DIP Episode 645 - USMLE Free 86 Series 7 (Q57-66, for Step 2/3)

Welcome, my name is divine. This is episode 645 of the divine intervention life lessons. I mean divine intervention podcasts into this podcast. We're gonna be continuing the 3d 6 series. This is gonna be series 7. We're gonna start from question 157. So, a 28 year old white woman returns to the office for full of hypertension. She says, my blood pressure keeps getting worse no matter what I do. Her hypertension has been had been controlled with a diuretic and a bit of blocking medication for four years, but her blood pressure has steadily increased in the past eight months. Despite taking maximum doses of the medications. She insists she takes her medications as directed. Family history is negative for hypertension. She does not smoke cigarettes hide his five feet four inches. That's 163 centimeters and weight is 75 kilograms. That's 165 pounds. A BMI is 28 kilograms per meter squared. Vital signs to their pulse of 96 per minute and blood pressure of 165 over 110 standing in both arms. Examination of the retina shows EV naked. Abdominal examination discloses a new epigastric brewery. The remainder of the examination is normal. So, we look at this question and we see this person. She's a young female. She seems to have this resistant hypertension. She seems to have developed things seem to have been getting worse over the past eight months. She has this EV naked. A tear of a no-snake in the eye. We tend to see that people have really nasty hypertension.

We also see she has an epigastric brewery. What condition should we be thinking about here? I really hope you're thinking about some kind of reno-vascular disease. Fibromoscular dysplasia. We just need to pick an answer choice that relates to fibromoscular dysplasia. Question 57 says, which of the following is the most appropriate diagnostic study to order next? Option A says, 24 are you in collection for creatinine clearance and protein excretion? No. We typically are going to do that for an euphrodiconephrinex syndrome. She says, 24 are you in collection for vanilla, mandelic acid, metanephrine and chanacolamine excretion? We're going to typically do that for a few chromosomes like tumor. That's not what's going on here. Option C says, seromyelin electron-like concentrations. That's a very, very non-specific answer. It's very non-specific or any kind of applied to almost anything. Option D says, seromyeline tsh cortisol and aldosterone concentrations. What you'd be doing is if you're worried about like con syndrome or cushing syndrome or hyperthyroidism as the cause of her high blood pressure. But again, this question is not talking about that. Option E says, your analysis and seromyelin and urea nitrogen concentrations. Absolutely. I'm going to go to option E here because it can help us evaluate her renal function to see if it's abnormal.

If you have fibromuscular dysplasia or it's close cause in the order of individual renal artery stenosis, you have abnormalities in those labs. So question 50 says, which of the following is the most appropriate imaging study? Well, option E says abdominal CT scan with contrast. B says abdominal ultrasound. C says adrenal MRI. D says, radionic light thyroid scan. E says renal duplex ultrasound. So again, we want to go with what is, can help us evaluate the renal arteries. The renal arteries you can evaluate them very easily with ultrasound. So I'm going to go to option E. The thing is, one other answer that may have been a little confusing here is like CT angiography of the renal arteries or MRI angiography of the renal arteries. But typically that's something you're going to do after you've done the renal duplex ultrasound. So I'm going to go to option E here. But no CT scan with contrast again. Pretty non-specific. Many pathologies go with that. abdominal ultrasound again. Pretty non-specific. Many pathologies go with that. And abdominal ultrasound. I know may not be the smartest way to evaluate the renal arteries itself. You want to go with a more specific answer here, which is going to be option E. Adrenal MRI is for like, you know, a person having a cushion syndrome where they have like an adrenaline, a normal something that's not what's going on here. And they're radionic light thyroid scan. That's a riu scan, right?

That's for a thyroid pathology, which is not what's going on in this week. All right. Now, question 59 says 27 year old, nolly gravity woman returns to the office to discuss results of a pap smear obtained two weeks ago during a health maintenance examination. At that time, physical examination, including pelvic examination, disclosed abnormalities. The patient's menstrual periods occur on regular 28 D intervals. She has been in a stable relationship with the same man for three years and she uses a diaphragm with spermisidol jelly for contraception. A pap smear obtained three years ago showed no abnormalities. Pap smear obtained at her last visit shows evidence of marked inflammation suggestive of a high grade squamous intrepid folio lesion, which of the following is the most appropriate next step. Right. So this person has a pap smear and he showed a high grade scrum of the intrepid folio lesion. Right. This is worrisome. Right. And I think I may have discussed this in a previous podcast, but actually, I have definitely disclosed this in a previous podcast, but whatever person has an abnormal pap smear, right, especially if they have like a C I N or, you know, a typical squamous cells of, I mean, if they have like a sketch or any of those things, I have a pap smear podcast. You should listen to you should go ahead and do a cool posca beer. So we're going to pick the answer that talks about cool posca. I hope there's an answer like that. All right.

So option A says, advise the patient that our partner should use condoms for contraception and repeat the pap smear in three months. No. Right. Whenever you have an abnormal pap smear, you always have to follow it. Up with a cool posca. And the specific specifics about that again, listen to my pap smear podcast and then option B says, do copus copy examination of the cervix after application of five percent acidic acid solution. That's definitely the right answer. I'm going to pick option B option C says do colonization of the cervix. I would not do that next right. So remember, you get an abnormal pap smear your next step is to get a copus copy and the copus copies like my cross copy of the cervix. And then based on those abnormal copus copy results, you then choose a biopsy method like colonization or cryotherapy or a leap procedure, a loop electric C session procedure. Right. So again, option C is the third step in the trajectory, not the second step. Option B is the second step. And then option D says we are show the patient and repeat the pap smear in three months. No, this is worse. I'm fine. It's high grade. You got to do something option A says treat the patient metronitis offer two weeks. No, we're not trying to treat like bacteria. Vaginosis here. No, right. No. So the right answer is going to be option B. All right. So question 60 says 46 year old man with morphine syndrome. And then he has had severe substance treatment for the past three hours.

He describes the penis tearing in quality and reading to the neck. One week earlier, he experienced similar, but less severe chest pain and treated himself with aspirin. And he's just likely on the line calls for his worst in symptoms. Well, we know that a person that has morphine. A person that has morphine. You know, they can have erotic problems. They can have erotic dissection, right, because of the cystic media, necrosis, right. So they can have a tear in the intima that ribs into the media and causes problems. Right. So this person probably has erotic dissection. Right. And the thing is taking aspirin may not be the smartest idea, at least in that acute phase, right. And aspirin is an anti-pletid drug. It's going to cause more bleeding. It's going to cause more of the more bleeding into the media. Right. That may explain why he symptoms are worsening. Right. So option A says acute bacterial endocraditis. That's wrong. Right. So that is going to present with fever or the new murmur and things like that. We don't see that here. Option B says acute MI again. And acute MI can cause a sudden onset chest pain. But again, in a morphine's person that has erotic problems. Probably not. Right. At least that's just not the most likely answer. Option C says dissection of the other. Yeah, that's the right answer there. Option D says it's a usual reflux with spasim. Well, it's not going to be causing these kinds of a very severe symptoms.

And then option E says a pifritate peptic ulcer. We'll have a question stem that talks about like free under the diaphragm or signs of periodionitis like rigidity, rebound guarding. We don't see that here. Right. So I'm going to go with option. Option C for this one. All right. So let's go to question 61. 30 year old man who has been your patient for several years comes to the office for a periodic health evaluation. He has been healthy, but has a birth defect involving his hands and feet. He is missing the second and third meter tarsals, metacarpals and corresponding fingers and toes. He has three healthy children and no one else in the family has this condition. He has adapted well to his condition during your evaluation. He asks, what do you think? If I have any more kids, will they have hands and feet like mine? You review the family history and his pedigree, which is shown his physical examination is otherwise normal. In addition to discussing your opinions with him, which of the following is the most upper-ridden step? Right. So if we look at this pedigree, he's the only one that has the problem. No sibling has the problem, no parent has the problem, no distant relative has the problem, no child has the problem. Right. So when you look at something like this, it kind of tells us that, okay, this is not a heritable condition. This is probably something that happens from some kind of sporadic mutation, right. From some injury during reproductive development, right.

So you know, like for example, a focumilia, right from a phallidomyte, right. Can affect the names, can affect the digits, right. Or even like a person having like just there are many things that can cause like injury, right during living development in your right. So this is not a heritable condition. His kids are not going to get it. Yes, that three kids already none of them have any issues, right. So again, it's a sporadic issue. So it's probably not even a mutation at all. It's probably like just some injury from some agent that he got exposed to in you, right. So skin biopsy for fibroblast culture, that's wrong, right. That's wrong. No, auto chromosome analysis of peripheral blood lymphocytes, no. Other aduny lights scan of his hands and feet, no. Other skeletal X-ray service of his three children, no, right. Again, this is not a heritable thing he has, right. So option E and like option E a lot, order no additional tests at this, at this time. All right. So again, just look at the pedigree. Like this is a pretty simple question that they're just trying to make look harder than it needs to be. All right. So question 62 says 75 year old woman and again, just quick, pretty, pray don't don't overcomplicate questions on your exams, right. That's what gets a lot of people in trouble. Just analyze it simply. Pick the answer that is the simple answer and move along. All right.

So 75 year old woman comes to the office because she has band like burning pain in her red opera abdomen, extending from the epigastron around to the midline of the back. Physical examination discloses no abdominal tenderness to palpation. Find this on our personality of the gobladder normal. Serum amelisk concentration is within the reference range, which of the following is the most likely diagnosis. So option E says E calculus, calluses studies, B says chronic relapsing pancreatitis C says diverticulitis of the C calm D says. Herpes, or stir and then he says penetrating to all the looser, right. So, um, okay. So this person's amelesis fine. Autosanography of the gobladder is fine. So this person probably doesn't have a good bronchritis, right. So, because remember in a good pancreatitis, you have like a gastric pain, red eating to the back, right. You have a elevated amelies or light base, right. And you can have like CT findings, right. Immigined findings consist of bronchritis. This person literally checks off none of those boxes. Right. So, okay, maybe other than the gastric pain going to the back, right. So, uh, but you need to add a three of those things. You only has one on a three, right. So she doesn't have pancreatitis, right. So get rid of option B. And then that particular is of the C calm will likely cause like regular quadrant pain, right. Because the C calm is in the right or quadrant. Right. So that's wrong. That's not where she has pain.

Option D says herpes, or stir and go with that because she's at 75 years old, right. She's 75 years old, like bun like pain, right. Bun like pain in a specific dermatome, right. That makes sense for herpes, oyster option. He says pain training to one of those. I would not pick that. You know why? Because again, you have signs of periodo nides because that's usually a sort of like rupture and things like that. She would be coughing or blood, you know, things like that. We don't see that. A calc los colosistitis is going to be a burn patient, ICU patient or, you know, burn patient ICU patient, very septic patient, right. Having biliary problems, you know, they will have like fever and all those things. We don't see that here. So I'm not going to pick that pick that pick that one. All right. So, uh, so the answer is going to be option option D herpes, oyster. All right. So, uh, question 63 says a 19 year old woman comes to the emergency department because she says I'm burning up. She's known to staff as an intravenous drug user. Physical examination discloses a systolic heart murmur over the precardium and expected physical exam finding will be which of the following. So all those patients have all this person has endocraditis, right. And being an IV drug user was going to be the most likely kind of endocraditis she has probably has like try cosplayed valve endocraditis. Because remember if you're an intravenous drug user, you injecting drugs into your veins.

Well, if you inject bugs into your veins was the first valve that is hit when blood enters into the heart. It's going to be the track of speed valve. So it makes sense that she likely has try cosplayed valve endocraditis, right. So, um, she probably has try cosplay valve endocraditis, right. So like a right side that hard valve problem. Right. So, so what physical exam finding we're going to see option A says decrease intensity of S1. No, that's actually wrong because if you have a murmur, right. You know, if you have a murmur, you know, because remember S1 is closure of the my trial and try to try cosplayed valve. Right. So because she has a murmur, she has like troubling from all those things through the valve. You're going to have an increase intensity. So that's wrong option B says increase intensity of the murmur with deep inspiration. Okay. So when you inspire you put down your diaphragm, you lower your diaphragm. So that's going to reduce intra thoracic pressure, right. Because intra thoracic volume is going up. So that's going to increase venus return. If you have increased venus return, you will have more flow through right side that hard valves, right. Because literally more blood is coming back to the right side of the heart rate. So you have increased blood flow. So if she has a murmur, she has a valve issue from the endocraditis. Yes. Now give you a you have a louder sound with that. So let's keep option B and like option B actually quite a bit.

Option C says increase the intensity of the murmur with forced exploration. That's wrong. Right. It's kind of like the opposite of inspiration when you inspire your bringing your diaphragm up. The intra thoracic volume is going down. So intra thoracic pressure is going up. That's going to reduce venus return. So there's going to be less flow through the right side that hard valves. So the murmur intensity should actually decrease, not increase. So C is definitely wrong. Option D says positive course more sign, right. Rising juggling of inos pressure with inspiration. This is something we tend to see in constructive pericoditis on the USML exams. This is not a constructive pericoditis question. This is an endocraditis question. So that's wrong. And then option E says a right side that gallop that's pretty non specific. Right. That's pretty non non specific. So I'm definitely going to go to option B for the reasons I explain right because of the increase venus return to the right side of the of the heart. All right. Now question 64 says 26 year old woman comes to the office because of fever. And increasing shortness of breath for the past three days. She has been living in homeless shelters and says she uses intravenous drugs. She recently tested positive for HIV infection. She takes no medications and has no history of asthma, pneumonia or tuberculosis. Her last medical evaluation was five years ago. Her temperature is 39 degrees Celsius or 102.2 degrees Fahrenheit.

Post is 100 per minute. Respirations are 28 per minute and blood pressure is 110 over 60 millimeters or mercury. Oskitation of the chest discloses crackles and bronchi posteriorly over the right lower lung field with tubular breath sounds and doneness to precaution. No sputum could be obtained due to splinting of the chest wall. Chest X-ray shows consolidation of the right lower low. Complete blood count on a terrible blood gas analysis while breathing room air show. So blood hematocritic 36% hemoglobin is 12.7. That seems to seem very bad. A white on is 7800. Neutral field segmented is 70% bonds 16%. So she has a bandemia, right? Limful size 14%. Then a ABG is PO 272 that's low PCO 233 that's low. It's not too bad. So which of the following is the most likely diagnosis? So again, remember whenever you say a pneumonia question on your exams, what should you approach B? First thing is, hey, what's the patient population? That's number one. Number two, actually, number one should be what was the pattern of pneumonia? Is it low bar or is it interstitial? This is a low bar pneumonia, right? So again, that's very helpful information because knowing that it's a low bar pneumonia, you can promptly get rid of option A, Legionnaires disease, Legionella, Namofila does not typically is on the exam is going to cause interstitial pneumonia. It can cause low bar pneumonia, but typically cause interstitial pneumonia, right?

So we're going to see like the humidity fire exposure or conditioning systems and things like that, you know, contaminated water supply. That's not what's here. So A is wrong. Option B is also wrong. Namofila caused by the most serious disease, because it's an interstitial pneumonia on your exam. So that's definitely wrong, right? And then option D says a PE, that doesn't make any sense, right? That's wrong, right? That's not going to be causing fever and all these infiltrates on a chest radiograph. And then option E says pulmonary TB. Again, pulmonary TB, don't get me wrong. Could that be what's going on? Yes, but this suddenly in presentation? Probably not, right? Probably not. The TB usually is going to cause like the upper lobe problems. You're going to see the cavitar, Legion. We don't see that here. So that's wrong. Right? So I'm going to go to option C and actually just epidemiologically, the most common cause very high, you know, the most common cause of low bar pneumonia in HIV patients is going to be strep, you must going to be strep, you know, right? Now question 65 says 60 year old man. And again, we see the bandemia, right? That tells us that, oh, this is probably a person that has a bacterial infection, right? Which strep, you know, is right? So question 65 says a 60 year old man had a total thyroidectomy and the exception of enlarged left joyla lymph nodes for follicular carcinoma. The operation was uncomplicated.

He is receiving intravenous 5% dextrose and 0.45% ceiling with potassium. 12 hours after the operation, he develops a comural numbness and prestigious in his fingertips and it becomes very anxious vital signs are a temperature of 37.6. That's 99.7. Pause is 90 per minute. Respirations are 16 per minute and blood pressures 14 over 90 millimeters of mercury. Physical examination discloses a dry neck dressing and no strider extremities or warm with brisk capillary refill time. Additional physical examination is most likely to show which of the following. Right? So this is a very classic illness script, right? You do thyroid surgery and then the person is not doing well after a set thyroid surgery. Let me ask you this. Is there something that is behind the thyroid that you can inadvertently divest colorize or destroy while you're doing thyroid surgery? Yep, it's the part of thyroid gland, right? And the thing is once your parathyroid are gone, your pth is gone, you're going to have high vocal see me, right? That's why this person has these numbness and prostitutions, right? We basically have to pick a high vocal see me a sign here, right? So option A says a binsky sign a present bilaterally. That's that's wrong, right? That's for upper motor neuron problems. Option B says the schwozstech sign. Yes, I'm going to go to the schwozstech sign. Right? Remember classic signs of high vocal see me the schwozstech sign you tap the cheek and the person will have official muscle spasms.

And all the classic one is the trussos sign where you put a blood pressure car for on the arm and you notice the presence of carbopietal spasms, right? I'm definitely going to go to option B here option C says division of the tongue to the left side. This would be a medial medial stroke, right? Left medial medial stroke, you know, like a problem with the cranial nerve, 12th, the hypoglossal nerve, right? The tongue divestors the side of the lesion. That's not what's going on here. Option D says a drooping left shoulder droopy shoulder rate. You're going to see that again if you have a problem with like cranial nerve 11, your spinal accessory nerve. That's not what's going on here. Hypo reflexes super non-specifically. Again, be guys be careful of these super non-specifically answers on your exams. That does usually lead to a good outcome for many people in my experience. Right? So, and you may be like, define how do you know this presentation so quickly? Well, the thing is, again, number one, you should have studied this. But number two, I remember when I did my surgery rotation at Hopkins back in the day, I did a rotate on an endocrine surgery surface for like a month. So this was something that I was going to do.

So I'm going to go to the hospital and I'm going to go to the hospital and I'm going to go to the hospital and I'm going to go to the hospital and I'm going to go to the hospital and I'm going to go to the hospital and I'm going to go to the hospital and I'm going to go to the hospital and I think we were always concerned and worried about. So yeah, I have certainly seen this like, you know, before finishing our thyroid surgery, then we'll just go and check a serum, PTH or check a serum calcium level, just just just to be sure, just to dollar eyes and cross our teeth. Right? So I'm going to go to the option B here. Right? But even if you never rotate on an endocrine surgery service, this is something should we study. All right. So last question to the question 66. A two year old African American child with sickle cell disease is brought to the ED by her parents because of painful swelling of her feet for the past three hours. Her temperature is at 30. 70 degrees Celsius. So that's 98.6 degrees Fahrenheit. Physical examination shows swelling and tenderness of her feet. No other abnormal findings were noted. A resource of lab studies are short. So the hemoglobin is 7.8. That's pretty low. But it makes sense. She's got sickle cell disease. White count is 13,000. It's kind of high. Right? So over 11,000. Right? So it's high. Neutral field segmented 60% lymphocytes 40%. Which other following is the most likely diagnosis. Right? So this is a person that has sickle cell disease.

They have like really bad, you know, sodium pain in her in her. So it's extremely right. This is going to be a sickle cell pain crisis. Right? And again, you get those pain crises because of his scheme. You know, it's getting hurts. Right? When a person has an MI, they just hurts because of the scheme. Right? Is he really hurts? It literally hurts. Why do people that have sickle cell disease of is chemial? Well, the thing is, those are sickle cells. They can occlude vessels. Right? Just their anatomy, the orientation makes it more likely that they will occlude vessels. Right? So they can occlude vessels. Right? So they can occlude vessels. So we need to pick the answer that looks about like visual occlusion or something like that. Right? So option A, bone infarction that seems like a slam-down cancer. Right? We're going to pick option A. But let's look at the other answers first. Let's look at the other answers first. Right? Option B says equalize sepsis. That's wrong. Right? Remember, equalize sepsis has an association with having an essential galactosemia. Right? Remember, the most one cause of death in those kids is an equalize sepsis. Right? Remember, essential galactosemia is a deficiency in galactose one phosphate, radio transfer. It's galactose one phosphate, radio transfer is right. So that's not what's going on here. So it's a decal-sepsis. Again, no. Right? And again, look at this. Right? Three hours.

You cannot just like be sitting down and then get an occal-sepsis in three hours. Right? That'll be quite the unfortunate person. So no. Right? Option D says, what's to my lightest? Again, can be osteomyelitis. But again, this person does not have fever. Right? And this person's symptoms develop very, very rapidly. It's like hyper-rappet. Right? So it's probably not what's going on here. Right? Option A says stuff, stuff, lococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococococ Right? So now again, if you like the way I teach, you like the way I teach, you like the way I make integrations, you're going to just absolutely love my classes. You're just going to what? Absolutely love my classes. Right? So I have classes that begin a God willing next week, Thursday. I have a test taking class for step one to three. It's just one half hours long. And then on Friday, I have a biostatistics class for step one to three to four hours long. And then I have a five hour class on Saturday, social sciences, quality improvement, healthcare systems. It's for step one to three, you know, ethics. I go over that five hour class, very high class. And then after that, I have a last minute review for step two and step three alone. Right? That's going to be taking place. You know, on Sunday, and then after that, I have a 20 hour course that begins right after that.

I have a 20 hour class that begins right after that. I do have a 20 hour class that begins right after that. Again, many people have taken these classes and found them to be extremely helpful. Right? Making integrations, I explain pathophysiology. I show you. And the thing is, it's not just a lecture like, oh, show up like, okay, what's the definition of this? No, I don't do that, right? Because that's kind of a waste of your time on my time. Right? What I do is I use literally questions to go through the concepts, right? To comprehensively go through the concepts. And then I also have a 25 hour step one class that many people have taken and found to be helpful. And then have a 50 hour step two step three class taking place in the first two weeks of June. That's the only time that's going to take place this year. Very limited spots available for that class, but it's a very high level class. Many people have taken and found you to be extremely helpful. It is an extremely, extremely wonderful, wonderful, wonderful class. And again, this class is the over Zoom, you can take them anywhere, right in the comfort of your home. Right? And I'm the person that teaches the whole class, right? It's not like some teaching assistant or whatever that's doing the teaching. And then I also offer one or one to learn for all the USM a reason, all the complex exams and also help with your applications, mock interviews, personal stipends, you know, editing those things and stuff like that.

Again, I work with many people this past cycle and a lot of people I worked with matched, right into very competitive specialties, very competitive programs. And then I also have this podcast on Apple Google and Spotify. So check those out. Also, on the You Tube channel that I post the podcast and videos that I make. And then also another website I have is divine intervention life lessons. Divine intervention life lessons calm many of you know, I'm a Christ follower. Right. So every week I post like one or two podcasts away from a biblical perspective address a life lesson. So you can check that out. Actually have an Apple podcast has read out called the Divine intervention life lessons podcast. So thank you for joining me today. I'll see you go really in episode 646. Have a wonderful day. God bless you and bye for now. Thank you.

Epigastric bruit and refractory hypertension despite maximum doses of anti-hypertensives.

Colposcopy examination after applying 5% acetic acid solution.

Increased intensity of the murmur with deep inspiration (due to increased venous return to the right heart).

Streptococcus pneumoniae (Strep).

Hypocalcemia; Signs include Chvostek's sign and Trousseau's sign.

Acute vaso-occlusive crisis leading to bone infarction/ischemia.

Epigastric bruit + refractory HTN.

Colposcopy examination.

Chvostek's sign or Trousseau's sign.

Renal duplex ultrasound (or basic serum Cr/BUN).

Community-acquired bacterial pneumonia (Strep).

Sickle cells occlude small vessels, causing ischemia.

Epigastric bruit + refractory HTN.

Colposcopy examination.

Chvostek's sign or Trousseau's sign.

Renal duplex ultrasound (or basic serum Cr/BUN).

Community-acquired bacterial pneumonia (Strep).

Sickle cells occlude small vessels, causing ischemia.