DIP Episode 561 - 2024 USMLE Step 3 Free 137 Discussion Part 8 (Q71-80, super helpful for Step 2!)

Welcome everyone. My name is Divine. This is episode 561 of the Divine Intervention Podcast. In today's podcast we're going to be continuing the series on the USMEL step 3137 and this is going to be part 8 I believe. I'm going to be looking at question 71 to eat. I'm going to jump right into it. So question 71 says 29 year old woman comes to the office for canceling. She comes to the office for canceling. She learned that she is HIV positive one month ago and she believes that she most likely contracted the infection approximately six months ago. Lab studies ordered in preparation for this visit show a CD4 positive telium full cycle of 800 per millimeter cubed and undetectable serum HIV RNA levels. She has no symptoms of AIDS. She has never been pregnant. She's considering pregnancy and wants to know her risk for transmitting HIV to future children. Which of the following is the most accurate statement? Okay. Option A says as a subgroup newborns have the fastest rate of increase in HIV infection. I think I'm going to go ahead and say that that's straight up wrong. The thing is, yes, don't get me wrong. Newborn get things vertically from mom absolutely. But no, it's actually the risk is actually quite low compared to other means of transmission. Again, obviously you're going to give the woman like intro part of the I dovd. But that newborns don't have the fastest rate of increase in a HIV infection. That's wrong. All right.

Intro part of transmission accounts for less than 50% of neonatal HIV infection. Again, that's wrong. Most cases where the child actually gets HIV, it's through intro part of transmission. Again, how many think of it? How many other ways can a newborn get HIV from mom? Right? And again, newborns, I guess almost missed on the student option A says as a newborn newborns have the as a subgroup newborns have the fastest rate of increase in HIV infection. No, HIV infection is not increasing in high amounts amongst newborns. No. If anything, with all these measures that have been taken public health wise, it's actually led to a decrease. All right. And then option C says maternal viral load is the best predictor of perinital transmission of HIV infection. Yeah, I think I definitely agree. I agree with that. Mertrional viral load because think about it basically for many of these infections, this is the higher your viral load, the higher risk of just giving something to anybody. Like for example, when a person has a head B infection, if you think about it, head B, if your eantigen is positive, right? It probably means you have a pretty heavy burden of disease. There's just a pretty high risk of transmissibility. So I'm going to keep option C for now. Option D says the risk for perinital transmission is higher among women who conceive within one year of initial HIV infection.

Again, I'm not buying that because remember, it takes a while for HIV, the virus to propagate throughout your immune system, kind of go through your city for positive cells and start bringing about that decrease. So again, it's not as quickly as not as quick as people make it out to be. So option D is definitely wrong. And then option E says, route of delivery does not influence the risk for perinital transmission of HIV infection. Again, that also makes no sense. Right? Again, there are some times where you're like, you know what? Let's maybe do C section instead of maybe doing vaginal delivery in managing these risks. Again, the USML is they don't go into a ton of detail on which one should you choose versus the other. Just remember, in general, if a woman is pregnant and she has HIV, you want to give her like intrapartum Zaidouv you didn't you want to give her and you want to start on an antiretroviral therapy during pregnancy. That's absolutely helpful. Starting on an antiretroviral therapy during pregnancy, that can be really, really helpful to the baby. So I think from all these statements, option C released the only one that just makes any degree of sense. Right? And again, option B is wrong because again, how many other ways can kids get HIV infection from their moms? Right? It's got to be, it's got to be intrapartum transmission. Right? Like, it's like the most common method. Just something you want to keep in mind. All right.

So we're going to go to question 72 or 50 year old woman who has been your patient for the past three years comes to the office because of heartburn and increased belching and bloating after a meals for the past month. Antisits provide little relief. The symptoms tend to occur after eating. She's currently a symptomatic. She has never had an operation. The patient identifies as African American. Physical examination shows mild sclerolictures and a four centimeter mass in the epicastric area. Uh oh, that's not good. Which of the following is the most appropriate initial diagnostic study? So again, what is this thing likely? This thing is likely, I don't know, maybe some kind of hydrohernia or something like that. But there are some findings here that are really, really worrisome. First, this person has sclerolictures. So that tells you that, oh, maybe this may be John this. This person is 50 years old. That's another higher risk feature. Don't get me wrong. She's African American. Right? The cancer I'm thinking about is not as common in African Americans. It's more common in Caucasians, EKA, pancreatic cancer. But because this is kind of worrisome, it just makes sense to work this person. Yeah, you want to we're thinking most likely hydrohernia. We also need to work on for pancreatic cancer. And the first step in working on a person for pancreatic cancer is going to be a CT scan of the abdomen. Right?

CT is what you always do first in pancreatic cancer because you want to see if it has involved a vessel. Because if it has an involved vessel, that's for certainly has a prognostica guidance that it can give. So I'm going to go to option A for sure here. Option B says get ceramamilies and lipase. The presentation here is not a cute pancreatitis. Option C says ERCP. You do ERCP when a person has like ascending colon gides or let's say you're trying to do like a endoscopic therapy. But we are not there yet for this person. We need to figure out what's going on first. Option D says hide a scan. The partobiliaries in Tography. That's what we're going to do when you're worried about a kid colicistitis and the retopercordion ultrasound is negative. And then option E says upper GI barium study. Again, we usually do this mostly for a syphagel disorders. If we have a newborn that has billions MSS, we can do those upper GI barium of study. So I'm going to go to option A for this one. All right. Now we're going to go to question number 73. 50 year old woman comes to the office because of the gradual onset of pain and swelling of both knees and distal interfalangio joints of the hands during the past 12 weeks. The pain is exacerbated with movement and is accompanied by more in stiffness that usually results within 15 to 20 minutes. Recently, the joint pain has occurred at night and has restricted her activity. I will profit as provided moderate relief of her symptoms.

Medical histories remarkable for type 2 diabetes, hypertension and obesity. Additional medications include glipiside, metformin and hydrochlorothiazide. She is 5 foot 6 inches and weighs 230 pounds, BMI is 37. That's going to put a lot of pressure on your joints. Her vitals are completely fine. Although blood pressure is 140 over 90, examination of the hands shows boonion largements of the DIP and PIP joints with mild tenderness to the interfalangio joints. Exhibition of both knees shows boonion largement with tenderness at the joint margin, limited range of motion and mild joint effusions. Results of lab studies are shown. So rheumatoid factor is non-reactive, uric acid 6 milligrams per deciliter. Again, I don't know if this is higher or low, but honestly I don't care. The context of the question has given me everything I need already. And then you see the white cells 8,000 per millimeter cube. So this tells you that this is probably not an infectious thing going on here. It says x-rays of the knees are most likely to show which of the following. So these are all person, this old person is obese. The PI Ps and DI Ps appear to be affected. Person is very obese. You see boonion largements at like classic weight bearing joints. Again, this looks an awful lot and this person is 50 years old. This looks an awful lot like osteoarthritis. They're trying to give you some flavor to get you thinking of other things. Don't think of other things. This is osteoarthritis.

Again, when you over think simple questions, you're getting trouble on your exams. So this is osteoarthritis. So option A says, bon dimeneralization on erosions. I don't think I'm going to go with that. Dimeneralization of boon is something you tend to see people that have like vitamin D deficiency. Again, this person I don't at least just doesn't have many bits of proof. At least we don't have anything here that tells us vitamin D deficiency. Option B says, soft tissue swelling is clearly joint margins and large cystic erosions. No, I'm not going to go with that. You see that point like rheumatoid arthritis. This person does not have R.A. Option D, soft tissue swelling with no evidence of cartilage or bone destruction. No. This person has OA. There's going to be destruction of the article cartilage, right? Because of that wear and tear on the on the joint. So that's wrong. Option D says, soft condral sclerosis of bone and asymmetric joint space narrowing. Yep, I'm going to go with option D. Remembering rheumatoid arthritis, you're going to have symmetric joint space narrowing. So in osteoarthritis, an option E says not normal findings that's clearly wrong, right? So remember in osteoarthritis, you're going to see asymmetric joint space narrowing. So condral sclerosis, so condral cysts are going to see thinning thinning of the article cartilage. So the answer for question 73, I'm going to see is option D.

Okay, question 74 says, a 17 year old high school football player is brought to the ED by his parents one hour after sustaining an injury to his upper back during a game. He says another player struck him in the back with his helmet. He immediately following the incident, the patient noticed weakness of his lower extremities. That's not good. On arrival, his temperature is 98.0 degrees Fahrenheit, pulse is 110 per minute, respiration is a 20 per minute, blood pressure is 130 over 80. Physical examination discloses point tenderness at the mythoracic spine. That's not good. Mosul strength is three fifths in the lower extremities. Okay, so both lower extremities. Sensation is diminished to pain and vibration below the lower chest margins. Okay, so that means that the dorsal columns are affected and it also means that the spinal thalamic tract is affected. We actually have something here called a sensory level. This is an extremely important concept to understand. A sensory level is where below a certain level, like a level you can pinpoint in the body, you've lost all of a particular kind of a modality. This person has a sensory level. Whenever he sees a sensory level, you always want to think of what of a myelopathy, I want to think of what of a myelopathy. My lopathy is injury to the spinal cord. It's injury to the spinal cord. The person's question then says, deep tendon reflexes absent in the lower extremities. Our binsky sign is absent bilaterally.

MRR of the spine is most likely to show which of the following again. This person has a myelopathy. They have a spinal cord problem. We definitely have a spinal cord problem. Definitely have a spinal cord problem. You have a sensory level. You see the bilaterally where extremities are being affected. I'm definitely going to go with myelopathy here. Let's see what makes sense. Opsion isis and terospinal artery territory ischemia. That is just fligrantly wrong. The reason that that's fligrantly wrong is because the anterior spinal artery does not supply the drosocoloms. This person has loss of vibration. That's drosocolometerritory. It cannot be anterior spinal artery injury. That's wrong. Opsion B says contusion of the thoracic spinal cord. I say that this is likely a myelopathy. And again, the person's sensory level is in the mid thoracic spine. It's probably Opsion B is probably right. Opsion C says lateral T7 discreonation nerve root compression. When you compress a nerve root, you have something called a radicalopathy. When you have a radical opathy, it's a nerve root injury. A nerve root injury is not the same thing as spinal cord injury. When you have nerve root injury, you're going to have radiating pain. That's the classic feature. Radiating pain. We don't see that here. So that is wrong. Opsion D says thoracic hemisection. Well, that's going to be wrong because this person has bilateral symptoms. If you had a hemisection, don't get me wrong.

You also have bilateral symptoms. But notice, you won't lose everything on both sides of your body. You'll lose like one more that. So, usually when you have a hemisection like a brown sequart syndrome, you'll lose like pain and temperature, control lateral to the problem, and vibration and pimprix sensation ifsy lateral to the problem. We do not see that pattern here. And if you notice, this person has like weakness in both lower extremities. So it tells you that this person's ventral horn, man, both ventral horns on both sides have been damaged. So this is no way going to be a hemisection. This is a bilateral spinal cord problem. These definitely wrong. And then traumatic serings, that's like a serings. If you have a serings problem, that's going to mess up your pain and temperature fibers, right? Predominantly, it can also mess up your, what is it called, your ventral horn neurons? And yes, we see the ventral horn neurons affected here. We see the pain and temperature fibers affected here, the spinal thalamic tract. Well, guess what? We also see the doso columns affected. That's just highly unlikely to be the right answer. So I'm going to go with option B here. Honestly, if you want to be an expert on this, listen to my neurology shelf exam series. It's like a series of like eight podcasts. I'm pretty sure I address this, I think in series six of it. I don't know for sure. I mean, I made that podcast many podcasts ago, but it's actually a pretty great, great podcast.

All right. Anywho, so I'm going to go with option B for sure for question 74. I think you can very logically get to option B. All right. Now question 75 talks about a 19 year old male. That is in the hospital. It's a college student admitted because of fever's fever, chills, intense headache, non-productive, carphone, generalized weakness for the past three days. Medical history is not remarkable. Takes new meds. Does not use any substances works as a green skipper at a local golf course in Western North Carolina. Whenever the USM is out of the way to give you location, right? That's usually something, right? North Carolina. I don't know. It kind of sounds like a Rocky Mountain spotted fever territory, but any who let's keep going. All right. On admission, it appears acutely ill. It's something a little bit arouseable. Temperature is 102.2. Presumably from North Carolina with fever. I don't know. I like Rocky Mountain spotted fever a lot for this one. The boss is 106 per minute. So he's taggy cardiac, he's the kipnic, he's hypotensive, auto-satisfaction is 90%. Examination of the skin shows an erythematosmachilar rash with superimposed PT count in the palms in soothes. All right. This is sounding a lot like Rocky Mountain spotted fever. Fundoscopic exam shows no abnormalities. Neck is super with no abnormality. Remained of the physical exam including neuroexamts, discloses no abnormalities. IV access is established.

LP for examination of CSF discloses a nookening pressure of 210. That's pretty high. The CSF is slightly turbid. ECG shows non-specific ST segment and T-wave abnormalities. Portable chest x-ray shows no abnormalities. Our results of lab studies are shown. All right. So let's look through these labs. The big things that kind of stand out here to me is that this person's CSF again we see a lot of lymphocytes. We see a lot of lymphocytes. The protein is pretty high as well. But Gramsden India ensures nothing and their labs, their white count is a little elevated, mostly neutrophils. Pliggly count is extremely low. This is something you can find in Rocky Mountain spotted fever. All right. So probably therapy is initiated. I hope they gave him like an X-ray, like an IV tetracycline, a pronto. And the patient's condition improves during the next week. Cultures of the blood and serbospinal fluid are negative. It's pretty hard to grow Rocky Mountain spotted fever. All right. So which of the fluids the most likely source of this patient's illness? This looks an awful lot. An awful lot like Rocky Mountain spotted fever. Right. So option E says in healing contaminated droplets. Nope. Rocky Mountain spotted fever is transmitted by the dermis center tick. So option E is definitely wrong. Option B says insecticide. Again we're kind of thinking of organophosphates. Right.

With all these pesticides and herbicides and insecticides, organophosphates cause more like a cholinergic toxidium because the acetyl is not going to be able to get any of these. So it's not going to be able to get any of these chemicals. So it's not going to be able to get any of these chemicals. So it's not going to be able to get any of these chemicals. So it's not going to be able to get any of these chemicals. So it's not going to be able to get any of these chemicals. So it's not going to be able to get any of these chemicals. So it's not going to be able to get any of these chemicals. So it's not going to be able to get any of these chemicals. So it's not going to be able to get any of these chemicals. So it's not going to be able to get any of these chemicals. Again, this person has Rocky Mountain Spotted Fever. You got a treat if no, the person is going to die. Basically every age, even if you're a little kid under age eight, if you have Rocky Mountain Spotted Fever, we're going to give you a doxy cycle. If not, you're very likely going to die. So the answer here is definitely going to be option E. All right. Question 76. We have a 30 year old female that is coming to the emergency department. So the patient is brought in by police because of a tour history of worst-name of WNO Pain, Daryan, joint pain. The same times we got well, the patient was incarcerated in the local jail where she was placed 12 hours ago after she was arrested for shoplifting.

Medical history is unknown. Arrival at the ED, the patient is irritable and sleepy. She yons frequently. All right. She's the athletic BM Is-18. Temperatures 90.7. She's tachycardic. She's the kipnic. Blood pressure is 145 over 92. Autosight is 94%. Dilated popils. Balsons are hyperactive. Her belly is turning and burning. All right. Okay. The remainder of the physical exam discloses not the malities results of urine toxicology screening in the patient. We'll most likely be positive for which of the following. Right. So let's look at this. This is clearly a toxic drone. Right. So look at this person has dilated popils. The person is tachycardic, the person is the kipnic. Right. And not just that the person's balls are hyperactive. This sounds a lot like a opioid withdrawal. I know some of you may be like divine. Couldn't this be cocaine intoxication divine? Well, here's the thing when you have cocaine intoxication. Many times your belly is not going to be turning hard because you're in a your belly is not going to be turning hard. That's number one. Number two, your blood pressure is going to be extremely high. 145 over 92 is almost no more blood pressure. I'm not buying that for cocaine intoxication. Cocaine intoxication is wrong. Right. And also, I'm not buying that for meth because I know some of you may be like divine. The blood pressure is high. And in addition to the blood pressure being high, the person also has dilated popils. Again, 145 over 92 is not that bad.

Dylated popils, you can also get in opioid withdrawal. And this person is like that for reddick. Right. Pressing kind of seems to be like, you know, the person is yawning. These are things you're classically seeing opioid opioid withdrawal. This is not meth. We don't see prominent hallucinations. We don't see the person having like meth mouth. They don't have bad dental hygiene. It's not meth. And this is not cannabinoids. Right. Cannabinoids. I'm not going to cause you to be tachycardic and kipnic and have all these things. No. You're going to have like red eyes, you know, like blood short eyes. You're going to be like demanding food heavily. Option A is definitely wrong. And things are going to be slow around you if you're cannabinoid intoxicated. So I'm going to go to option D. This absolutely opioid withdrawal. Right. So you don't have the pinpoint popils you have my dress. It's instead because you're withdrawing. You don't have respiratory depression. You have respiratory like tachypnea because you again, you're withdrawing. Right. You don't have constipation. Instead, you have like almost like diarrhea. So your your belly is like going. Right. I'm going to go to option D for this one. All right. Now question 77 says 39 year old woman comes to the office because of a six week history of malays fatigue and a 10 pound weight loss. She has not had difficulty sleeping or depressed mood. Medical history is unremarkable as she takes no medications.

She does not smoke cigarettes or drink alcoholic beverages. BMI is 28. You know, temperature is 99.0 degrees Fahrenheit. Pulse is 110 per minute. Transvision is 12 per minute. Blood pressure is 140 over 90. She has a fine tremor. We should have full and additional signs or symptoms will be most consistent with the underlying diagnosis in this patient. So see a young-ish woman, you know, losing weight, having tremors, being tachycardic. This person is probably hyperthyroid, right. This looks a lot like hyperthyroidism. So honestly, maybe option C makes sense. But let's look at the other answers though. I was in ACES constipation. Now hyperthyroidism, believe it or not, can actually cause diarrhea. Your metabolic rate basically increases everywhere, including in your GI tract. Option C is actually wrong. Option B says delayed relaxation reflex. No, I don't know if I'm necessarily going to say say that. You can find delayed relaxation reflex in many different things. You may see it sometimes in hyperthyroidism, but I don't know if it's super specific for hyperthyroidism. I'm not going to make that judgment call here. That's wrong. Option C says hidden tolerance. Again, folks, go for the simple classic thing. Stop trying to come up with these high-falutin hypercrazy responses, hypercrazy thoughts on exams. Just go for the simple thing that's standing right in front of you. I'm going to go to option C. Option D says skin-tentin.

Skin-tentin, you're going to see in a person that is volume, the pleated person that has like hypovolimic shock. This person does not have hypovolimic shock. I blood pressure is like 140 over 90. So I'm going to go to option C here. All right. I'm going to go to question number 78. Okay, we have a 25-year-old female that is Caucasian and is coming to the office. The patient works as an attorney at a large law firm. It presents because of a one-week history of pain in and around her left upper jaw. She's unable to open her mouth wide. And when she attempts to do so, she feels a snapping sensation in the joint in front of her ear, the jawbone. She has not sustained any recent trauma. She was recently diagnosed with MDD. For which she has been taking peroxetine. She remembers being advised in the past by her dentists to consider braces for her teeth, but she never wore them because they were unaffordable. It extends with health insurance in this country. Medical history is otherwise unremarkable and she takes northern medications. A temperature is 98.6. Really, a vital is her fine. A vital is her fine. Well blood pressure is kind of low 104 over 60, or as version 20 per minute. Physical exam disclosies point tenderness at the left TMJ. Temporal and Diabologenic Examination of her ears of the ears shows good light reflects by lateral and the tibanic pain brains. Other patient removes chewing gum from her mouth.

Examination of the oral cavity shows ping-buck, boco, mucosa, and no evidence of dental abscess or trauma. The patient should be advised to do which of the following. So what does this person have? This person has TMJ dysfunction. Temporal and Diabologenic dysfunction. The classic way is going to present for you exams. We tend to find it in young females. It tends to be as three of people having a pretty storied history of psychiatric disorders. This person has a history of major depressive disorders. This is a pretty classic patient for TMJ. We'll talk about how to treat TMJ. Let's look at the answers. What should you do? Option A says avoid chewing gum and eating harder chewing foods. Option B says consult an orthodontist. Option C says cradle the phone receiver between shoulder and jaw. That makes absolutely no sense. Hey, correct cradle your phone reader. No. Option D says open and close for a jaw widely three times daily. That's not a smart idea. My time when I don't talk about TMJ dysfunction, I'm going to know why that's not a good idea. Option E says take oxycoron as needed for pain. No, we're not going to be giving you opioids for TMJ syndrome. You're going to become addicted. The patient that has a history of psychiatric disease is not a very smart decision. So, basically, TMJ dysfunction is something you kind of need to know about for your exam. But again, usually you're going to present in younger females, history of psychiatric disease.

They're going to have tenderness over the TMJ. And this is why I'm going to have trouble opening the mouth. The thing is there is no great treatment for this thing. You can tell them, hey, take insets for your pain. You can tell them CBT. You can tell them to use muscle relaxant. They can take like a cyclobanzer print, a pentine walknut. We try not to do those. We try to kind of stick with insets. We tell them mostly lifestyle things. Take insets, CBT, cognitive behavior therapy, because there's probably some psychiatric undertones to some of this. And then we also tell these people what you eat. Be careful of chewing things that are hard. Things that are chewy. They can actually exacerbate your symptoms. So I'm going to go to option A here. We're not going to go to an order of don't test. Many times there's not much they're going to be able to do for you. Unfortunately, again, the thing is there is no great treatment for TMJ syndrome. So most times on your exams, just pick the lifestyle option and move along. So I'm going to go to option A for this one. All right, question 79 says, a 68 year old woman was admitted to the ICU, 36 hours after becoming uptunded due to respiratory distress. She's now intubated and chest texture is consistent with CHF and pneumonia. She has a long history of morbid obesity, chronic bronchitis, kids who affective disorder and cigarette smoking. She's reported to have been relatively stable on Hallopere doll, Benstruping and Lithium carbonate.

A present medication regimen includes a sedimental phen, methylprednisolone, syphrofloxacin, Hallopere doll, Benstruping and Lithium carbonate. She does a lot of drugs. She also requires IV lorazap at every two hours for agitation. That caused her to fight the ventilator. Vital signs now show a spike in temperature at 1.02.0. Physical exam discloses lead by prejudice. Serum CK is 846. Serum Lithium concentration is 0.86. So she's in the therapeutic range. EBG while bringing 40% oxygen is shown. Apo 2 is low. Apo 2 is not that bad. pH is 7.46, O2satz 91%. At this time, it is most important to discontinue each of the following medications. This is looking at a lot like NMS. Very rigid muscle. So neorelectric malignant syndrome. Super rigid muscles. And this person has a fever. This sounds a lot like NMS to me. So we should probably go ahead and stop the Hallopere doll. I'm going to go with option C. Benstruping, remember we used to treat some extra pyramidal symptoms. You can use it to treat Parkinsonism. Although you can use it to treat Parkinsonism. Although you can use it to treat other EPS symptoms. Parkinsonism is a big one. They go after on exams. C. Pro. No, we don't need to stop C. Pro. Although remember, C. Pro can prolong your acute interval. It's a fluoroquinolone. And it can also rupture your Achilles. Option D says L'Harrasapem. Well, do you want this patient to get even more hydrated? Don't do that. Option D says methylprednisolone.

Again, steris can cause amyapathy. But this is not amyapathy. This is NMS. This is a medical emergency. We need to do something about this. All right. Question 80 says, 35 year old woman comes to the office because she noticed the lump in her neck two months ago. She has no heart pain, difficulty swallowing or change in her voice or changing her voice. She's a native of Germany and immigrated to the US 10 years ago. Medical history is an event for Hodgkin lymphoma at each 12 years treated with mantle radiation. You got a lump in your neck. Okay. Hypothyroidism was diagnosed at each 25 years. Only routine medication is liver thyroxin. The patient has smoked one pack of cigarettes daily for the past 10 years. She appears well. BMI is 26. This is a straight-up risk factor question I can almost predict. Temperature is 97.8. Pulse is 82 per minute. Respirations are 18 per minute. Blood pressure is 1.8 over 66. Physical examination discloses a 2.5 cm nodule in the right loop of the thyroid gland. You have got a relation to your neck. That tells you all you need to know. There's also one cm nodule in the left thyroid loop. It's not good. There's also serum thyroid function test. TSH of 0.6. Free thyroxin concentration of 1.7. The thyroid lops seem to be pretty good. This is probably a cold nodule. Which of following factors in this patient is most indicative of a proper diagnosis. This is pretty straightforward.

This is a person that has had previous radiation to the neck and chest. Pressing has a thyroid nodule and it's cold. Because we see that the thyroid lops are not out of whack. This is probably going to be thyroid cancer. Again, remember the biggest risk factor for thyroid cancer, especially popularly thyroid cancer, is having a prior history of radiation to your neck and your chest. Framing it as which of the following factors in this patient is most indicative of a proper diagnosis. I'm going to put up some E here for sure. That's the right answer. That's the truth. You know, cigarette smoking is the biggest risk factor for many things. Renel Selcarcinoma, bladder cancer, pancreatic cancer, COPD, MI. But that's not what's going on here. B says hyperthyroidism. This person is not hyperthyroid. It doesn't even have signs of hyperthyroidism. Our identity efficiency, yeah, I mean she's going to say hyperthyroidism. But everything seems pretty well controlled with the liver thyroxin she's taking. I'm going to go ahead and stop here. Again, I have a bunch of classes starting on Monday. You still have some time to register. Starts on Monday, test taking class. Sorry, not on Monday on Tuesday. Tuesday, test taking class. Wednesdays, the bio stats class. Thursdays, the social sciences, QI, hospital medicine, ethics review. Those first three classes are step one to step three. And then on Friday, we have the last many review. That's for step two, step three.

The first three again are for step one to three. And then starting the following week from Monday to Thursday, we have the 20 hours step two, step three review. If you're interested in that, again, I encourage you to shoot me an email. Again, if you love the way I teach, you're going to love these classes. They over zoom. And there's tons of food I've taken these classes that I've done phenomenally well on the USM Ls. Again, I've had a lot of 250s, 260s, 270s as recently as even last month. Actually, I got a, I love Wednesdays because I get emails from people that have crushed the exams from taking my classes. So again, I think you're really going to benefit from it. And then I also have this podcast on Apple Google Spotify. I have a You Tube channel you can check out where I post the videos that I make. And then I also offer one I want you to learn for all the USM Ls, all the complex exams. And then I have another website called divininterventionlifelessons.com. Every week, I post like one or two podcasts where from a biblical perspective, I address a life lesson. And also I have those podcasts that divine intervention life lessons podcasts on Apple podcasts. So you should check those out. And again, I also help with ears applications and personal statements and mock interviews and things like that. So thank you for joining me today. Again, I hope you'll find this podcast to be helpful. I'll see you in episode 562. So God bless you. I will see you in the next podcast.

Thank you.

Intrapartum (during labor/delivery).

CT scan of the abdomen.

OA shows asymmetric joint space narrowing; RA typically shows symmetric joint space narrowing.

Rhinorrhea, lacrimation, piloerection (sweating), and diarrhea/abdominal cramping.

The dog tick (Dermacentor species).

Prior radiation exposure to the neck or chest.

The presence of a distinct sensory level and bilateral motor/sensory deficits below that level.

Conservative care, including dietary modifications (avoiding hard/chewy foods) and physical therapy.

Fever, rigidity (lead-pipe muscles), altered mental status, and elevated CK levels.

Asymmetric joint space narrowing and osteophyte formation/sclerosis.

Discontinuing dopamine antagonists (e.g., haloperidol, antipsychotics) to prevent further muscle rigidity and hyperthermia.

CT provides better staging information by assessing vessel involvement and local invasion before invasive procedures are considered.

The presence of a distinct sensory level and bilateral motor/sensory deficits below that level.

Conservative care, including dietary modifications (avoiding hard/chewy foods) and physical therapy.

Fever, rigidity (lead-pipe muscles), altered mental status, and elevated CK levels.

Asymmetric joint space narrowing and osteophyte formation/sclerosis.

Discontinuing dopamine antagonists (e.g., haloperidol, antipsychotics) to prevent further muscle rigidity and hyperthermia.

CT provides better staging information by assessing vessel involvement and local invasion before invasive procedures are considered.