabilizing drugs.	High	Review the management algorithms for Aortic Dissection and Tamponade (Board-style flowcharts).
Neurolocalization	Practice identifying classic syndromes based on deficits.	Medium-High	Use mnemonics/flowcharts to map CN deficits to specific brainstem nuclei locations.
Infectious Disease	Master the differential diagnosis for pneumonia and neutropenia causes.	High	Create tables comparing antibiotic regimens (e.g., CAP vs. community guidelines).

Question pattern recognition

Pattern: Tearing chest/back pain + Diastolic murmur -> Aortic Dissection. The combination of severe pain, hypertension history, and new aortic regurgitation murmur is pathognomonic for dissection involving the ascending aorta.
Pattern: Ipsilateral Horner's + Contralateral sensory loss + CN IX/X deficits -> Wallenberg Syndrome. This constellation points directly to a lateral medullary infarct (PICA territory).
Pattern: Hypotension + Muffled heart sounds + JVD -> Cardiac Tamponade. Recognizing Beck's Triad is the most critical step, leading immediately to pericardiocentesis.

Test yourself

Common mistakes to avoid

🚫

Mistake 1: Treating Aortic Dissection with Vasodilators. Using agents like nitroprusside or excessive vasodilators can lead to a sudden drop in systemic vascular resistance, causing profound hypotension that may precipitate cardiogenic shock and worsen the dissection. The goal is controlled reduction of shear stress , not just blood pressure.

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Mistake 2: Assuming all Pneumonia Infiltrates are Interstitial. Localized lobar consolidation (as seen in bacterial CAP) must be differentiated from diffuse interstitial infiltrates, which suggest atypical or viral etiologies ("walking pneumonia").

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Mistake 3: Ignoring the Initial Stabilization Phase for Aortic Dissection. Jumping straight to surgery without first administering a beta-blocker is dangerous because uncontrolled blood pressure increases wall stress and risks rupture.

Common traps

⚠️

Trap 1 (Aortic Dissection): The question might list multiple stabilizing drugs (e.g., nitroprusside, esmolol). Remember that the mechanism of injury is shear stress; therefore, reducing contractility via a beta-blocker is superior to simply lowering blood pressure with vasodilators.

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Trap 2 (Wallenberg Syndrome): The sheer number of deficits can overwhelm the student into trying to localize every single finding. Focus on the core pattern: lateral medulla -> PICA -> specific CN/sensory loss.

⚠️

Trap 3 (CAP Antibiotics): Students often default to a broad, expensive antibiotic like Piperacillin/tazobactam. Always check if the question requires coverage for atypical organisms; if so, Doxycycline or Azithromycin is mandatory.

Original transcript with highlights

Welcome everyone, my name is Devine. This is episode 568 of the Divine Intervention Podcast. And into this podcast we're gonna finally, finally, finally be finishing up the free 137 step three series. And you know we're gonna be this is part 14, it's gonna be the final part. And again if you're studying for step two, very useful podcast to listen to. And again I'm telling you this series is is something that because it's like hey why go through 137 questions in a series of podcasts but I'm telling you it's very helpful. There is so much learning, so much integration and so many test-taking principles I've discussed in this series so far. Again trust me as well worth your while. And if you're studying for step three, consider listening to the free 121 on step two as well. Why go through 120 of the step step two questions. Again I think something of a very helpful to your learning process. Alright so question 131 whoever's 62 year old male is African American. He's in the emergency room. And it appears he passed out slowly at home. So let's look at his HPI. Has a collapse while making breakfast or gain consciousness. No precipitating factors or symptoms. No one witnessed the fall but wife heard the fall called an ambulance. Chest and back pain. Pain is constant and crushing 10 out of 10. It's not able to get comfortable. As a past history of hypertension is on low-deep pain. Doesn't have any drogologies. Drinks want to talk. Holy beverages doesn't smoke. We look at his vitals.

His stachycotic. His stachypnic. Small pressure is extremely low 80 over 38. O2 satyr a little bit low. BMI is 30. Okay now we look at the physical exam. He is visibly uncomfortable. He has shallow breath sounds. His stachycotic has a dastolic murmur. He has a radio pulse is a 1 plus 3d femoral pulses. It's not a good situation right. ECG shows non-specific ST segment and T wave changes. And we see the CT and diagram of the chest. This is a classic image I would really really hope you can recognize on your exams. And then he says which of the four is the most appropriate next step in management. Right so looking at this question we can clearly see a false looming within the order. Even if you don't see the false looming this guy has a history of hypertension. This guy has this chest and back pain. We see he has a dastolic murmur. This guy is not doing well right. So if you see all these things together what should he be thinking about. I hope you're saying divine sounds like this person has aortic dissection. He does have aortic dissection. And again a few key facts about theortic dissection. Number one we know that the biggest risk factor is going to be hypertension which this guy has.

Right and then beyond that we also know that theortic dissection is associated with the murmur of theortic regurgitation because that false looming that's created almost causes like an occlusive lesion of the order especially when it's an ascending the yorecan dissection a type A dissection remember this type B there's type B type B has a sending involvement. It could also have descending what at least it must be sending involvement and then type B is a descending involvement only. So this person has aortic dissection so it kind of creates that occlusion so you can have blood backtracking into the left ventricle in the form of aortic regurg. That's this dastolic murmur that this person has. So when a person has aortic dissection they see he was going to be the next best step. He was going to be the next best step. So option A says coronary angiography I would not pick that right. We're not dealing with an M.I. here or dealing with an uortic dissection. B says CT of the head. Again we're not dealing with a stroke here because remember CT of the head a non-conhead CT is what you're doing to inspect the stroke but that's not what's going on here. Narapinephrine infusion. I wouldn't do that because Narapinephrine is a you know it has activity on our energy receptors especially beta-1 receptors. If you hit those beta-1 receptors that's going to be a huge problem right because that's going to make the blood that's coming out of the heart. It's coming out with more force.

That's actually going to worsen the dissection because if blood is coming out of the heart with more force more contractility it's going to rip more hard through that into the media. Then option D says placement of an intra-aortic balloon pump. Again balloon pumps the things that they're going to be answers to some questions. But I'll venture that the one be answers to questions you see on a US Emily exam. It's going to be more like an internal medicine training exam, an internal medicine board exam. So I'm going to skip that. So we're going to go with option E replacement of the aortic root because again whenever a person has an aortic dissection typically you're going to at least give every single person a beta blocker. You got to give a beta blocker. Everybody be type A that type B. But the thing is we also see something else here right like this involves the as and the other right. So whenever you have a type A dissection you're not just giving a beta blocker like Esmololo or whatever but in addition to that you also have to do you have to do some kind of surgery. So remember aortic dissection you got to get a beta blocker first right. Because again those beta blockers they will basically make the negative I know tropes so the heart will stop contracting as hard. So the blood that will be coming out of the left ventric will be coming out with that much force. So you have less shear stress on the walls of the of the aorta you know that will make the dissection not as bad.

Just something to keep in mind. All right. So 63 year old man so 132 so the answer to the first one is E. Okay 63 year old man is brought to the EDI by his wife because of a 2 D history of double vision. Feeling of balance difficulty walking and leaning to his right side while standing. He also has had so throat, horciness, difficulty swallowing and talking and fatigue during this time. He had severe stabbing pain on the right side of his face a few minutes before he seemed other symptoms again. The severity of his symptoms have been constant since onset. The patient is right handed. He's right hand dominant but he has that difficulty I currently using his right arm during this time. When he tries to eat his right forearm and hand do not accurately guide food to his mouth. He has not had a fever, has hypertension, should have a lysinopril. His temperature is... if we look at his vitals, his vitals are not too bad. Although his blood pressure 140 over 90 that's kind of high. His auto-satisfying. He lends to the right while seated. Left purple measures 6 millimeters and constructs to 4 millimeters in response to light. Right purple measures 4 millimeters and constructs to 3 millimeters in response to light. There is no conjunctiva lectors horizontal and rotational niestagnus on right gaze. Fast phase of niestagnus is to the left. There's my right toses. He can hear finger drops and whispers bilaterally. Right soft palate does not elevate.

Patients voices hoarse, has desathric speech, peripheral pulse is a 2 plus, also strength, bulk and tone are normal, deep tendon reflexes are a 1 plus, but binskies absent bilaterally. Sensation to pin on temperature is decreased over the right side of the face. The left extremities on the left side of the trunk, fingernails, testings shows the smithre on the right only. It is broad based and the patient lends to the right while walking. Based on these findings, this patient is most likely developed which of the fallen. Right so looking at a question like this, it's probably causing you to shake in your boots. You see all these neuro deficits and of course in your mind you're thinking that oh my goodness I need to localize every single thing here. No you don't. No you don't. The thing is I'm telling you this, these questions are written to be answered in the time interval that has been provided. So that's one thing that you need to keep in your mind. So if you see a question this long with these many problems, it tells you that there has to be an easy solution. Again this is just the name of the game with critical thinking on the USMD exams. And something I really try to emphasize in many of my classes, right? You just got to critically think with this. Think about it. If you truly wanted to start localizing every single thing here, you'll probably take you like a solid for maybe five minutes.

If you did that for a few questions in a block, you're gonna definitely run out of time on your exams, right? So clearly that's not a way to go here. Again that's why knowing context and just having like a general on and on the standing of general basic patterns is very helpful on this exam. Like we see this person, they seem to have been on temperature loss on one side of the face on the other side of the extremities. We're seeing a bunch of cranial nerve deficits. Like you see the issues with the pallet. So it's like ooh this is like probably cranial nine cranial 10 territory. We see this person having some not all but some antecedents of hornar syndrome, right? They have like the person has I think I saw like to say somewhere, right? All these things are very classic for a lot of brain stem stroke. And the thing is when you have a lot of brain stem stroke, right? With all these patterns I've just emphasized, you can use your cranial nerves to kind of tell you what you're dealing with like where? I always say this that your cranial nerves are like the GPS of your brain stem. They tell you where things are. So we see cranial 9 and 10 seem to have a few issues here. So that tells you that oh of course this is probably this probably has to be some medulla problem because cranial 9 through 12 in the middle. So we know that the right answer has to relate to some issue with the brain stem in the middle, lateral medulla, right?

This is actually a wallenberg syndrome that this person has remember has remember that's a lot of brain stem stroke is typically caused by some kind of pica, posterior inferior serbal artery, inford. All right, so let's look for an answer that relates to that. So notice again, I didn't start walking through every single deficit because that's just not realistic for the exam. That's just the truth, right? So I'm saying he says Ecclesian gastroparesis. I don't know why a medulla is fricking consta. No, come on. I could have closure glaucoma. No, no relationship there. Although static hypotencia, hyper tension, no, no relationship there. Sleep related hypogenitilation. So like a sleep apnea kind of situation. Yeah, you can definitely get that with brain stem stroke, especially something along the lines of like almost like a central sleep apnea if you may. So yeah, because remember your respiratory centers, your brain stem, right? Especially your lower brain stem. So if you mess those up, yeah, you may have like sleep apnea like symptoms, probably more central as against like an obstructive sleep apnea. So let's keep that. The option is says third degree AV block. And I'm not going to go with that. Again, third degree V block is a hard condition. Although you may see third degree V blocks are associated with moms that have low post or show grinks.

And then they have fetuses with third degree hard blocks because those people are prone to making an anti-run, anti-lar, IgG antibodies. Yeah, it's IgG, right? So remember, IgG can cross the placenta and it can damage the conducting system in the fetus and cause a third degree AV block. Alright, so I'm going to go with option D, right? Again, when you have a brain stem stroke, liver or not, that can cause sleep apnea style symptoms, probably more like a central sleep apnea. Again, don't forget the pattern for a lot of brain stem stroke. But in a temperature also one side of the face, the opposite side of the body and some antecedents of hornar syndrome, right? Some antecedents of hornar syndrome. And when it's the medulla, you also notice that we have like some cerebellar issues. Just look at the name, posterior and furacerebellar. I don't know, maybe it touches some parts of the cerebellum, right? So let me have like cerebellar issues like etaxia and things like that, dismissal and all those fun things. Alright, we're going to go to question 133. So we have a 75 year old female, going to the hospital, says I felt tired for a while and I've been bruising easily. Alright, let's look at the HPI. So three weeks of progressively worse than bruising the fatigue, gradual onset of symptoms. Okay, nothing else there.

Has a five year history of hyperthyroidism, 10 year history of hyperliplidemia, 50 year history of coronary artery disease, takes carvedic lull, lysinopril, atovastatin methemazole and delia aspirin, has no drug allergies, that died at 56 from an MI, doesn't smoke, drink, or use bad stuff. Alright, let's look at our labs. My temperature is fine, actually. Let's see. Yeah, nothing here to write home about our vitals are okay. And then we look at her physical exam. Yep, everything is fine on the physical exam. I don't see anything crazy. They I'm not going to re through the whole thing, right? That's ridiculous. Let's look at these labs. Okay, he might have created his low. That's for sure. Oh, look at this white count, 1200. Oh, that's not good. And the platelet count is 43,000. That's pretty low. That's not good. Alright, ECG show sinus for them without SD changes. Chest x ratio is not formalities. Right? So I'll really hope just from like this synopsis, I've given you know what's going on. Right? Your methemazole, your white count is 1200. What do you think that is? Like seriously, what do you think that is? Right? This person has neutropenia. This person is not fair brow. Well, they're neutropenic. And that's all we need. Right? Sorry, remember, drug induced neutropenia can be caused by a bunch of drugs. Right? So what are the classic ones you love to test on the exams? Your anti-thyroid drugs like Ptu or methemazole.

Those things, remember, the thyroid peroxidides inhibitors, they can cause, they can cause a bunch of problems, right? They can certainly cause neutropenia. Don't forget clasipin with psych, remember clasipin is like a third line drug for treating schizophrenia. Don't forget carbamysa, pain, carbamysa, pain can also cause that problem. We easy to treat trigeminal neurangia. Don't forget trimethylperm cell from the thoxesole. So they can, no, bacterium can certainly cause those problems. So fasala zine, I would tend to use for these inflammatory bowel diseases can cause that problem. Right? So methemazole is the right answer. This one is pretty straightforward. So I would not pick as heriasprin doesn't cause this problem. Neither does atover. Remember, aspirin can cause, if you take a ton of aspirin, you can get bleeding. It can cause you a bunch of issues, right? You can get like the respiratory or colosis and metabolic acid dosis at the same time. I've talked about that already. Atover statins are statin ready can cause a myopathy and those things also can be hepato toxic. Although having those toxicities, those initials stop the statin. We almost always want to keep people on statins. Carvedo law is a bit of blocker, right? What will correg really do terribly to your life? Probably not much, right? Lycinopryl. I remember dry cough because inhibits ACE. So your bradykine levels are going to go up. As know the toxicity is going on here, right?

I remember Lycinopryl inhibitors, you don't give them to pregnant women, right? Because they can cause renal problems for the fetus and they're not just that. Don't forget that they could cause a rise in creatinine, a big time rising creatinine, people that have a bilateral real and arystynosis. So though having bilateral renal arystynosis is not a contraindication to getting an ACE inhibitor and arb. Just only want to keep in mind. And I guess I just want to mention here that Carvedo law and Lycinopryl, the certainly improves survival in heart failure, right? Just sort of throwing those extra tidbits there. All right. Now question 134 says, a 26 year old man is brought to the 80, 30 minutes after his roommate found him confused at home with a bump on the left side of his head and fresh urine on the floor. On arrival, the patient is confused, but his mental status returns to normal shortly after arrival. He's a medical student. Wow, he's one of us. And the last thing he remembers is coming home from class 30 minutes before he was found. Has no had disease as blurred vision fever and nausea. Medical history is remarkable for bacteria meningitis five years ago. An ACL injury, so steam well-plained basketball 10 years ago and a lot of renalygenesis were proteinuria. All right. Okay. Now his only medication is Lycinopryl, state a week, all night, twice during the past week to study for final exams. He works the night shift at a fast food restaurant on weekends. Wow. Okay.

He has smoked a half buck of cigarettes daily for five years, drinks four, 12 pounds, beers weekly. He uses kind of this three times weekly. I would not do that if ERAS is, you know, NRNB is coming up soon. You'd be amazed that the kinds of trouble you can get into, like, you know, losing where you matched because of a, on very unlicensed sessions like that. Okay. So this is being my 27. Okay. Let's not skip things. So usually drinks one to two cups of coffee daily. But I've been drinking it for eight ounces of coffee daily for the past two days. That's a lot of coffee. BMI is not too bad. His vitals are fine. Shoes blood in the mouth and bite marks on the left lateral aspect of the tongue. So that's for the physical exam shows. Remedov the exam, gluten, neuro exam, no abnormalities, right? Sounds like a seizure. This guy has had, we look at his labs and all his labs are fine. There's nothing abnormal here. Here in talks for any results for negative blood alcohol is zero. MR of the brain and EG fine. In addition to decreasing his caffeine intake, again, 40 ounces just seems like a lot. Which of the following recommendations is most likely to prevent recurrent seizures in this patient, right? Again, this guy seems like he's been working himself to the bone because of, you know, studying for finals. I think this is something many of us can relate to. And I'm actually going to discuss a life lesson at the end, relating to some of these things. But so stay tuned for that.

Don't don't run away right after. I want to discuss a quick life lesson that relates to this. This guy has not been sleeping enough. He's drinking like a ridiculous amount of coffee. He's working night shifts at a fast food restaurant and he's a medical student. All that stress, I won't be surprised if that's causing seizures. So let's look for again, a simple answer. Again, notice the way this question was analyzed. You can really try to overthink this thing, make it a lot harder than it needs to be. Start jumping on the renal age, Genesis that he has and that it takes like Ceno Pearl and start finding some high sounding nonsense to defend some crazy answer. No, again, most of these questions just analyze it from a simple, thoughtful logical perspective. You can dispatch these questions pretty quickly. That's a testic in principle by the way, right? So avoid alcohol. No, his blood alcohol is zero. This continued to like Ceno Pearl. No, that's no, right? He has renal problems, right? That's probably why they put him on like Ceno Pearl to slow down the rate of renal decline. You know, kind of save the one kidney that he's got. C says maintenance of adequate sleep. Yeah, this guy needs a lot of sleep in his life. I'm going to go with that one. Option D says occupation change. Yeah, being a met student and working shifts on the weekends. It's kind of a tough life, but never know. I'm not going to do that, right? Tell you to change your occupation.

That's more for a social thing. That's beyond that scope on the USNL East. No, he says tobacco cessation. Yeah, he should stop smoking. You know, this smoking is going to do him to him in down the line in life, but we're focused on the seizure that he has. This guy needs to get more sleep. I'm going to go with option. Option C. All right, question 135. 33 year old woman is admitted to the hospital because of a three day history of fever, shortness of breath, and progressive cough, productive of dark yellow spirit. She felt well before the onset of symptoms, use of cough, suppressant and acetaminophenaz provided no relief. She has a five year history of my senior graves, a coin meds, or a pyrididose stigma on an OCP. A temperature is 102. She's tacky cardiac. A blood pressure is 130 to the over 72. O2 side is 94% on oxygen at four liters permitted by nasal cannula. She's a lyrthon appears fatigued, coughs intermittently throughout the exam because membranes are dry. Pony exam discloses crackles and ronka in the left or prolonged field. Remind of the exemptions, not normalities, extra of the chesholes are patching and filtering in the left upper loop, which of the following is the most appropriate pharmacotherapy for this patient at this time. Right, this person looks like they've got pneumonia. Right, and honestly, I know some of you may be thinking patching and filtering, so is this like a walking pneumonia? No, it's not. This is not a walking pneumonia.

There's a few reasons why I'll say that this is not a walking pneumonia because my walking pneumonia are thinking of microplasma. Again, the US released their not stupid in the way they set up these questions, right? Because they're like, oh, patching and filtering. So they may think that, oh, some people will extrapolate the words patching and filtering to mean interstitial infiltrates. But no, this is not a walking pneumonia. I'm going to explain why. Number one, this woman's symptoms have gone from like zero to 360 relatively quickly. Right, usually walking pneumonia can go for a couple of days, just kind of going, going, going, you know, this called walking pneumonia for a reason. You can leave life relatively okay while having that pneumonia. Right? And usually when people are walking pneumonia, they don't produce like insane amounts of like nasty speed of this person is producing like dark yellow speed of this is a legit bacterial pneumonia. And also again, on a chest extra when you have walking pneumonia, you're going to have diffused interstitial infiltrates. It's not just going to be localized to one low, but that'll be somewhat unusual. I'm not saying it can never happen. So please don't say divine said it can never happen. No, it can certainly happen, but that'll be unusual. Right? So if this person has patching infiltrates or notice it's low bar is localized to one low. So this person has a low bar pneumonia. This person has a bacterial pneumonia.

And nothing that also tells me that there is no way this is a walking pneumonia. Look at this person's fever, 102. You don't get fevers of 102. Usually again, I will never say, again, never say never, but again, 102, that's pretty high. This is not a walking pneumonia, right? This person has a legit bacterial pneumonia. So you're going to treat it like the way you treat like a pneumococcal pneumonia, for example, right? And typically what you're going to do for these people is you're going to give a cell wall inhibitor. And then you're going to give something that can cover atypical organisms, you know, so like doxycycline or zythromycin. You're going to give that combination. That's very, very important to know for you exam. So option A says amoxicillin clavolanic acid. That's a cell wall inhibitor, but you're not covering atypical organisms. So that's wrong. Remember, amoxclav is also something we use as second line for acurotitis media. B says is zythromycin. Again, zythromycin is what you do if you were just worried about walking pneumonia alone, but that's not all that's going on here. This is a real legit bacterial pneumonia. So that's wrong. Option C says cephepimantobromycin. This is awful, awful, awful, anti-botic stewardship. You know, cephepim is like a fourth generation cephalosporinda covers to the monos. To be honest, it is an amino glycoside that covers to the monos. You know, why would you give two anti-sodomonal drugs together?

He's like, oh, I have no covers to the monos enough. Let me, let me go over it even more and again. It's to the monos, the most common cause of bacterial pneumonia. No, right? Option C is just a little too broad spectrum, right? I would not do that. Option D says septraxone and doxycycline. Yeah, that's a cell wall inhibitor. That's a septraxone part. Covered strepneum are really well and the doxy is going to cover atypical organisms like microplasma, you know, chlamydia, stuff like that. So I'm going to pick up shondi. That's generally how you manage a quantity acquired bacterial pneumonia. Cell wall inhibitor plus doxyoryzythromycin. Option E says lival floxicin. Again, lival floxicin covers to the monos and it's probably good for strepneum as well. It's a very good respiratory fluoroquinolone. But again, you got to cover some of these atypical organisms, right? That's just not the first line treatment generally for a quantity acquired by turnomony. Option F says TMPSMX, right? Now we got to do that for the most issytravezii, right? That doesn't make sense here. So I'm going to go with option D for this one. All right. Now question 136. Two we call newborn, two we call newborn, who was delivered at 34 weeks, is being urgently evaluated because the nurses have reported recent decreases in his oxygen saturation and blood pressure.

The newborn was diagnosed with respiratory distress syndrome shortly after his birth and his return, his required continued adjustments to his mechanical ventilation settings, which now show a peak of 10. That's kind of high. It's not too bad. It's kind of high. Ventilatory rate of 50 and peak respiratory pressure of 32 centimeters of water, Nefio 2 of 0.8, right? This kid's oxygen requirements are pretty high. The patient is 3 pounds, 9 ounces. His temperature is 90.2, pulse is 200 per minute. That's not good. Respirations are 50 per minute. That's kind of what they said it on the vent. So probable blood pressure is 22. That seems really low. This child is extremely hypertensive. His auto side is really low, giving all the oxygen they're giving him physical exam shows San Jose's and poor proficient to the extremity. So this kid is very hypertensive. Breath sounds are present bilaterally. Fluid ball loss is initiated intravenously. Chest X-roader 15 minutes ago is obtained and is shown. Very classic chest X-roader will be aware of which of the most appropriate management of the patient's condition. So what do you see on this chest chest X-ray? This person's heart, which is like the really dark stuff, looks like a water bottle. Right? Now we see this kid is like super high put. I mean, bubbles are still in blood pressure in 22. That's really bad, right? That's really, really bad. That's really, really bad. He's also such a like in the toilet with all the oxygen he's getting.

This is cardiac tamponat. Right? Remember, you see that water bottle sheet part? That's pretty, pretty, pretty classic for cardiac tamponat. So the patient has cardiac tamponat. Well, what do you think you're going to do? Hope you're going to do a pair of cardio synthesis, right? Option D is going to be the right answer for this one. There's no other answer that makes any makes any sense. In option A says insertion of a centrovenous catheter. So that's like a central line. Again, that's a reasonable thing to do. But don't forget that central line is used if you want to give antibiotics or you want to do that. This is like in a nice CU or you want to give pressers, you know, I wouldn't pick that, right? Option B says medium sternotomy. By the time you don't with your medium sternotomy, this baby may have died, right? That's like medium sternotomy, literally means open heart surgery, like saw the sternum. Come on. Percardiosis and TCS, this is literally like a magical emergency. You don't want this child to die. Option C says P-production to 6. This kid is pretty high-boxic on people of 10. Do you think that reducing the P-2 to 6 is a great idea? I don't know. It's probably not something I will do personally. Option D says percardiosis and TCS, that's clearly the right answer. Option E says please be out of a left chest tube. That's what you do when you're doing the pneumothorax. And that's what you do when you're doing the hemothorax, which this child has neither of.

So, option D is going to be the right answer here. Now, question 137 says a 14-year-old boy is brought to the office by his parents because of a three-month history of fatigue, recurring abdominal pain and 15-pound weight loss. Here it is the abdominal pain and it's worst as a 6 on a 10-point scale and notes that the pain is associated with lose bowel movement. His tool has not continued because of blood. The symptoms have caused him to miss approximately 20 days of school during the past semester. In addition, the patient has developed two to three recurring mouth ulcers, because not had any rashes, chest pain, difficulty breathing or swallowing, or joint symptoms. Though his health aches slightly when he walks. That sounds like an incisive incisive. Inflammation of an enthisi or whatever you call it. Medical history is not remarkable. It takes no meds. His and the fifth percentile for height. His and the third percentile for weight, vital signs are normal. Has an S1 and normally split S2 N. Don't examine this closest mouth, extension, diffuse tenders to palpation and mouthfulness in the right lower posture. That's the terminal helium air. Neal beds appear normal. No painful adema arthritis. Near exemptions, no focal findings. Which of the most likely complication of this patient's condition? So what does this kid have? Look at this. He's been having an abdominal pain, losing a ton of weight, having a loose bowel movement. He has an enthisi, so you know, where the ac ac is.

This child probably, obviously, is started on therapy. Sometimes when you have these fistulas, many of them respond pretty well actually to TNF inhibitors, like adalimimab, and things like that, or etanersept, which is a decoy TNF receptor. So let's stop here. Again, I said I'm going to have a life lesson. Wait for that. But again, before I talk about the life lesson, if you're studying for the USML Es, I have a bunch of classes coming up this month. Step one, all the way to step three, I do have a class starting on, you know, on the, my classes for this month started on the 10th. I have a test taking class on the 10th. That's 2.5 hours long, biased class on the 19th. That's 4 hours long, and five hour social sciences, ethics, quality improvement, hospital medicine review, 5 hours long on the 20th. That's first step one to step three, those three classes, and then for step two, and step three specifically, I have the last minute review on the 21st. It's a 3 hour class and a 20 hour review from the 24th to the 27th. And then in the month of June, it's one time alone this year. I have a 50 hour step just a 3-week I made a podcast where I really talked about the technicalities of that class. And then next month in the month of March, I do have a step one review. So again, if you're interested in any of these classes, just shoot me an email, I'll give you some more information. Again, lots of people have taken these classes and have done extremely well on their exams.

I also offer one on one tutoring for all the US Emily and complex exams. I also have with ER As applications, mock interviews, personal statements, recliders, and things of that nature. And then I have a You Tube channel that you can check out and I have these podcasts on Apple, Google and Spotify. And then I also have another website called divineinterventionlifelessons.com. Divineinterventionlifelessons.com every week, I post one or two podcasts, usually about two, or sometimes three, we're from a biblical perspective address, a life lesson. There's more than 300 podcasts on there. There's actually an Apple podcast associated with that called the divineintervention life lessons podcast, really, really helpful podcasts. Again, lots of people listen to those and find it to be really helpful for them. All right. Now, one thing I'm going to say in terms of a life lesson is just the importance of self-care. The importance of self-care. And I'm going to discuss self-care from a somewhat different perspective from what you're used to. You know, I know some people think divine self-care just means mental health.

No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no Don't get me wrong. There is nothing evil in drinking coffee. Coffee is not evil. There's nothing wrong with coffee, right? Although myself and coffee were not good friends, but coffee is nothing wrong with it But the thing is if you're drinking that much coffee to kind of keep yourself going, you probably need some level of rest, right? So the thing is self care includes rest and the thing is don't again, don't get me wrong. I've been in medicine just like many of you. I know what long shifts look like. Trust me, I did I'm not seeing this as on that doesn't know. But the thing is even if you're working really hard in the hospital, there's probably certain things you can cut out of your life to create an off time for you to rest and sleep. Like, I mean, I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know. I don't know.

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Practice questions — USMLE style

Question 1 — Cardiology

A 62-year-old African American male presents to the emergency department after passing out at home. His wife reports constant, crushing chest and back pain rated 10/10. Past medical history is significant for hypertension. On physical examination, he is visibly uncomfortable, has shallow breath sounds, and a diastolic murmur heard best at the base of the heart. Physical exam also reveals diminished femoral pulses. ECG shows non-specific ST segment changes. A chest CT confirms a false lumen within the aorta. Given this clinical picture, what is the most appropriate initial management step?

A) Coronary angiography to rule out myocardial infarction
B) Immediate administration of high-dose intravenous nitroglycerin
C) Placement of an intra-aortic balloon pump (IABP)
D) Initiation of a beta-blocker infusion and preparation for surgical consultation

Answer: D. The constellation of hypertension, acute severe chest/back pain, signs of aortic regurgitation (diastolic murmur), and CT evidence of false lumen strongly suggests Aortic Dissection. The primary goal in managing aortic dissection is to reduce shear stress on the aortic wall by controlling blood pressure and heart rate. Beta-blockers are mandatory for all patients with suspected or confirmed aortic dissection (Type A or B) because they decrease contractility, thereby reducing the force of blood ejection and preventing further tearing of the aorta.

Question 2 — Hematology

A 75-year-old female is admitted due to three weeks of progressively worsening fatigue and easy bruising. She has a five-year history of hyperthyroidism and takes Methimazole daily. Laboratory studies reveal a white blood cell count of $1,200/\mu\text{L}$ (absolute neutropenia) and a platelet count of $43,000/\mu\text{L}$. Which of the following is the most likely cause of her current hematologic findings?

A) Drug-induced thrombocytopenia secondary to aspirin use
B) Bone marrow suppression due to chronic hyperthyroidism
C) Neutropenia caused by Methimazole therapy
D) Autoimmune hemolytic anemia related to thyroid disease

Answer: C. The patient is taking Methimazole, an anti-thyroid drug. A classic and well-known side effect of the antithyroid drugs (like methimazole or propylthiouracil) is drug-induced neutropenia. While other medications can cause cytopenias, given her history and current medication regimen, this is the most likely etiology.

Question 3 — Neurology

A 63-year-old male presents with a sudden onset of symptoms including double vision, difficulty maintaining balance, hoarseness, and right-sided sensory loss (pinprick/temperature). Physical examination reveals ptosis and nystagmus on the right gaze, diminished sensation over the right side of the face, and impaired palate elevation. These findings are highly suggestive of a lesion affecting the lateral medulla oblongata. Which condition is most likely responsible for this syndrome?

A) Multiple sclerosis
B) Guillain-Barré syndrome
C) Wallenberg Syndrome (Lateral Medullary Syndrome)
D) Brainstem stroke due to vertebrobasilar occlusion

Answer: C. The combination of ipsilateral cranial nerve deficits (CN IX and X involvement, leading to hoarseness/palate issues; CN VI involvement, causing nystagmus) and contralateral body sensory loss is the classic presentation of Wallenberg Syndrome. This syndrome results from infarction in the lateral medulla, most commonly due to occlusion of the posterior inferior cerebellar artery (PICA).

Question 4 — Pulmonology

A 33-year-old woman presents with a three-day history of fever ($102^\circ\text{F}$), shortness of breath, and productive cough yielding dark yellow sputum. Physical exam reveals crackles and rhonchi in the left lower lobe, and chest X-ray shows localized patchy infiltrates limited to one lobe. Based on these findings, which combination of antibiotics is most appropriate for initial empiric therapy?

A) Amoxicillin/clavulanic acid (Cell wall inhibitor only)
B) Azithromycin (Atypical coverage alone)
C) Ceftriaxone and Vancomycin (Overly broad spectrum)
D) Ceftriaxone and Doxycycline (Cell wall inhibitor + Atypical coverage)
E) Levofloxacin (Broad-spectrum fluoroquinolone monotherapy)

Answer: D. The patient presents with signs of acute, severe bacterial pneumonia (high fever, localized infiltrates, purulent sputum), ruling out typical "walking" or atypical pneumonia. Empiric treatment for community-acquired bacterial pneumonia requires covering both common pneumococcus pathogens and potential atypical organisms. A combination regimen using a third-generation cephalosporin (like Ceftriaxone) to cover encapsulated bacteria, plus Doxycycline to cover atypicals (Mycoplasma/Chlamydia), is the standard of care approach.

Quick fire review

What are the major risk factors for aortic dissection?

Hypertension (HTN) is the biggest risk factor.

If a patient has an ascending aortic dissection (Type A), what specific murmur might be heard due to the false lumen?

Diastolic murmur, indicating acute aortic regurgitation.

What are two key drugs that can cause drug-induced neutropenia?

Anti-thyroid drugs like Methimazole or PTU.

Which artery is typically involved in a lateral medullary syndrome (Wallenberg)?

The Posterior Inferior Cerebellar Artery (PICA).

What does the "water bottle" appearance on a CXR suggest?

Cardiac tamponade.

For bacterial pneumonia, what combination of antibiotics is generally recommended for community-acquired pneumonia?

A cell wall inhibitor plus an atypical coverage agent (e.g., Ceftriaxone + Doxycycline).

What type of aortic dissection requires immediate surgical intervention due to involvement of the ascending aorta?

Type A dissection.

Name three drugs that can cause drug-induced neutropenia.

Methimazole, PTU (Propylthiouracil), and Carbamazepine are examples.

What is the classic triad of signs associated with lateral medullary syndrome (Wallenberg)?

Ipsilateral CN IX/X deficits, ipsilateral ataxia, and contralateral body/face sensory loss.

What immediate procedure is required for a patient presenting with cardiac tamponade?

Pericardiocentesis.

When treating community-acquired bacterial pneumonia, what two classes of antibiotics should be combined?

A cell wall inhibitor (e.g., Ceftriaxone) and an atypical coverage agent (e.g., Doxycycline).

What is the most critical component of self-care when dealing with chronic stress or illness?

Adequate rest/sleep.

Quick recall / Anki-style questions