DIP Episode 646 - USMLE Free 86 Series 8 (Q67-76, for Step 2/3)

Alright, welcome. This is episode 646 of the Divine Intervention Podcasts. Today's podcast will be continuing the 3.86 series, first step 2. Step 3. This is going to be series 8. Alright, I'm going to pick up from question 67. A for the old female, Greek American newborn is brought to the office by her mother. Because the infant developed yellow in her skin one day after hospital discharge, and approximately 20 red spots over her skin yesterday. The infant has continued to feed well. Pregnancy and delivery were uncomplicated. Birthweed was 3400 grams. 7 pounds 8 ounces, 50th percentile. Upgrad scores were 8.9 at 1.5 minutes respectively. The model gravity 2.2 has blood group A, Irish positive. The neonate blood group is O, Irish positive. Results of a direct anti-globulin that's a cum stress was negative. The newborn, the neonate was breastfeeding and was doing well at the time of discharge. Waits today's 3250 grams, that's 7 pounds 2 ounces 25th percentile. Physical examination discloses John Dessence Clarelectors. Many papules containing small vesicles with clear to slightly tributythloid are present over the newborn's face, trunk and extremities. No organomethally or adenopathy is noted. Serum total bilirubin concentration is 8.7 mg per deciliter. And serum conjugated direct bilirubin concentration is 0.7 mg per liter per deciliter. So question 67 says, in addition to scheduling a full-of-visit in one week.

Which of the following is the most appropriate next step regarding the newborns? So option A says, advice the model to avoid eating foods containing large quantities of carotene. B says, begin at Benistrian's small doses of phenobarbidol to the newborn. C says, recommend this continuation of breastfeeding until the John Dessence has disappeared. D says, recommend home full therapy for the newborn. He says, recommend no change in child care or feeding of the newborn. I'm going to go with option A here. This child has a physiologic John Dess, usually the Rises after the first 24 hours of life. It's going to peak within a few days and then it's going to go down. This child since his first week of life is probably breastfeeding John Dess. Typically, that's just John Dess that arises because the baby is not feeding enough. He's not eating enough, which is not unusual. For the old, mom is still figuring out how to breastfeed and all that stuff. That's why the bilirubin is high. It's almost like a bilirubin concentration effect in a sense. It's 8.7. The child is fine. This child is four days old. That's like 96 hours old. We don't start doing phototherapy and any of that in a 96 hour old until their total bilirubin is 20 milligrams per decilator or higher. What I'm going to do that here, that's ridiculous. Option A is the right answer. Home full therapy. Phototherapy, we don't know in the hospital setting, right? Not at home. Then, this container breastfeeding, no.

You should actually breastfeed the child more. Give phynobarbitol to the newborn. No. To increase UDP glucose or transfer his activity, no, you don't need to do that. Advise the mom to avoid eating foods contain large amounts of carotene. No. This John Dess again is physiologic because it rules after 24 hours of life and it's indirect. Remember, physiologic John Dess is never direct hyperbilirubin. Now, question 16. Which of the following is the most appropriate management for the newborn's rash? Again, what rash does this newborn have? It's red. It has an aerothemano's base, small vesicles. It's on the face, the trunk and the extremities. This is ETN. Everything about toxic on your nature. Again, it usually picks a few days of life and usually with them by two weeks or whatever it just resolves on its own. So it's not a big deal. I don't do anything here. Again, you see most of this question is benign. You really should be picking a benign answer. So option A says 0.5% hydrochlorism, cream applied twice daily. Now, daily wet to dry, povidone iodine, soaks with goss pads on each vesicle. No. Polymixing, ointment applied twice daily. Routine skincare with soap and water. Yeah, that's a benign answer. I'll pick D. Option E says scrubbing daily with in-soufone cleanser, firmly enough to unroof the vesicles. I've not even heard of in-soufone before. I don't know what that is. You have to look that up on your own. But option D makes sense here. All right. Question 69.

Six month old male, his panic infant is brought to the office by his parents. Because of intermittent swelling of his right scrotum, that is more pronounced when he cries. The swelling has never been red or stark. Vital signs are normal. All right. In-soufone is confirmed on physical examination. In discussing repair of the hernia with the parents, you should inform them which of the following. So this is panic infant. Like if we look at this, this looks like an inguinal hernia. And what kind of inguinal hernia is this likely going to be? I hope you're saying divine. This is probably an indirect inguinal hernia. This is probably an indirect inguinal hernia. Remember, indirect inguinal hernia is a very common in little kids. And we tend to find the more commonly males. We tend to find the more commonly males, males, people that were born preterm. And he's usually going to be on the right side. Right. Because the pathophysus we know involves a persistent pretency of the processes vaginalis. And the thing is, you know, there is obviously a right process vaginalis and a left process vaginalis. And there are one on the right side tends to close later than the one on the left side. Right. So if it's patent, then the abdominal contents can come through that road. Because remember, the process vaginalis. I actually think of it as a highway that connects the abdomen to the testicles. Right. So you can to the scrotum.

So you can basically have like if that highway is open, then abdominal contents can come through the highway. Right. From the abdomen to the scrotum. Right. And the thing is, for this, you know, you want to fix them. The way you manage inguinal hernias is kind of different from the way you manage um, um, um, um, um, on the local hernias. On the local hernias, I can wait till close on his own in most cases. But I'm going to hernia. Um, you, especially in inguinal hernia in a little kid, uh, child that's like less than a year old, you want to try to close it electively. Right. You want to schedule the surgery because the thing is, especially in kids under each one, they have a pretty high risk of incarceration and a strangulation. Right. So you want to, you want to fix it. It's not crazy high, but you want to fix it. You don't want to just leave it dangling or whatever. Um, so you want to, you want to fix it if you can. Right. So let's look at the right answer. So option A says, herniography can be postponed until each two years because many hernias close spontaneously. I'm again, the risk of incarceration, strangulation and death is high. So you don't want to do that. Option B says, herniography can be postponed until each 12 years, because so it goes permia does not develop before each 12. I would not do that. Option C says, herniography should be scheduled at the earliest convenient time. Okay. That seems like a reasonable answer.

Option D says, herniography should be scheduled as an emergency operation. No. Right. Deal with a mess first. Prevent a mess instead of cleaning up a mess. Um, so deal with it sooner rather than later. Right. Don't don't don't wait until it becomes an emergency. That doesn't make any sense. Right. Option E says, there's no need to repair the hernian childhood unless incarceration occurs. No, you want to repair it. The thing is when a child that is more than a year old that has lived for a few years of life has an inguinal hernia, the risk of incarceration, strangulation is low actually. But for a child that's like less than a year old, the risk of incarceration, strangulation is pretty high. So you want to fix it. It's not an emergency operation, but you want to fix it. It's an elective procedure, but you want to fix it. All right. Now, question. So the right answer is going to be option C for that one. All right. Question 70. Three weeks ago, a 45 year old man was admitted to the hospital because of frostbite of both feet. He was treated by rapid, rewarding and protective care of the feet. All the tools on the right's foot have turned black. That's not good. He has become slightly febrile and progressively more confused over the last few days. Examination discloses cellulitis in the midfoot. Which of the following is the most appropriate treatment? This guy has gangrene, right?

I can see many things going wrong here like I don't know like neck fascia or compartment syndrome or sepsis and death. So option E says amputation probably pick that one right. Get rid of that bad foot. Option B says application of topical collagen is that's like a thing that kind of breaks down collagen. That's not going to help with gangrene. Option C says the bremen of necrotic skin. Seems like the problem involves more than the skin. So I'm not going to pick that. Option D says hyperbariacoxygen. Again, gangrene has happened necrosis of the tissues happen. You need to amputate. E says wearable therapy. Now the right answer is A you're going to amputate that that extremity. Alright. Okay now question 71 says a 44 year old African American construction worker comes to the emergency department because of excruciating left flank pain that radiates to his left testicle. He describes the pain as occurring waves and says this is the worst pain I've had in my life and that includes closing my thumb at my in my truck door. He's extremely restless as in an obvious pain, genitalia or normal. Abdominal examination discloses intermittent guardian with spasms of pain, plain extra of the abdomen shows no abnormalities. Results of your analysis are shown. So the pH 6.5 specific gravity, 1.025 glucose, negative protein, negative, of course the neglect to show us the red cells. MbM Es. Alright, so urinary sediment is shown which of the following is the most appropriate diagnostic study.

Option A says CT scan of the abdomen, B says CT scan of the kidney, C says culture of the urine, D says determination of serum uric acid concentration, E says measurement of 24 hour urinary calcium excretion. This person has got a kidney stone. Alright, the abdominal film did not show you any effect. Well how do we find kidney stones? We find kidney stones with C Ts, right? Non-contrast C Ts. Remember you use a non-contrast CT because if you use contrast, you'll obfuscate the stone and you'll be able to see it. So option C is wrong, right? Urine culture does for UTI, that's not what's going on here. D says checking serum uric acid concentration, E says checking urinary calcium excretion again. Let me help you, you don't really need to do that, right? You don't really need to do that. Like the direct way you diagnose a kidney stone is by doing a CT. So we have two kinds of C Ts here. We have a CT of the abdomen and a CT of the kidneys. So you're like, those two answers are correct. No, they're not. Only one is correct, right? So remember, will kidney stones always be at the kidneys? No, right? There are many places, they can be, they can be in the kidneys, they can be in the uriders, they can be in the renal pelvis, they can be many different places. So between the CT of the abdomen and the CT of the kidney, which one is going to give you a more complete visualization of the urinary system? I hope you're saying C Ts kind of the abdomen, right?

So the right answer is going to be option A. It's not going to be option B. All right, because option B only shows you the kidneys, option A shows you the kidneys and the entire internal collecting system. All right, urinary collecting system. All right, so question 72 says a 52 year old woman who has had low back pain for several years is admitted to the hospital because the pain is suddenly worsened. Her chronic medications include oxycodone, Amy tryptoline, perfenozine, flow oxytin and chrasodone. The patient's body weight is 10% below ideal weight. Puppels are constructed and skin turgor is poor. She seems sluggish and her speech is slow. Neurologic examination and x-rays of the lumbar sacrospine disclose no abnormalities. If a medication is responsible for this patient's mental condition, the medication is most likely to be which of the following. So we see this person has constructed poopels. You don't say she's sluggish, her speech is slow. All right, let's look at this. So option A says Amy tryptoline. Well, no, that's a TCA. TCA is a type of anti-colonurgic properties. So the cost popular in my dry assesses, not meiosis. So that's wrong. Option B says flow oxytin. Well, flow oxytin does not cause ocular findings. Option C says oxycodone. Oxycodone is an opioid. Opioid can cause popular meiosis because the decrease in the repinephrine release at the adrenergic synapse. So that seems right. Let's keep that. Per phenazine, I believe is an anti-psychotic.

Anticycotics, especially the first generation low potentianticycotics, they also have anti-colonurgic effects. Remember, your tricyclic antidepressants and your first generation low potentianticycotics, they have those anti-harm effects. Anti-hitch ones so they can cause sedation, anti-alphones, so they can cause orthostasis and anti-muscularity. Anti-M1. So they can cause anti-muscularity, anti-colonurgic effects. Option D will cause popular meiosis. That's not what's going on here. Trousodone. Trousodone is kind of a weak opioid. But again, between oxycodone and trousodone, which one is a more powerful opioid, more likely to cause these systemic effects? I'm going to go with option C. So yeah, oxycodone makes the most sense for this person. All right, so I'm going to go to question 73. 65-year-old man is admitted to the hospital. After he has an inferior wall myocardial infarction. For eight hours later, his vital signs are stable. ECG is shown. The most appropriate course of action is to do each of the following. All right, ACES administrator atropine B says administrative isoprotarinal. C says begin synchronized cardioversion. D says insert a pacemaker. E says observe. All right, let's look at the CKG. Okay. Oh, okay, that kind of makes sense. So first things first, let's look at the rate. Right? So we can see between the QR's complexes. I mean, boxes do we have so one, two, three, four, five, oh, like about six. So his heart rate is pretty low. It's probably about 50.

So he's got a pretty cardio. It has maybe a pretty arrhythmia. All right, now let's look at the PR intervals, right? Because again, if the USML is again, just think in odds on your exams, right? I feel like people like to overcomplicate their lives, just thinking odds on your exams. If the USML is at testing a pretty arrhythmia, which one do you think they're going to go for first? Probably some kind of AV block, right? So whenever I see a person has a pretty cardio, the next thing I think about on my exam is G-divine. Let's look at the PR intervals. Well, we'll look at the first PR interval. We'll look at the second one. We'll look at the third one. We'll look at the fourth one. We can see the PR intervals are getting longer and longer and longer and longer and then, boom, QR's disappears. So what kind of AV block is that? That's going to be second degree, which one? Mobids one, right? Winky Bach. Mobids one. Do you do anything for a Mobids one? AV block? Nope, especially if they're asymptomatic. If they have symptoms, then yes, you can paste them, but this person doesn't have any symptoms. So I'm not going to do anything, right? So I'm not going to be doing an atropping. We use atropping when a person has a symptomatic bradycardia. Symptomatic bradycardia, and you notice that pacing is not even a supply dancer. I'm not going to do that. Isoprotarynol is a beta one and beta two-organist. There's no reason to do that. This person literally has no symptoms.

He's completely fine. Synchronized cardioversion is typically for tachyroidism. He's not brady arrhythmias. Instead of pacemaker again, that's for people that have a Mobids two or a complete hard blocks. That's third degree. And typically Mobids two and third degree hard blocks tend to be associated with led infarts. led infarts, okay? And TRIMI's. Post in phyroval LMI's, RCE infarts tend to be associated with Mobids one. And those tend to be transient, right? Usually within a few days, it'll kind of go away. You know, as the Schemia and everything results, right? So I'm not going to put a pacemaker, right? Like I'm not going to put a pacemaker. So option E makes sense, right? The right answer is to observe. Right. So the answer is E. All right. So a healthy two-year old African-American child is brought to the office for a routine well-child visit. The child was wind at six months of age and began to walk at ten months of age. On physical examination, she has mild bolex, 10 degree genuvarum. The parents should be advised about which of the following. Again, this child is fine. Coming for a routine visit, right? And then the US Emily's, you know, she started walking at ten months. She was, she's crushing it, motorwise. mild bolex. Guys, pick up the nine answer here. Don't overthink this thing. Option A says braces should be applied immediately. Option B says no treatment is needed at this time. Yes, I'm going to pick up option B.

Option C says surgical correction is necessary. Come on, from our bolex, no. Option D says the child's intake of vitamin D should be increased. Do we see any indications of rickets in this child? Vitamin D deficiency? Nope. Special exercise program is needed. We don't need that right now, right? Again, most times bolex or resolve within like, you know, two to three years or whatever, right? You know, this child is just a two-year old. You know, likely resolve is just a part of development. It's not a big deal, you know. If the person has lived for, you know, maybe longer than three years, they're like four or five year olds, they still have bolegs or they have like very severe bolegs, then you can maybe do exercises and things like that or brace in, but you don't need to do that right now. This child is fine. This child is just a two-year-old. Chill out. I'm going to go with option B for this, for this one. Alright. Yeah, that's the thing. I feel like many times people overcomplicate the US Emily exams. They actually fairly straightforward. If you don't overcomplicate things for yourself. Alright, question 75 says a three-year-old child is brought to the ED by his teenage sister, because he refuses to walk. Okay. The sister reports that she has been babysitting for three days, while her parents are away on a trip. What? And that the boy has been faulty for the past two days. Physical examination is normal except for a painful swelling of the left lower leg.

In addition to radiography of the leg, you should obtain which of the following. And the story is not adding up. What kind of parent? Goodness gracious. What kind of parent leaves a three-year-old in the care of a teenager? Okay, maybe two hours. I understand that. We got to go grab ice cream or something, but for three days. Wow. Okay. This story is not adding out. There is something strange going on here. Well, let's look at the answer choices here. Option A says abdominal ultrasound. B says CT is kind of the abdomen. C says CT is kind of the head. D says skeletal survey. E says Cermlet concentration. So what do you think is going on here? Whenever you have a story in a kid that does not add up. We're kind of worried about child abuse here. Right? Kind of worried about child abuse. So this child has a problem in the low extremity. Maybe they have issues in other bones. I do a skeletal survey. Right? The thing is, you want to be really careful about ordering CT scans in kids. Right? There's a three-year old white giving that big dose of radiation. Right? So, certainly will not do options B or C. And then option A, abdominal ultrasound. Well, the thing is again, the question is directly focused on the musculoskeletal system. Why don't we examine that first before we start looking at the abdomen? Right? And then option E says Cermlet concentration. Because remember, lead can cause abdominal pain. It can cause like wrist drop, foot drop.

It can cause neuropathy on all those things. But again, it will probably not arise this suddenly. Right? That doesn't really make sense. So I'm going to go to option D for this one. Right? A skeletal survey is basically like an X-ray, like a series of like 20 X-rays. I know, I know, it sounds like a lot of radiation, but it's not as much as a straight-up CT. Right? So like a series of 20 X-rays, you assess the major bones of the body. Just to make sure that hey, there's no kind of like non-acadental trauma going on here. Right? So I'm going to go to option D. Right? This story just does not add up. It just does not add up. All right. Now, question 76, our last question today, a 32-year-old man and his 29-year-old wife come to the office for evaluation for infertility. The wife's gynecologist has reported that her anatomic and physiologic evaluation disclosed no abnormalities. And that assessment of potential male factors is needed. The husband is 188 centimeters. He's 6'3", tall, with fair skin and little facial hair. He has male gynecomasthia and small firm testicles. No sperm are seen on similar analysis. Which of the following tests is most likely to establish the underlying cause of this couple's infertility? Well, the wife seems fine, but what do we think the husband has? Tall guy, gynecomasthia, small testicles. Right? Not making no no no fine nutrients. So they have like decreased baby connects area here. It's probably client filters. Right?

Client filters, client filters. Right? 47, XXY. So, okay, let's see what it was going to help us here. So option A says, carry a type from peripheral leukocytes. That sounds reasonable. Let's keep that. Option B says, serum estrogen antistus from concentrations. No. That's not going to be specific for anything. Right? Option C says, serum FSH and LH concentrations. That's not going to be specific for anything because the question is same, which of the following tests is most likely to establish the underlying cause of this couple's infertility? Option D says serum prolactin concentration. No, prolactin doesn't explain this guy being this tall. No, that doesn't make any sense. Option E says, testicle ultrasound. No. This person has client filters. You're going to see very well with carrier typing. So I'm going to go to option A for this. All right. So we're going to stop here. Again, you like the way I teach, you're going to love my classes even more. So I have a bunch of classes for this month, taking place starting on the ninth, right? So starting this Thursday for step one to three, there's a test taking class, bio stats class and a social science class. And then for step two and step three, there's a last minute review on a 20 hour class. And then in the month of June, first week of June, I have a 20 hour step two step, I have a 50 hour, sorry, step two step three review.

And then I guess in the month of July, if you're a person that is studying residency, internal medicine, residency, or you're graduating from residency and you're taking your internal medicine boards or you're researchifying, I have a 50 hour, EBIM review that's coming up. All right. If you're interested, I've meet podcasts where I talk about those classes and what you should expect from them. Or if you want more information, shoot me an email. Again, these classes are not lectures. I use problem sets to go over content, explain pathophysiology, make integrations, show you how that information is presented on exams. And then also, I offer one or one tutoring from all the US civilis and complex exams. And then I also have this podcast on Apple Google on Spotify. I've got a You Tube channel you can check out. And then I have another website called divine intervention life lessons.com. Divine intervention life lessons.com. You know, many of you know, I'm a Christ follower. So every week I post like one or two podcasts where from a biblical perspective address and life lesson. I uploaded a episode 300 and E.7 I believe yesterday. And there's actually an Apple podcast associated with that called the divine intervention life lessons podcast. There's actually many people that listen to those and find them to be extremely helpful, like getting emails from people all the time on those. All right. So thank you for listening to me today. I will see you God willing episode 647 I think.

And I believe that should be the last part of our series on the 3 D 6 O. Can move on to something else. All right. So have a wonderful day. I'll see you next time. God bless you and bye for now. Thank you.

It is physiologic jaundice; no intervention (phototherapy) is required as the level is too low and the direct fraction is normal.

Indirect inguinal hernia, caused by a persistent patent processus vaginalis connecting the abdomen to the scrotum.

Contrast agents can obscure or "obfuscate" the visualization of the stone itself.

High risk of incarceration and subsequent strangulation.

Tricyclic antidepressants (TC As) and first-generation antipsychotics.

Amputation of the affected extremity.

A constellation of symptoms (e.g., pain in one area) combined with a suspicious or implausible narrative (potential abuse).

Mobitz I (Wenckebach) second-degree AV block.

A localized musculoskeletal issue when the overall clinical picture or story is suspicious/implausible.

The processus vaginalis; if patent, abdominal contents can pass through, leading to potential incarceration.

Non-contrast CT of the abdomen (as it visualizes the entire urinary collecting system).

Karyotyping (to rule out Klinefelter syndrome, 47, XXY).

A constellation of symptoms (e.g., pain in one area) combined with a suspicious or implausible narrative (potential abuse).

Mobitz I (Wenckebach) second-degree AV block.

A localized musculoskeletal issue when the overall clinical picture or story is suspicious/implausible.

The processus vaginalis; if patent, abdominal contents can pass through, leading to potential incarceration.

Non-contrast CT of the abdomen (as it visualizes the entire urinary collecting system).

Karyotyping (to rule out Klinefelter syndrome, 47, XXY).