DIP Episode 559 - 2024 USMLE Step 3 Free 137 Discussion Part 6b (Q55-60, super helpful for Step 2!)

Welcome to episode 559 of the Divine Interversion Podcasts. Into this podcast will be continuous series on the USMLE Step 3, 3137. This is going to be Series 6 B. Again, 51 or 54 had a lot of twists and turns and I felt compelled to discuss a bunch of test-ticking principles. So I figured we should do a 6 B and do 55 to 60. Alright, so I'm going to go straight to 55. If you missed out a part of the series, listen to them. Trust me, it's worth your while. Okay, so patient information, age 64 years, this is a 64 year old female. Coming to the office, she says, I can't catch my breath. They won't when I'm sitting still. So look at the HPI, she's going to shut her breath for 12 hours. Has a 15 year history of COPD even her nearly a week ago. Takes out a bit of her all, no allergies, doesn't smoke or drink alcohol. Okay, now look at her labs. I physically examine what stands out. She's tachycardic, she's tecnic, her auto-silence is 86% on rumour, BMI is 23. Her appearance is in acute distress, her intercostal and sternoclydo mastoid muscles are retracted. Honestly, every other exact, she has cardiac exam, she's tachycardic, but every other thing is fine. And then we look at the rest of her labs where D dimer is markedly elevated, is almost like 50x, the upper limit of normal. Every other lab is fine, chest x-ray is fine. So what's the most likely diagnosis, right? So this should make perfect sense to anybody listening to this.

Think about it, this is a person that has like sodium tachycardia, her cardiac enzymes are fine, but her D dimer is elevated. And this thing started acutely, started 12 hours ago. Again, what else do you, as she's present, hypoxic. I've pretty much framed the question for you, this sounds a lot like a PE, right? So I'm going to pick PE, option E is going to be the right answer here. Option A, again, this cannot be a COPD exacerbation. First off, the didn't give us anything about hypercopnea. And a COPD exacerbation, you don't just go from zero to a while. I'm crushing and burning in like just 12 hours. It can happen, but not very commonly. And this person's COPD is not that bad too. You know, they only use it a bit or all, they don't smoke. So the chance of their COPD just exacerbating is not as great as the average individual. This is no heart failure, the BMP is fine. The person doesn't have crackles on a quotation of the long. So they have many, any of the heart failure symptoms, no ordinary D, no peripheral or preliminary DMA. And then this is not pneumonia. Again, you don't go from zero to all, no, dine of pneumonia in 12 hours. That makes no sense. No thorax, kind of the same thing, right? Neymothorax, the chest extra will be abnormal. And the pulmonary exam will be abnormal, right? You have a hyper resonance to precaution and all those things, right? And you have decrysbrate sounds and a certain section of the lungs. So the answer here is E, this is a PE. All right.

So the number to question 56, 20-year-old primary-gravied woman comes to the ED at 8-weeks gestation, because of a 2-day history of persistent nausea and vomiting with a 2-pound weight loss during this time. During this time. She also notes that she has not avoided during the past 8 hours. Oh, she has not peed, okay? She has not had fever, chills or contact with anyone known to be ill. Medical histories are remarkable. She has taken prenatal vitamins sporadically during her pregnancy, but the worsening of nausea and vomiting. Temperature is 98.2, pulse is 90 per minute, respirations are 18 per minute, and blood pressure is 18 over 60. Auto-sad is 99% of the room air, physical exam discloses no abnormalities. Your inspecure gravity is 1.030, which of the full-length lab study results. It's most likely to be abnormal in the patient. All right. So Pshani says, local psychcount, B says LTNST, C says serum calcium, D says serum glucose. E says serum urea nitrogen concentration, and F says normal disease likely. Well, look at this. This is a pregnant lady. And for the past 2 days, so she's at 8 weeks. For the past 2 days, she'll be having nausea, having vomiting. She has lost 2 pounds of weight. That's a lot of weight to lose, and she has not avoided. So she has like, she basically has oligory. That's no good, right? That's no good. And then we see that everything is fine, though. Her vitals are pretty okay. But how urine appears to be very concentrated.

It says that a urine-specure gravity is greater. So it's not 1.030 is greater than 1.030. Remember, urine-specure gravity is a measure of relative density. Specure gravity literally means relative density. It's just a measure of how concentrated your urine is. So basically, we see a person that has been having nausea and vomiting. The person's urine-specure gravity is pretty high, telling you that the urine is pretty concentrated. And the person has not peed for a while. I've pretty much pointed out all the abnormalities here. What does that sound like? Sounds like pre-renol-EKI. When the person has pre-renol-EKI, I'm going to tell you something. The urine is going to be very concentrated, because we usually get pre-renol-EKI in states of volume depletion. And if you have volume depletion, you're not going to be profusing your offering at zero well at all. If you're not, then the hydrostatic pressures within your glomerular capillaries will be decreased. And if that happens, your GFR will decrease. So your BUN is going to rise, and your creatine is going to rise. All right. So the thing that's going to be abnormal here, I'm going to vote for option E here. The serum urine nitrogen concentration. The serum glucose concentration doesn't really make any sense. We're not talking about a woman that has diabetes, you know, like a diabetic mom. Serum calcium, that doesn't make any sense, right? We don't have any signs of symptoms of hypercalcemia or hypocalcemia. LTEST option B.

We'll be shooting for that. If they are giving you a question about those problems like interoperic holostasis of pregnancy or acute fat level of pregnancy or help syndrome. But those things are things that usually show up like after 20 weeks of gestation, not at eight weeks. And they look like, no, she doesn't appear to have any infection. All right. So I'm going to go to question 57. She says, a 60 year old woman who leaves alone is brought to the ED on a Friday evening by her next door neighbor. Who says the patient has fallen several times during the past several days? An emergency department record from a visit one year ago for a minor laceration indicates that the patient has Parkinson's disease with mild dementia by polar disorder and hypertension. Her brother feels her weekly medication organizer, but he's overseas on a business trip for the week. The patient is unable to remember which medication she takes and whether there have been any changes recently to a medication regimen. The neighbor was unable to look at her pillow,ganizer in her home. And her and the patient thinks her brother keeps her pillow bottles at his house to prevent her from inadvertently taking extra doses. She has her brother's address on a card in her wallet along with the names and phone numbers of her primary care physician, psychiatrist and pharmacy. This is a responsible lady actually.

The medical record from her visit one year ago shows that her medications included clonazapam, clonidin and lithium carbonate. Those things of each medication also listed. Attempts to contact the patient's primary care physician and psychiatrist for more detailed medication history have been unsuccessful. Which of the following is the most appropriate initial approach to managing the patient's medications? Option A says ask the police to enter the brother's house to locate the patient's pillow bottles. You don't have a warrant. I would hope you don't do that. That's a way to get sued quickly. Option B says contact the patient's pharmacy to obtain information on her primary medications. Let's keep that. Option C says observe the patient closely well continuing to try to reach her psychiatrist. We've tried to reach the psychiatrist. Why do you want to do that again? That doesn't make any sense. Option D says order the medications as listed in the ED records from her previous visit. What if the doses have changed? That doesn't seem very wise either. Option E says order certain concentrations of the medications listed on the previous emergency department record. Then prescribe doses of the medications and accordance with those concentrations. Again, it doesn't make sense. You're like, oh, let me wait. Well, here's the problem with waiting. What if a situation keeps getting worse? What if it takes a day, two days, three days for those labs to come back?

Does that seem like a wise thing to do? No. So I'm going to go with option B here. And here's why. So this person there for people could get do seen information from we could get it from the primary care physician. We get it from the psychiatrist. We get it from the pharmacy. We could get it from her brother. Now, the first thing I want to ask you is this an emergency situation. Not really. It's not really an emergency situation. So the thing is you have enough time to do the right thing. You don't have to start going gangbusters here. But here's where you need to be very careful. The MBA needs I like to call this the principle of a reliable historian. They love you to go for reliable people when you're trying to clarify information. So like for example, a good classic example of this principle is with ethics where you're. You know, you're trying to get a patient doesn't speak English. You know, doesn't have good language skills and trying to get an interpreter. The MBA means love you to get a certified medical interpreter. If it's a non-emergent situation. So this question kind of mirrors that same principle. Therefore people will get history from PCP psychiatrist pharmacist brother. But we've asked the we've tried to reach the psychiatrist. No go try to reach the PCP no go. So who's the only last reliable historian that's available? It's the pharmacy. They're healthcare professional. They know what's what with the medications reach out to them. Reach out to them.

Chances are pretty good. You probably be able to reach them. The brother no you'll only try to do the reach the brother if it's an emergency situation. But again, the MBA means they generally try to shy away from you contacting unreliable historians. Okay, like the brother in this case because we don't have any indications in this question that the brother is a healthcare professional. So I'm going to keep in mind. Alright, we're going to go to question 58. It's not good. Oh, gross. Okay, so my three year old man is admitted to a nursing care facility from the hospital following a prolonged hospitalization for pneumonia, septicemia and respiratory failure. Medical history is remarkable for advanced dementia, Alzheimer type, hypertension, anti-todibidious mellitus. Career medications include lysinopril, entericated aspirin and insulin-glarging. That's a long act in form of insulin, right? The patient appears free and is confined to bed. Confined to bed. He opens his eyes to voice but is non-communicative. BMI is 27. Temperature is 37.2 degrees Celsius, that's 99 degrees Fahrenheit, pulse is 66 per minute, respirations are 15 per minute. Blood pressure is 142.86 millimeters of mercury. O2 SAD is 97% on room air. Physical examination discloses the finding on the patient's right foot, as shown in the photograph. The remainder of the examination discloses no abnormalities. Which of the following is the most likely underlying cause of this patient's condition?

Again, this question just illustrates what the MBM needs to do a lot of these days. Many questions these days, they don't ask you for street answers, they ask for like the pathophysiology. That's for the mechanism behind those things, right? So, see the gross image I'm going to scroll away from. But again, many times I tell people this, for MBM, questions involving images and stuff. If you just read the question carefully, usually you don't even need the image or the audio or whatever to get the answers right. Most of the time, not all of the time, but most of the time. So, honestly, for this question, I'm going to go, let's look at the answer as option. This is infection with MRSA. No, no. This guy doesn't have fever. We don't get any kind of lucositis. MRSA is a serious infection. We don't see pause or anything coming out. No. Option B says prolonged immobility. I'm going to keep that because we have clear direct evidence of that in the question. This guy's been kind of sitting out for a while. Option C says pyrodomogangrenosa. It could be, when I don't see any histroventilometer about disease, I don't see that classic thing I expect for pyrodomogangrenosa. So, I'm not going to pick that. Option D says systemic atheroembolive. Well, this is something we see with Bluetooth syndrome, where, you know, a person has had like a cardiac cath procedure and then cholesterol crystals.

As you're trying to put that stent, they get removed from the coronary vessel and then they just kind of show around the body. They can begin to occlude tiny vessels and they can cause like Bluetooth. These guys, these guys, big chunk of his food is blue, not just not his toes. All right. Now, option E says venestasis secondary to vavelin competence. First, this is not a woman. This is not chronic venous insufficiency. We don't see the osfer of the medial maliolus. We don't see the lexwellin that is worse by the end of the day because of vavelin competence. This is not, no. This person, no, it's not it. All right. So we're going to skip that. So I'm going to go to option B here, right? This is a pressure ulcer. Again, many people would not believe this. But pressure ulcers can actually be really, really bad. They can be really, really bad depending on how long they've gone on for. Right? They can be really, really bad. Well, the fact that they look very bad on girls doesn't mean that they're infected. They have a high risk of infection, but doesn't mean that they're infected. For this guy though, with how about this is, I have a feeling that the bridment potentially amputation may be in this guy's future. All right. But the end beam is the last that's what I'm going to jump there. All right. But again, this guy needs some heavy wound care and he will almost certainly need the bridment.

Basically, whenever a person has a pressure ulcer, and the ulcer is going so bad that it goes to the level of muscle or bone, the bridment has to be part of your treatment regimen. That's just the truth. You know, many people they try to memorize the different stages of ulcer, stage one, two, three, four. I've generally found that to have very little utility on the USMEL exams. All right. Now, question 59 says 78 year old woman who was admitted to the hospital three days ago, because of worsening renal failure, has become increasingly lethargic and non-responsive. Medical history is significant for type 2 diabetes, hypertension and stroke a year ago with residual right side of weakness and slurred speech. Medications include insulin aspirin and furostamine. On admission, the patient was alert with mildly slurred speech. Shows oriented to person please in time, physical examination disclosed, decreased modus strength, and muscle atrophy in the right operand lower extremities. Results of lab studies showed a sermereanitrogen concentration of 82, and a creatinine concentration of 6.1. Yeah, that's not good. Immodalities was recommended, but the patient declined and expressed an understanding that she would die without intervention. In addition, she requested a do not attempt to resuscitation order. This was documented in a medical record, and her code status was changed to DNR. Sermereanitrogen concentration now is 130, it's getting worse, right?

She has had no urine output during the past 48 hours. That's really bad. The patient's daughter arrives in a state that she is named as the Sargit decision maker by her mother's advanced directive. The daughter insists that he modalities being initiated and the code status be changed to full code, which are the following is the most appropriate course of action. I've dealt with this principle in a previous question from this, I think, from this free 137. The fact that you have a durable power of attorney that you've appointed does not mean you cannot make decisions for yourself. I'm going to say that again, the fact that you do not have a durable, the factory, the fact that you have a durable power of attorney does not mean you cannot make decisions for yourself. This 78-year-old female appears to still be lucid. She has clearly expressed her wishes. I don't want dialysis. I don't want to be resuscitated. But the MBM is, of course, to kind of confuse you, to put the situation of, oh, he has an advanced directive. The advanced directive appoints her daughter as a Sargit. Well, this woman has made a decision. So, it doesn't matter what the advanced directive says, we know her current decision. We know her recent decision. We're going to stick with that. So, basically, the answer we're looking for here is an answer choice that involves us honoring the woman's wishes and not the daughters. Option A says, continue current management do not initiate himodialysis.

I like that answer a lot. But let's look at the other ones. Option B says, initiate himodialysis and change the code status to full code. Nope, I'm not going to do that. Option C says, shake himodialysis, but keep the code status as DNAR until the patient is more alert. Nope, I'm not going to do that. Option D says, obtain consent from the patient's daughter to initiate her medically indicated interventions. The daughter already said what she wants done, but the patient has said what they want done. We need to respect the patient's autonomy. I'm going to go to option A and we're going to move on from that. All right. Question 60. An 88 year old man. An 80 year old woman, sorry, 80 year old woman, is transferred to the emergency department from the nursing care facility where she resides for hours. Four hours after facility staff noted that the patient had a rectal bleeding. Oh, that's no good. Medical history is significant for long-standing dementia, secondary to multiple prior strokes, coronary artery disease, hypertension, hypercholesterolemia, and chronic reno disease. Medications include 81 milligrams of aspirin, sinverstatin, lysinopryl, and hydrochlorothiazide. On arrival in the ED, temperature is 37.2, that's 98.90 degrees Fahrenheit. Post is 102 per minute, transpiration is at 20 per minute, and blood pressure is 105 over 60. Auto SAD is 95% on room air. The patient is awake, but is not oriented to person, place, or time.

She's unable to speak coherently and becomes agitated and combative when a physical examination is attempted. Which of the following is the most appropriate initial intervention? All right. So, option A says, administer lorazapam and proceed with physical exam. Option B says, contact the patient's healthcare proxy to discuss how to proceed. Option C says, place the patient in soft wrist restraints and proceed with physical exam. Option D says, schedule outpatient flexible sigmoidoscopy and discharge the patient. There's one answer here that seems pretty obvious as the right thing to do. So, let's frame this question first. This is an 8-Edeer, or she's pretty old. She's been having a recto bleed in. This person just seems like a person that has a really bad prognosis. Dementia, long standing, lots of strokes. This person's quality of life, their life expectancy is not great. That's just the truth. And as this person is having a recto bleeding, it's kind of high-potensive not doing well. So, this person, chances are, comfort care is what this patient needs. But hey, let's not make those assumptions. That's never a good idea on the USML Es. Let's see what the CDC's answers. Option D, I will not pick option D. I'll patient flex sig. No, this person has an acute illness. This is bad. GI bleeds are no joke. This person could die from it. I'm not going to chill and send this person home. That makes absolutely no sense. Option C says, place the patient in software strings.

Alright, let me tell you this. Val shall not place patients in software strings on the USML Es. If Val do has that, Val shall get in trouble with the MBA mis. Just don't do it. Alright? Option B says, contact the patient's healthcare proxy to discuss how to proceed. That seems like a reasonable answer. I'm going to go to option B. But let's just look at option A to fulfill our righteousness. Option A says, administer lorazapam and pursue a physical exam. No. So, even if this person may be delirious, which may not be the case, delirium, if you had to go to the extent of giving a drug for delirium, you want to give an anti-psychotic. Don't give benzos for delirium. Benzos can paradoxically worsen delirium, not a good idea. So, we'll go to option B. Let's reach out to the proxy, C-O-D-C. Because chances are the pathway we want to go for this lady ultimately is a comfort care. Alright, so that's question 60. Now, before we wrap up, just one quick thing I want to say. And then I'll give a life lesson at the end. If you're interested in any of my review courses, I have a bunch coming up a week from today. For step one to step three, I have a test taking class on the 21st of this month. Bio-starts class on the 22nd of this month. Social science and ethics class on the 23rd of this month. And then for step two and three specifically, I have a three hour last mini review, three hour last mini primer. And I have a 20 hour review for step two, step three.

First of June, I have a 100 hour step two step three class. If you're interested in any of these classes, just shoot me an email. Again, very soon, I'm going to make a podcast where I talk about the 100 hour step two step three class. Actually, opened up signups already. Because there are limited spaces available for that one. But I'll make a full podcast where I talk about the 100 hour class shortly here. Again, these classes, if you're interested, I have a podcast I made where I talked about what you're going to get from these classes, how these classes differ from my podcasts. And again, I'll tell you these these classes are regularly heavily updated. I've had tons of people take these classes and they've done extremely well. I've had 260s, 250s, 270s. I'll save you overwhelming majority of who would I take my classes do really well. I've got in feedback from many different people. And again, it's not a steel class. I try to stick with what the NV Me's are doing at pretty much every point in time. That's why it's updated very regularly. And nothing I will also say is this. The classes may seem short, but they're actually very effective. They're actually very, very effective, very, very effective. And again, I don't just throw facts at you. I give you a context. I explain pathophysiology with these classes. Alright, so if you're interested, shoot me an email through the website. I can give you some more information. And then I have this podcast on Apple Google on Spotify.

So check those out. I have a You Tube channel, divine intervention, USMD podcast and videos, where I post the videos that I make. And then I also have another website called divineinterventionlifelessens.com. Every week I post one or two podcasts where from a biblical perspective, address a life lesson. So divineinterventionlifelessens.com is actually an Apple podcast associated with that. God divine intervention life lessons podcast. And then also I offer one I want you to learn for all the USMD and complex exams. And I also help people with US applications, rec letters, personal statements, walking, reviews and things like that. Now my life lesson is to pay attention to the little things. I feel like people despise their little beginnings. People are always thinking of the big goal, the major score. But they don't realize that that major score generally will not come if you've not been a good steward of the little beginnings. In fact, there's a part of the Bible that says that don't despise the days of little beginnings. Don't despise the days of little beginnings. Many people despise those days of little beginnings. What does it mean to despise something? To despise something basically means you don't take it seriously. It means you're not a good steward of that thing. But the thing is if you pay attention to the little details, you'll notice that over time, those little details you are being serious with will compound and become something big.

Again, compound interest really is the friend of a person that is willing to pay attention to the little details. I like to think of like basketball players. You can just tell that they are certain people that every season, every offseason, they work on little parts of their game and they just become better and better. For example, it's no big secret for you to listen to this podcast and a huge LeBron fan. So whatever team LeBron goes to, I become a fan of that team. So the A.K.A and a Laker fan. So let's look at people like Austin Reeves or people like Max Christie. Shut up to those guys by the way. You notice those guys, they've come into the season, Gones Blazing. Why they come in Gones Blazing? What do you think they did in the offseason? Mester Round? No. They worked on little parts of their game and they became better. Max Christie is not an elite 3-point shooter. He's an elite defender. He can navigate screens really well. Austin Reeves has now become like a legit point guard. You'll probably be an austere this year. Well, if things go right. So I'll just encourage you, take the little things. Take that morning of the two of your dedicated periods seriously. You'll be amazed that just those little things you're taking seriously. Those reviews you're taking seriously. Those following a good sleep schedule are taking seriously. Exercising during your dedicated period. Just those little things.

I'm telling you, you'll be amazed with how quickly it can compound to a very solid USMLE score. Alright, so thank you for listening to me today. I will see you in episode 560 God willing. Have a wonderful week ahead. God bless you and bye for now. Thank you.

Acute dyspnea plus markedly elevated D-dimer, especially if other causes (like CHF/Pneumonia) are ruled out.

Pre-renal AKI due to volume depletion/hypoperfusion.

Elevated BUN/Creatinine ratio (or simply elevated BUN/Cr) with concentrated urine specific gravity.

A healthcare professional, specifically the dispensing pharmacy or PCP.

The patient's own current expressed wishes (autonomy).

Benzodiazepines (like lorazepam), as they can paradoxically worsen delirium.

Pulmonary Embolism (PE).

Urine becomes highly concentrated; BUN and Creatinine levels rise.

Use the "reliable historian" (e.g., pharmacy records) rather than family memory or old charts.

The patient's own current expressed wishes (autonomy).

Contacting the healthcare proxy/surrogate decision-maker before any invasive procedure or restraint.

They can paradoxically worsen the state of confusion and delirium.

Pulmonary Embolism (PE).

Urine becomes highly concentrated; BUN and Creatinine levels rise.

Use the "reliable historian" (e.g., pharmacy records) rather than family memory or old charts.

The patient's own current expressed wishes (autonomy).

Contacting the healthcare proxy/surrogate decision-maker before any invasive procedure or restraint.

They can paradoxically worsen the state of confusion and delirium.