DIP Episode 643 - USMLE Free 86 Series 5 (Q37-46, for Step 2/3)

Alright, welcome to episode 643 of the Divine Intervention Podcast. Into this podcast we're going to be continuing the free 86 series. Again, guys, I'm telling you, if you're taking your USM Ls anytime soon, don't ignore the stuff. It's going to pop up on your exams. Alright, so we're going to pick up from question 37. A 35-year-old white man with spina bifida is admitted to the hospital for urologic procedure. He has been functionally independent in activities of daily living and is employed doing inventory control in a local sporting goods store. He has maintained continuance through periodic self-catharization. The vision is paraplegic, has recurring calcium oxalic kidney stones, and is set on set of incontinence secondary to detours from blood or neck dysfunction. Vital signs are normal. Physical examination shows a well-developed world-march money in no acute distress. Aside from paraplegia, lower extremity muscle hypertrophy and lower abdominal surgical scars. The physical examination discloses no abnormalities. He had an episode of anaphylaxis secondary to latex allergy during a previous operation for functional expansion of his bladder through a bowel and asthmoses. Which of the following is most important to consider in the care of this patient? A. Administration of Injectable Medications with Disposable Seringes B. Preparation of food by outside contractors C. Type of clean agents used to sterilize bed linens D. Use of rubber, urethro catheters E.

Use of topical moisturizing agents for skin care. For this, I'm going to go ahead and say D. Again, that makes sense. Why? Because this person has latex allergy. Remember, latex allergy can absolutely positively cause anaphylaxis. You don't want to be exposed to latex ever again. I wouldn't be surprised that this guy developed his sensitivity to latex because he's been heavily involved with the healthcare system. When people have these neurological disorders, they don't pre-term or whatever, they tend to be in the hospital for a while. They tend to be in and out of the hospital a lot. Those people may develop a sensitivity to latex because so many healthcare workers have touched them and developed a latex sensitivity. Alright, question 38. A 14-year-old boy is brought to the walking clinic by his father later on a Saturday afternoon because his left ear is swollen and painful. The ear has been black and blue since he injured it in a wrestling match three days ago. Symptoms have increased significantly following a repeat injury during a match three hours ago. Vital signs are normal. The left ear is markedly swollen and tender to palpation. Each of the following is the most appropriate next step in management. A, reassure him and start aspirin D. Reassure him and start co-din C. Recommend that he apply cold packs to the ear for the next 12 hours D. Recommend that he apply hot packs to the ear for the next 12 hours E. Refer him to a surgeon for immediate drainage of the lesion.

So look at what's going on here. So this kid seems to have a problem with the ear, the outer ear, the oracle. Kind of like a blood collection, kind of seems like a hematoma. The thing is whenever you have something like this you need to drain this. You need to drain this. And the thing is the ear is an especially sensitive region for stuff like this. And here's why. Here's why. The thing is your ear is pretty much filled with cartilage, a ton of cartilage. So here's the thing that's going to happen if you don't fix this. The thing is cartilage tends to be surrounded by a connective tissue known as pericondrum. Pericondrum has like the, it brings in the nutrients, the blood and everything that feeds the rest of the cartilage. So it's like the, it's like the hemoglobin for the cartilage. So the thing is whenever you have a hematoma it kind of separates the pericondrum from the rest of the cartilage. And once that blood organizes, you know, you can have fibrosis and all these things, then that cartilage that's underneath can become ischemic. Because remember cartilage is largely a vascular and that can cause problems. So what do you do here? Find that hematoma, right? Drill that hematoma. And you want to put like some kind of dressing that will bring the pericondrum as close as possible to the cartilage so that you can keep restoring nutrients to the cartilage so that it doesn't die, right?

In fact, this is kind of worrisome that this has been like three days, three days and it's worse thing. You got to do something about it. If not, the person's cartilage in there, ear will become ischemic and die. And then also they can develop like almost like I'm not kiloids, they're not going to develop kiloids. They develop like deformities of their outer ear is going to look kind of all jacks up, right? So I think it's very important. This boy needs to have this injury. And so I'm going to go with option E for this one, right? Hot packs are terrible idea, right? Because it's going to worsen the bleed, right? Hot packs are going to worsen the bleed. Because remember, heat causes visodilation, right? I also would not pick option A because aspirin is an anti-pletidic drug is going to worsen the bleed. It's going to worsen the hematoma, right? Co-Din is going to control the pain, but it's not going to prevent the ear from not being good in the future. And then again, apply cold packs to the ear for the next 12 hours. Again, hey, that may help with the bleeding, stopping it, but again, you need to drain that bleed. You need to drain that bleed. So the answer is going to be option E. All right. At 25 year old woman who is 19 weeks pregnant comes to the office for a prenatal examination. Her father had classic hemophilia.

A carrier type obtained from an amniotic fluid sample of the patient shows that the philosis X, Y, which of the full age should you tell the patient regarding her infant? Option A, the infant will neither have hemophilia nor be a career option B. The infant has a 50% risk of hemophilia option C. The infant has a 50% risk for being a career option D. The infant has a 75% risk for hemophilia option E. The infant has a 75% risk for being a career. So this infant is male, right? X, Y. So think about it, right? So the mom is a carrier, right? The mom is a carrier. The mom has to be a career, right? Hadad literally. So oh, sorry, wait. Okay, yes, hadad was a had hemophilia, right? So that means that X chromosome for sure had the abnormal hemophilia gene, right? So chances are, it's not chances are the woman must have gotten that bad X chromosome from that. Because remember, women are X, X, men are X, Y. So this woman's dad had hemophilia. So he had the bad X and he had the Y chromosome. Obviously as a dad, you're not going to pass on your Y chromosome to your, your daughters is your X chromosome. You're going to pass on. So you give her the X, right? And then her mom probably gave her another X because she's a woman. So she has to be X X. So she probably has one good X chromosome and one bad X chromosome. Well, the thing that could have happened, that can happen here with this her fetus now that is X Y is the fetus is Y chromosome has to come from the data of the fetus.

So that's not a problem. So the fetus is X chromosome has to come from mom and mom has one good X one bad X. There's a 50 50 chance that the fetus could get either X, right? So that's why this child has a 50% risk of becoming a hemophilia. So I'm going to go to option B for this for this one, right? That's just the right probability. All right. Now question 40 and 18 month old child is brought to the ED by his parents because of fever and irritability. The child was well until four days ago when he developed right in Rhea, Miso congestion and diarrhea. A week ago, he was sending the office by your partner and received a routine vaccinations at that time. His mother says he felt warm to touch two days ago, but his temperature was not taken. She has been giving him a set of men of in every six hours during the past two days. Since this morning, the child has been eating poorly. There is a four year old sibling at home who is healthy vital signs or temperature of 100.8. So that's a fever. That's a temperature over 100.4, right? Pulse is 100 per minute. Resolutions are 25 per minute and blood pressure is 170. In physical examination, the child is a fever is irritable. He is on cooperative during the examination and his neck is stiff and painful when flexed. He is whining that he wants to go home. Extremities are cool with no more capillary refill time and there is no rash. This findings are most consistent with which of the following.

So A says a set of menophaned toxicity, B says aceptic environment in jihadist C says gastroenteritis with maldihydration, D says rice syndrome, E says vaccine reaction, right? For this one. I'm thinking I'm going to go with varumine in jihadist, which is also called on the MBM Es aceptic meningitis. So we see this child got a vaccine recently and then now you're seeing that this child has a stiff neck, has a fever, irritable. This is pretty classic for meningitis. But if you notice the fever is low grade. It's not like a crazy, crazy fever. The child seems to be relatively okay for the most part. This tends to go more with varumine in jihadist. The thing is most of the varumine ingitities tend to cause mild symptoms. The only varumine in jihadist, or let me not say the only, but the classic varumine in jihadist that tends to cause really bad problems on the USMEL exams, is going to be HSV, right? HSV, you're going to have very high fever, then you have seizures, it messes up your temporal lobes. Right? But this is more of a guardian variety, varumine in jihadist, right? So remember if you check their CSF, you're going to see low glucose or you know it's going to be just a little bit lost, likely normal, right? Their opening pressure is going to be just normal, just a little bit elevated. The protein is going to be normal, just a little bit elevated, right? So eseptic meningitis, right? And most times you're just going to do symptomatic care. That's pretty much it, right?

So I'm going to go with option B for this one. This is not a set of menophaned toxicity. You're going to see LFT abnormalities, right? It's going to explode your liver with that NEPQI, right? This is not gastroenteritis. This is not a rice syndrome. Rice syndrome, you're going to see again a lot of liver dysfunction, right? A lot of liver dysfunction, a lot of liver dysfunction, right? And rice syndrome tends to be a zero to aspirin, aspirin, right? Not acetaminophen, not acetaminophen, right? And then vaccine reaction. Again, this could be a vaccine reaction, right? But again, the more direct answer to this question is, viral meningitis, right? Like there are many kinds of vaccine reactions of which this meningitis could be part of it. But again, the meningitis answer is just more specific for this question that we just read. So that's like the smarter play in terms of selected answer. All right. Question 41, a 22 year old woman is brought to the ED by her parents. Most of muscular weakness, muscle, muscle twitches and repetitions. She's extremely thin and somewhat chaketic. Her parents report that she has a history of self-induced vomiting and overuse of laxatives and thazide diuretics. Routine blood studies are obtained. Which of the following findings is most likely to explain these signs and symptoms?

Option A, decrease hematocrate and hemoglobin concentration option B, decrease term glucose concentration option C, decrease term potassium concentration option D, increase term calcium concentration option E, increase term sodium concentration. So what should we be thinking about here? I really hope you're saying option C, right? This makes sense, right? This person has anorexia, right? And you say a lot of muscle problems. Many people don't give potassium enough credit. Potassium is very important for muscle function. That's just the truth. Very important for muscle function. And this lady has so many risk factors for hypokillinia. Like what do you mean say? Well, she vomits, uses laxatives. Those things are going to make you volume depleted. What happens to the activity of your Routine and Jotensin system? It's going to get cranked up, right? So you're going to make a lot of our dust run. And what does our dust run do? It makes you dump potassium in your urine, right? So you're going to develop hypokillinia from that. And then she also uses thazide diuretics. Well, firesize, what do thazides do? Firezides, their diuretics, they make you volume depleted. That's going to again lead to the cranking of your Routine and Jotensin and our dust run system. So your dust run is going to rise. You're going to dump a lot of potassium in your urine. That's going to cause you to have hypokillinia. So I'm going to go with option C here.

There's just so many risk factors for that in option C, right? Dicres from glucose. Now you're going to have more of like an ultra mental status, right? A lot of ultra mental status if you have a glucose problems, right? So, so that's not going to be the answer. Option A decrease hematocritin, hemoglobin is not like she's like blood letting herself or cutting herself or having like heavy mentees or whatever. If anything, this person is going to have like very little mentees, right? Because remember, if you're pressing that is not eating enough, you have a lubey in your mind. Your body is going to be like, whoa, you were not consuming enough calories for us. Why should we try to be sustaining another human being, right? So these people's HPG axis is going to shut down. So the gene average is going to be decreased. FSHLH is going to be decreased. So the agonad is actually not going to be stimulated. So they're actually not going to be having their mentees. They're going to have like a functional hypothelemic in a real functional hypothelemic in a real, right? So they're going to have almost like no period, right? So they're not going to have a very high risk of blood loss and iron deficiency and all those things, right? And then increased serum calcium, no, you're not consuming enough food. Why should you have increased serum calcium? You're probably going to have like decreased calcium. And again, because these people are not consuming enough electrolytes, right?

And also they're, you know, they're pooping a lot, peeing a lot, vomiting a lot. If anything, they probably have hypo neatrymia, right? So I'm going to go to option C for this one. I remember, she may have palpitations because she's having a cardiac abnormalities. Remember potassium, if you have hypochylemia, that can lead to a prolongation of the QT interval and that can lead to torsata point, right? Okay. Question 42, a 50 year old woman comes to the office for the first time because of recurring abdominal pain. Review of her extensive, extensive medical chart, which she has brought with her, discloses that she has a long history of very physical complaints. Definitive causes for these complaints have not been found, despite extensive diagnostic studies, consultations with many physicians and several surgical explorations. She gives dramatic and exaggerated descriptions of her present and past symptoms and she makes conflicting statements about her history. She has been hospitalized at least 23 times since 18 years, 23 times. Well, which of the following is the most likely diagnosis option? A says, borderline personality disorder, B says, conversion disorder, C says, he's strontial personality disorder, D says, a court medical disorder. Really? You don't say. E says, somatization disorder, right? I remember, it's no longer called somatization according to the DSM-5. DSM-5 is called somatic symptom disorder, right? So look at this person.

She has physical complaints, but she blows them out of proportion. She literally has physical complaints, but she just explodes them out of proportion, right? So you have real physical symptoms, but you exploding them out of proportion. That is somatic symptom disorder. So I'm going to go to option E for this one, right? A court medical disorder is not a thing. Get rid of that. Option C, he's strontial personality disorder. These are just dramatic people, right? So if you're a person that watches reality TV a lot, or you spend a lot of time on social media, you're going to see a lot of these people. They're just dramatic, right? You always want to be the center of attention, right? That's going to be he stronic. That's not what's going on here. Option B, conversion disorder. Conversion disorder is you have neurologic deficits that make no sense, right? You have neurologic deficits that make no sense, right? But it's a psychiatric disorder, right? We don't see neuro deficits here, so that's wrong. Borderline personality disorder is going to be a woman that has caught in behavior, right? And then this woman has no middle ground. You're either all good or all bad to her. You're either the devil or a saint. There's no middle ground for those people. We don't see that here, so that's not going to be the answer. So the answer is going to be option E, somatic symptom disorder.

All right, question 43, 27 year old woman comes to the office for an uno-physical examination and says, two weeks ago, I noticed some small bumps on the outside of my vagina. They don't hurt, but they do each a little. She has never been pregnant and she takes an oral contraceptive. Physical examination shows several small, moist warts on the labia minor. VDRL test is negative. Pap smear shows moderate, high grade, squamous intrepid folio lesions. So, you know, HGSIL, that's CIN2. After removal of the vaginal warts, which of the folings is the most appropriate next step? Option A says colposcopy, option B says combiopsy of the cervix, option C says endometrial biopsy, option D says hysterectomy, option E says repeat pap smear in six months. This is something that a person can easily get wrong on the exams. Let me teach you the trick, right? The thing is, according to our friends at the NBM Es, there's a very specific order you take for cervical lesions, right? The first thing you're going to do obviously is going to be a pap smear. You're going to do a pap smear. Pap smear is a screening test. And then based on the results of that pap smear, you determine if you do a colposcopy or not. But after a pap smear, you either do nothing afterwards and just resume regular screening, right? Or you do a colposcopy, right? Colposcopy is what is typically done after a worrisome pap smear finding. Colposcopy, look at the name.

Colposcopy sounds like microscopy, it's just like my car scopy of the cervix. If the colposcopy then shows you something, right? It's almost, colposcopy is almost like a more like just like a more sensitive test than just doing a pap smear. It like really looks at things, right? It's like it's like my crosscappy of the cervix. And then based on your colposcopy findings, you didn't get a biopsy sample. You can do a corn biopsy or you can do a loop electric decision procedure or you can do a cryotherapy, right? So again, we've got in a pap smear and we saw something that is really worrisome CIN to, right? You got to do a colposcopy after this. I'm going to go with option A for that, right? Option B is something that will come after you've done a colposcopy. Option C in the mitral biopsy we do it when people have abnormal vaginal bleeding, right? This person doesn't have that, right? So we're not going to do that. He's direct to me. Come on, this person doesn't have an mitral cancer, right? Repeat pap smear in six months. No, this is a worrisome finding. You ain't going to be waiting for another pap smear. Go ahead and look closely at that CIN to lesion. All right, question 44. A previously healthy 54-year old man comes to the idea of his wife's insistence. Six days after a stray dog sprung up and beat his right leg. While he and his wife were walking near the dog during a trip to South America. The bite punctured the skin.

He immediately cleaned the wound thoroughly with soap and peroxide and has done so daily since the incident occurred. The area of the bite is not painful and the patient has not had fever or chills. He takes no medications. He had a tetanus booster vaccination three years ago. Vinyl signs to their normal. Examination of the right to the right to the extremity shows healing bite puncture wounds. There is minimal erythema and the area is not fluctuated. Lymph nodes in the groin are not palpable, which of the fluene is the most appropriate next step. A says administer obese vaccination. B says administer tetanus immune globulin. C says order CSF analysis. D says order an MRI of the brain and spine. E says no intervention is necessary at this time. Getting by a dog in a South American country. You don't know the origin of that dog. What do you think we're worried about here? Reveas. This guy has been smart though. Although it may be a smarter decision would have been to come in like not six days later. But the smart thing he did is that he irrigated that one big time. That is the first step in the management of a potential rebees exposure. Irrigate, irrigate, irrigate, irrigate, irrigate, irrigate. Rebees reduces the risk of your contracting rebees by like more than 90%. So irrigate. Then typically, when I give the rebees immune globulin into the wound and then give the rebees vaccine in another extremity. So we are worried about rebees. We got to pick some rebees answer here.

I'm going to go with option A for this. Administer the tetanus immune globulin is a decent answer. But we need to fix the rebees first. That's just a better answer. Because rebees will kill you. Tetanus is not going to kill you. Well, it may kill you. Rebees will first kill you if it progresses. So we're going to pick option A here. CSF analysis. No. The rebees probably has not got into the central nervous system by then. Again, do the more pressing thing first. Do the more pressing thing first option A. Right? MR of the brain and spine. That's ridiculous. You're not going to diagnose rebees with a MRI. Right? No intervention is necessary. No, you need to do something. Rebees, once he gets to the central nervous system, bye bye. That's the end of the present life. All right. Now, question 45 says, a 35 year old man with hypertension comes to the office because of high fever, malaise and a thro� is during the past four to five days. He also mentions having pain less red bumps on the palms of both hands during the past few days. He excruciate medications that lie seen or pray on a spring. He denies any alcohol or tobacco use, but admits to the deli use of intravenous heroin during the past month. He has been careful to use clean needles except for one incident two weeks ago in which he shed needles with his girlfriend. His most recent heroin shot was yesterday vital signs to their temperature of 103.6. Whoa. That's a high fever.

His 120 per minute resperations at 20 per minute and blood pressure is 110 over 68. The patient appears weak and pale skin is warm and moist. Small non-tender lymph nodes are poppable in both axiomely and in the anterior neck and superclavicular regions. There is a new gratuitous six-houlosistolic murmur heard best below the zyfoid that reduced to the apex and is increased slightly during inspiration. There are several small non-tendery retaminous nodules on the palms of both hands. Non-tender. Physical examination is otherwise normal. Based on the physical findings, the most likely cause of his fever is infection on which of the following. Let's ask ourselves what's going on here. What does this patient have? IV drug user. New murmur. High fever. Pink less lesions on the hands. They are painless. They are probably gene-we-legions. This preserves the infective endocraditis. What is the most common cause of endocraditis? Especially in an IV drug user. It's going to be stuff for you. The right answer is going to be option D. Trapponema organism starts option E. That's syphilis. Syphilis usually doesn't cause endocraditis. Remember syphilis can cause pain-full lesion on the palms. I mean, pain less rush on the palms and soles. It can cause a TB or salis and stuff like that. That's not what's going on here. Seresia marcesens. That's wrong. HIV. No. HIV does not usually cause endocraditis. Option A says hebbi. No. Hebbi does not usually cause endocraditis.

This is a straightforward question. It's going to be option D. All right. Let's do question number 10 and then we wrap this up. 46 year old married woman comes to the ED because of increased vaginal bleeding for two days. She says her mencees have been irregular during the past six months and that she has not had a menstrual period for more than two months. Huh. Okay. She thinks she may be going through menopause. She says she has a history of lyomaiomada uderite but has not had an operation of taking medication. Vital signs are normal. Abdominal examination is normal. Pelvic examination is consistent with an eight week size uterus which is likely tender. A 5 cm right at nexomasis pulpyated. The cervical osse is closed and there are small clots in the vaginal vault which of the pulling nexepsis most appropriate. So she has had increased vaginal bleeding. And she has not had a menstrual period for more than two months. Whenever you see a menoria in a woman that is of reproductive age, what is the first thing you always got to do? You need to make sure that she is not pregnant. So we're going to do option E. Serum pregnancy test. Right. Pelvic ultrasound. Do the serum pregnancy test first. You may be worried. Today is an ectopic pregnancy or whatever but check if she is pregnant. It is a blood test. Actually blood test or urine test. Pretty easy to figure out. So I will do option E first. Pelvic ultrasound doesn't make sense as a right first step.

Intravenous conjugated estrogen. No. Why not do that? Doesn't make any sense for this. And the mitral biopsy is if you're worried about endometrial cancer. But again, this person check if she is pregnant first. It's like an easy thing to do. Maybe non-invasive thing to do dilation and curatage. We tend to do that for like, for like, molar pregnancies and stuff like that. But again, check if she is pregnant first. You need better HCG's to even figure out if a person has a molar pregnancy or amount. So we're going to do option E first. Again, you like the way I teach. You're going to love my classes. Right. I have a bunch of really good classes coming up in the month of April. Right. 20 hours step two, step three class. Last mini review for step two, step three. And I have some classes for step one, all the way to step three. I have like a five hour social science quality improvement and ethics class. I have a four hour biostatistics class. I have a two and a half hour MBA me test taking strategies class. Many people have taken these classes and found them to be extremely helpful. Right. And then in the month of May, I have a 25 hour step one class. You know, good for people taking step one or people taking step two, step three that have poor basic science foundations. Because again, believe it or not, basic sciences are heavily represented these days on the USML Es. Then I also have a very, very good 50 hour class in the month of June.

So 50 hour step two, step three class only held once a year. All these classes over zoom and the one that teaches all these classes. Again, these classes are not come. Let information be thrown at you classes. No, you're going to come. You're going to learn pathophysiology. You're going to learn test taking principles. You're going to learn the mechanisms behind things. You're going to learn, hey, how will they present this thing on the USMLE exams? Right. Again, many people have taken my classes, don't extremely well on their exams. And this is not people from two years ago. No, I literally have had people that took the exams like two, three weeks back, they've got in their results, they crushed the exams. Right. So again, if you like the way I teach, you're going to love my classes. Also, if you want to want to learn for all the USML Es and complex exams. And then I also help with era's applications, more interviews, personal statements and all those things. And then I have these podcasts on Apple Google and Spotify. So you should check those out. And then I have another website called divineinterventionlifelessons.com. Every week I post like one or two podcasts, where from a bibliocoperspective, I do address a life lesson. There's actually an Apple podcast associated with that called the Divine Intervention Life Lessons Podcast. I have like almost actually 400 episodes on theirs as well. So thank you for listening to me today. I will see you God willing in episode 644.

But have a wonderful day. God bless you and bye for now. Thank you.

Avoid all latex products (gloves, catheters, etc.) to prevent anaphylaxis.

Drainage of the hematoma; this prevents cartilage ischemia and subsequent deformity.

Hot packs (heat worsens bleeding) and antiplatelet drugs like aspirin (worsens bleeding).

Serum pregnancy test (hCG), to rule out pregnancy complications.

Normal opening pressure and normal/slightly elevated protein; glucose levels are usually normal.

Hypokalemia (low potassium).

Repeated exposure to latex materials during frequent hospitalizations.

To prevent separation of the pericondrium from the cartilage, which can lead to ischemia and necrosis of the cartilage.

Serum pregnancy test (hCG).

Colposcopy.

Hypokalemia.

Treponema organism (or often Staphylococcus aureus).

Repeated exposure to latex materials during frequent hospitalizations.

To prevent separation of the pericondrium from the cartilage, which can lead to ischemia and necrosis of the cartilage.

Serum pregnancy test (hCG).

Colposcopy.

Hypokalemia.

Treponema organism (or often Staphylococcus aureus).