DIP Episode 563 - 2024 USMLE Step 3 Free 137 Discussion Part 10 (Q92-100, super helpful for Step 2!)

Welcome to episode 563 of the Divine Intervention Podcast. My name is Divine and we're going to be continuing our 3137 series. This is going to be part 10. We're going to start with question 92. A 67 year old woman with us to Opinia comes to the office because of a six month history of increasingly severe constant pain in her left hip and thigh. Before her symptoms began she walked one mile daily. She now walks with a limp and was used a walker. Her whole history of suicide is remarkable for hypertension. Medication is a hydrochlorothia side. I will prevent an calcium-invitamin de-supplementation. Hadexas can't T-score was negative 1.8 to 1 year ago. Vital signs are within normal limits. Examination of the left lower extremity produces mild growing tenderness. Passive range of motion of the left hip is limited by pain. Serum studies show a calcium concentration of 8.6. Interpret a thyroid hormone concentration of 55. That's normal. And 25 hydroxy-vitamin de-concentration of 30. That's normal. X-rays of the left hip and femur show cortical thickening of the sub-trocanteric region. MRI of the left hip and femur shows moderate edema of the bone marrow and soft tissue in the sub-trocanteric region. This cortical discontinuity laterally. Which of the following is the most appropriate next step in management? Right? So this person has osteophenia. This person is not doing well. But we see that this person has gotten pretty intense image of the hips.

And we see like this bone is very unstable. I mean, I would not feel comfortable walking around with this kind of bone. You're seeing like a dim of the bone marrow. You're seeing a dim of the soft tissue around the bone. You're seeing cortical discontinuity. Right? And this is a bone that she uses a lot. Right? She walks. But now she's walking and all that stuff. This bone can break at any time. So basically whatever answer we pick has to fix that problem as quickly as possible. Basically ASAP. If not one day, this one is going to fall and that bone is going to explode. You don't want that. That's not good. Right? So option E says bisphosphonates. Again, bisphosphonates is the person should probably be on bisphosphonates long term. But that's not going to immediately fix this problem. Again, you got to make sure you're answering the problem that's posed in the question. Abristabilization. This bone is about to fracture. Like I would do something for I would do something more immediate for it like surgical. Option C says caustic toning. That doesn't make any sense. Again, option D is kind of similar to option B. Custom mobilization. So not going to really help the impending problem. Impending demise of this bone. Option E says inject steroids that makes no sense. Option F says surgical fixation. I will certainly do that. That seems like a really good option here. Option G says observation only. So this person has like a fracture that is almost like a pathop.

Almost like an impending pathological fracture. The bone is very unstable. You know, sometimes this is done in cancer patients where he's like, oh, you see this person has like a bone met and this bone is just about to break. You're not going to be murking around with drugs. Yes, you can do drugs at some point, but you actually have to intervene pretty quickly by doing a surgery. So I'm going to go with option F for question 92 or a question 93. To have a 65 year old male, you know, he's in the hospital. He is admitted because of a four week history of progressive shortness or breath on exertion and swelling of the lower extremities. The shortness of breath also weakens him at night. Medical history is remarkable for hypertension and type two diabetes. Medications on low-deep pain, metformin and delia sprain. He does not smoke cigarettes, drink alcoholic beverages or use other substances. These temperatures 90.6, pulse is 90 per minute and regular. Respirations are 20. Blood pressure is 142 for 64. O2 SAD is 92% of room air. Piersmily uncomfortable. GVD is, uh, juvenile pressure is 12. Oscrotation discloses in preteric records in the mid longfields bilaterally. Cardiac exam discloses an S-300 at the base. At the middle exam shows normalities by lateral pit in the dim of the knees. And then we look at his labs. What kind of sticks out like a surf thump here? Nothing really bad on these labs. Well, the bike car is kind of low, but not a big deal. ECG is shown.

Administration of which of the following is contraindicated in this patient. Again, I've said this many times on this podcast that, you know, a lot of people kind of persevered and sweat about the imaging and the EC Gs and all the audios and videos that they throw in the exam. Most times, if you just read the question carefully, you're going to be pretty good to go with many of these questions, right? Like the troponins are fine. And again, looking at this ECG, I don't really see any like ST elevations or whatever. But this question, even without looking at the ECG, just common sense. This person has crackles in the lungs. All right, they have been in a dima. You're hearing an S-3. Sounds like CHF to me. And then they're like, ooh, what should we not give to this patient right now? Well, if a person is having like CHF and it's almost like exacerbating, it's just not doing well, you maybe want to avoid something that would depress cardiac function even more or something that will kill preload. That will not be a good idea, right? So for example, I like Metoprolol for this, right? Beta blockers, another one that you go test with this, is a non-dihydroperidine constant channel blocker like Vera Pamelodil tires them. Don't give that when a person is acutely decompensated from a CHF perspective. Don't do that, right? Because those are negative vinyl tropes, depress cardiac function even more and that's not very good.

The jox will probably help the person actually for their hearts to contract better. Furious some eye, again, it's not contraindicated, it can help get some volume off. Like Ceno-Prayal, not contraindicated can get some volume off. It's not a negative vinyl trop. It's not lactone, actually does improve survival in heart failure, but it's not a negative vinyl trop. The specific reason why we're not doing Metoprolol is because it's a negative I know tropes. I'm going to go with option D for question 93. All right, let's go to question 94. 62-year-old man comes to the office for a routine follow-up examination when he after undergoing hemicollectomy for stage 3 colon cancer. Postop serum CEA was one, so that's normal at the time. The patient had completed a six-month course of adjuvant chemotherapy. Today, he says he feels well and reports no symptoms. Medical history on the wise is unremarkable and currently takes no medications. Vital signs are within normal limits. This collection examination shows a well, healed, midline surgical scar. Coronoscopy shows no lesions, polyps or recurrence of cancer at the anatomosis site. Serum CEA is 20. That's not good. Pet CT of the chest, abdomen and pelvis shows a new one centimeter pulmonary nodule with irregular boulders and increased optic in the left lower long lobe. The nodule does not involve the plural with all the major structures and there is no plural of fusion. Okay, that's good.

Which are the fullings the most appropriate next step in management. So let's kind of frame this question. This is a present in the hospital on cancer that has metastasized. Now again, this is one of the few reasons why you'd use pet CT to find like distant meds. And also, this is one of the reasons why we occasionally measure these CE As and CA99s and all those stains, right? Because those stains, we can use them to kind of monitor for recurrence, right? Like it's like, ooh, this lab that was normal, normal. After you got treatment, if you start skyrocketing again, it's like, ugh, this is kind of worrisome. Let's chase it down with a pet CT. So they found this lesion in the lungs and thankfully this lesion is like well localized. It doesn't seem to have spread anywhere. Right, whenever you have like a well localized lesion that has not spread anywhere, just take it out surgically. That's like a general, again, it doesn't always work, but that's like a good, nice solid principle of oncology should keep in mind. Right, you have a well localized lesion, just take it out. You know, it's not spread anywhere. So just kind of like scoop it out and problem solve. Right, so option A says bronchoscopy. We don't need to do that. We literally know where the problem is. B says chemo. Again, chemo is something you do when something tends to be systemic.

Although you can also use it for some localized malignancies, but most times, if you have a, even if you're doing chemo, you want to do surgery first because that's like the quickest, most direct way to control the problem. No, this person doesn't need palliative care. Right, this thing is not sp- it's pretty well localized. Option D says radiation again. Why risk all that damage when you have something that can just easily scoop out the lesion? I like option E on lots, resection of the nodule. All right, a 60, so question 95, a 64 year old man is admitted to the hospital for evaluation of anemia and constant non-redeeding epigastric abdominal pain that began three days ago. He rates the pain as a four and a 10 point scale and says he partially improves after eating. Hmm, okay, sounds like a dwarf, not lost. Okay, he has not had nodule vomiting, medical histories remarkable for hypercholestero leami and hypothyroidism. Medications are low, the pain and level thyroxene has no allergies, drinks alcoholic beverages only occasionally, and does not smoke cigarettes. His temperature is 98, pulse is 90, respiration is 14, blood pressure is 110 over 70. Cardiopominar examination discloses no abnormalities, abdominal examination discloses mild tenderness in the epigastra with no guardian or rebound. Test of the stool for a cold blood is positive. Himoglobin concentration is 8. Operating dosculation shows a non-bleding ulcer.

Biopsy of the ulcer is done in results show polymorphic infiltrate of small cells with reactive follicles that stain positive for a B lymphocyte marker CD19 and 20. In addition to prescribing a metrosol therapy, which of the following is the most appropriate initial treatment, right? So, let's frame this question. This is a person that has an ulcer, you biopsy the ulcer, you see polymorphic infiltrate of small cells with reactive follicles and their CD19 and 20 positive. Again, don't overthink this thing, right? This is like a slam dunk question. If you get this wrong, that's not very good. I'm just going to leave it at that. This is a classic maltoma, right? And most maltomas, they respond very well to triple therapy for each bilogen-striple therapy. Clarithromycin, amoxicillin, and a PPI by chomeprizol. Right? If that doesn't work, then you can start reaching for things like retoximabri. Retoximab is like a second line treatment, so I'm going to go with option A here. No, option B makes no sense, right? Cyclofoist for my command. That's like using a nuclear bomb for a minor cancer. No, that's a lot. Don't do that. Radiation, nope, retoximab, yep, you can do retoximab after you've done option A. And then E says surgical resection, no. Most of these things respond beautifully if you're ready to get the H by large. So the answer is going to be option A. All right, question 96. A 19-year-old man comes to the urgent care center because of severe lower abdominal and scurdo pain.

He was elbowed in the groin one hour ago during a basketball game. The pain decreased 15 minutes after the incident and he continued to play in the game. Approximately 20 minutes later, the pain resumed with increased intensity causing him to vomit. He has otherwise felt well. Medical history is on remarkable and it takes no medication. Family history is on remarkable. Temperature is 90.6, pulse is 100 and regular, respiration is 14 and blood pressure is 150 over 88. The patient is rather in pain. Now sounds are normal active. The abdomen is soft with no tenderness. G.U. examination discloses an exquisitely tender left testicle that is situated in the transverse plane. The patient is fearful that this injury may cause him to be infertile. At this time, it is most appropriate to inform the patient of which of the following. Right? So this person had trauma to the testicle. And this trauma to the testicle, hey, maybe it's caused a hematoma or it's caused torsion or whatever. Whatever it is, it's kind of valid that this guy is worried about his fertility. So whatever is going on, just I don't know, fix it. If it's like torsion, remember, testicular torsion, there's this female statement I have. The time is testicle. Right? So, you know, the torsion, maybe try to fix it quick. If you fix it quick within like six hours or less or thereabouts, the person's testicle will survive and no one will be the wiser. Right? You know, you do that bilateral or kilpaxial.

Although obviously the testicle is dead, you're going to do an orchidectomy. So this guy just fixed the problem quick. So let's look at the answers, I guess. What he says is fertility will be adversely affected because of lots of functional testicular tissue. Do we know that? No, we don't. Until you do the surgery and see the tissue, you don't know. Option B says, his fertility will most likely be unaffected, full of immediate reversal of the condition. Yeah, that seems reasonable. Let's keep that. Option C says his fertility will not be adversely affected with conservative management. If he's testicular torsion and you do conservative management, buy, buy fertility, buy, buy testicle, don't do that. Option D says whether his fertility will be affected, cannot be predicted without full evaluation and tested. Yeah, that's a decent answer about again. I always like asking myself, what is like the answer that is like a just clear caught, very direct. Doesn't involve any ifs and bots and all these things. I like option B, right? This guy probably has testicular torsion. If you fix it quickly, you're going to be fine. That's like a commonly known medical fact. So what is fertility will be affected, cannot be predicted without full. No, we can predict it because if we actually fix the problem quick, it's not going to have any long-term repercussions. So I'm going to go to option D for this one. All right, question 97.

39 year old woman at 32 weeks gestation returns to the office for a prenatal visit. She previously used IV heroin and has been in a methadone maintenance program for the past two years, including throughout this pregnancy. That's good for her. She had needs to cigarette use. Ah, it's not very good. An occasional cocaine and I'm fed up in use during the early part of this pregnancy. In the past two months, she has tested negative for any drug use of a methadone. Good for her. Okay, she's being responsible now. Now, you have discussed with her the probability of a prolonged hospitalization of this new unit, if there are signs of withdrawal after delivery. At this visit, she tells you that she wishes to breastfeed her baby. Which one following the most operator response? So this one is on methadone. And methadone kind of causes it's safe in pregnancy. So it probably be holds you to think that if this thing is safe in pregnancy, I can probably breastfeed well among it. Just certain wise things you should do if you're taking methadone number one, the child may have to be in the after you give birth, the child may have to be in the knee for a little bit. Just observe for withdrawal because it's an opioid. So you can cause some withdrawal. And there are just some prudent things you can do as a mom if you take methadone, like, you know, don't like take your methadone and like 2 p.m. and breastfeed at 2.30, right? That's not very wise.

You'll be giving pretty decent doses of methadone to the baby. It's small, but it's not wise. You know, so maybe breastfeed before you give the methadone, before you take your methadone dose and stuff like that. So again, we've kind of framed the question, discuss the concept. Now let's look at the answer. So she says, because of your high risk for HIV infection, breastfeeding is on C for your baby. She have HIV right now. No, we don't have that information. That's wrong. Option B says, because of your pasties drug abuse, breastfeeding is on C for your baby. No, you can breastfeed. Breastfeeding has a lot of benefits for kids, right? Reduces the risk. I've talked about this already. Acute otitis media, allergies, asthma, um, seeds is pretty good, right? So you should try to breastfeed whenever possible, except you have like a contraindication like HIV, for example. Now, option C says, because you have participated in a methadone maintenance program, I encourage you to breastfeed. Okay, that's a pretty good answer actually. Let's keep that one. Whenever you have an ethics question, you always have to run through all the answers. Option D says, many drugs enter the breast milk and can cause problems for the baby. Let's develop a plan to give your baby a safe breast milk. Okay, let's keep that one actually. All right, option E says, because they involve patient education. I'm going to talk about a patient education principle shortly here.

Okay, option E says, methodon cocaine and amphetamines do not enter the breast milk in sufficient amounts to harm the baby. So proceeding can be permitted. That's, that's false, right? That's false. That's not true. It actually does enter enough. I can certainly cause problems. So option E is definitely wrong. So option C, she's been in a methadone maintenance program, encouraged her to breastfeed. That's actually a pretty decent answer. Option D, many drugs enter the breast milk and can cause problems for the baby. Let's develop a plan to give your baby a safe breast milk. So that option kind of agrees with a lot of what I've said. You know, because you want to maybe take your methadone after you've just breastfed, you know, so that you decrease the amount of methadone that's getting to the breast milk to go to the baby. And one thing I've noticed with a lot of ethics questions on the USML Es, especially on more recent USMLE exams, is that an answer choice that provides patient education is usually a better answer. I like to call it the patient education test tick and principle. So you have an answer choice that provides patient education. It's a good answer, right? So let's make a plan because I can almost promise you you're talking to pediatrician or obstetrician. And the plan is going to be like, hey, breastfeed your baby for your tick and methadone bill. So I'm going to go with option D. Option C is great though.

If option D was not here, I'd go with option C in a heartbeat. All right. Question 98, a 25 year old, nolly gravied woman comes to the office for now. He helped maintenance examination. She has a history of PCOS and has been taken on OCP to regulate her menses medical histories otherwise on remarkable family histories remarkable for obesity. She is 5 foot 6 inches tall and weighs 148 pounds, BMI is 24. At temperature is 98.6, pulse is 82 per minute, transpiration is 16 per minute, and blood pressure is 126 over 76. Physical examination shows mild facial hersuteism that appears to have remained unchanged since the last visit one year ago. The remainder of the physical examination shows no abnormalities. The patient should be concerned that she is at greatest risk for acquiring which of the following conditions. PCOS, we know again, the classic signs of hyperindrogenism, polycystic over is on ultrasound, an ovulation which is good word for irregular menses. You meet all of those three criteria, you got PCOS. Now what are some other associations for PCOS? Well, you can get an omicro cancer from it, has an extremely strong association with insulin resistance. In fact, you see some women that have PCOS and they get them at forming and boom, they get pregnant just from the met forming. So you know, those are the major associations. Endometrial cancer, insulin resistance, those are the big ones. I'll see those are the big ones to know for example. Let's look at the answers here.

Isis diabetes, that's kind of code word for insulin resistance. Let's keep that. PCOS hypertension, yeah, but not as strong as diabetes, right? So we're going to cross that off. Option C says hypothyroidism. No, PCOS doesn't raise your risk of hypothyroidism. Nephrodite syndrome, that makes no sense, right? Option E says uterine cancer. All right, that's another good one. But again, between diabetes and uterine cancer, think about it. Just most of the people you know that have PCOS or most of the vignettes you've read, or most of the practice questions you've done on a PCOS patient. What do they almost always have? They almost always will be yeast, they almost always have diabetes, they almost always have some metabolic thing going on. Don't get me wrong, they get uterine cancer. Yeah, but even that uterine cancer is probably going to be like later, right? After many, many, many years of on-opposed estrogen exposure, you know, because they have an ovulation, so they almost never go to the uterine phase. And this person is 25, right? Percent has, you know, there's a reason why we're not too worried about uterine cancer in PCOS people until they're like in the 30s or whatever. Honestly, option is just a better answer, just epidemiology wise, I'm going to go to option A. Alright. Now, question 99. 111th old infant is brought to the office by his mom because of a 24-hour history of progressive swelling and blushing of the left index finger and thumb.

Two days ago, it developed fever and running nose. Yesterday's mother noted sores on his left thumb and index finger, which have become progressively, which have become larger and more blistered today. He has no known history of trauma, no one at home has similar lesions or history of skin problems. The infant attends the care five days weekly. Medical history is significant for recurring diaporashes and operates with retraction infections. Temperature is 101.8, pulse is 140 per minute and refrigeration is at 32 per minute. The appears don't toxic but fussy physical examination discloses rhinorrhea with clear mucus and several small, and it's a bit of a popular vesicular vesicular. What do you think that means near his mouth? No. Okay. Left hand appears as shown. Which one is the most appropriate pharmacotherapy? Whatever the NV Me see vesicles, usually means one thing. It usually means something that's either herpes or her pediform. For example, the martyredis are pediformis, vesicular lesions, in celiac disease, herpanjina, vesicular lesions in the mouth, in a person who coxacchi a virus. This person you can see the vesicles. It's pretty classic herpes. Again, even for the description in the question, you don't absolutely need this photo. Yeah, it makes you feel a lot more confident but this is classic herpes. Herpes usually has only one treatment, acyclovere. So I've got a good option here.

If a lexin makes no sense for herpes, that's something that you can give for skin and soft tissue infections or clean the mice in again. We use it for covers, MRSA. It's also good for infections when we're worried about anaerobic. Clean that is pretty good for those. And you also use oral clean that actually for some dermatologic conditions. You can use it for hydrodynamics, super active, just something to keep in mind. Which one says topical muopyrusine? Use that for people that have a petiglo. This is not in petiglo. In petiglo, I would hope that those not cause temperatures of 101.8, that means no sense. Topical silver, sulfur, diazine. No, that doesn't make any sense. Herpes is scalded with acyclovere. So we're going to do option A. All right. Question 100, last question. 57 year old woman comes to the office. Because of a two week history of intermittent populations, the populations are worse the morning of this visit. And I associated with a queasy feeling now for abdomen. Her symptoms began after she started training for a 5 kilometer race, the origin of her partner. And I've been increasing in intensity after a training session. Medical history is significant for type 2 diabetes, treatment, and forming. For me, history is significant for M.I. and her father. She has smoked one half pack of cigarettes daily for the past 30 years. She does not drink alcoholic beverages. She has five foot tall and weighs 141 pounds. B.M.I. is 28. O2 SAD is 94% in room air.

Oscutation of the lungs disclosed by lateral bisiler carcels. Cardiac examination discloses a no more less one and S2, an S4 and a great 12 and 6 stolic murmur. The remainder of the physical examination discloses no abnormalities. Easy to obtain today shows ST segment elevation. Whoa! In the anterior leads and Q is in least 2, 3 and EVF. Radiant strip shows intermittent premature ventricular contractions. Which of the most upper rate pharmacotherapy at this time? So this sounds like an M.I. Although, yeah, this sounds like a stemming. So you're going to treat it like you treat a stemming. So let's look at the answers. Oscutin A says, I am morphine. You can use that for pain. Oscutin B says oral aspirin. Like aspirin a lot. That's always the first drug you're giving an M.I. Always. It doesn't matter what the question is. If you've not got an aspirin 3124 milligrams, you get aspirin 3124 milligrams. Oral deotias M, that makes no sense, right? Because that's a negative vinyl trope. When you're having an M.I., that doesn't sound like a really great idea. Subcutinos and occiporing. You can give a HEPRIN-B's product when a person has an M.I. But again, you have to give aspirin first. B is the right answer here. Oscutin E says sublingual nitroglycerin. Again, you can give a nitrate. But it can give aspirin first. So I'm going to go to Oscutin B for this one. All right. So I'm going to go ahead and stop here. I kind of want to keep things organized.

So the next series will start off with 101. But basically, again, if you like the way I teach, you like the way I make integrations, you love the way I clean pathophysiology. I'm all in. I'm going to consider my classes. If you're taking step one to step three, I have a series of classes starting today. I have a test-taking class starting to this one, half hours long, a biostat class tomorrow, four hours long, and a social sciences quality improvement and healthcare systems class on Thursday. That's five hours long, actually. They're all over Zoom. That's for step one to three. And then if you're a step two, step three taker on Friday, I have a last minute review. And next week, Monday to Thursday, I have a 20 hour step two, step three review. If you're interested in those classes again, many people have taken those classes, found them to be extremely helpful. I've literally had people, and again, these classes are updated regularly. Just to keep up with the MBA meetings, I like to think of my classes as software that needs to be updated so that you have proper functioning on your tests. I've had people get very, very high scores. I've had like recent 260s, 270s, 280s from these classes. I kid you not. And those classes were a big, I know these for a fact. Those classes were a big portion of those people's prep. So again, I think the classes have been pretty well validated. A lot of people have done extremely well with them.

So again, if you can interest that, shoot me an email through the website. And then I have this podcast on Apple, Google, and Spotify. I have a You Tube channel you can check out. That's where I post the videos I make. And I also help with your applications, working reviews, personal statements, and all that fun stuff. And then I do want to want to learn for all the US Million complex exams. And then I have another website called Dividing Intervention Life Lessons.com. Dividing Intervention Life Lessons.com. There's actually an Apple podcast associated with that called the Dividing Intervention Life Lessons podcast. Every week I post like one to two podcasts where from a bibliocoper perspective, address the life lesson. Many people have listened to those, found them to be really helpful. I'm about 300 episodes on there right now. So I'd advise you to check that out. All right, so thank you for listening to me today. Have a wonderful day ahead. God bless you and the life for now. Thank you.

Time is testicle; prompt surgical intervention is crucial for viability.

Acyclovir.

Insulin resistance/Diabetes mellitus.

Immediate surgical stabilization to prevent catastrophic collapse.

Patient education regarding timing (e.g., breastfeed before taking the dose) and acknowledging that drugs can enter breast milk.

Biopsy showing polymorphic infiltrate of small cells with reactive follicles, staining positive for B-cell markers like CD19 and CD20.

Acyclovir.

Beta-blockers or other vasodilators/negative inotropes (e.g., Metoprolol).

Aspirin (antiplatelet agent).

Insulin resistance/Type 2 Diabetes.

Immediate surgical fixation/stabilization.

Triple therapy (e.g., Clarithromycin, Amoxicillin, and PPI).

Acyclovir.

Beta-blockers or other vasodilators/negative inotropes (e.g., Metoprolol).

Aspirin (antiplatelet agent).

Insulin resistance/Type 2 Diabetes.

Immediate surgical fixation/stabilization.

Triple therapy (e.g., Clarithromycin, Amoxicillin, and PPI).