DIP Episode 557 - 2024 USMLE Step 3 Free 137 Discussion Part 5 (Q41-50, super helpful for Step 2!)

Alright, welcome. This is episode 557 of the Divine Intervention Podcast. Into this podcast we're going to be continuing the series on the step 3, 3137. This is part 5. This is questions 41 to 50. So let's begin question 41. A 44-year-old woman who is a known patient comes to the office for a pap smear. She says she has felt fine but has noted a significant increase in the amount of bleeding with her menstrual periods. She says my periods are still regular but they now last 10 days instead of 6. It seems the flu is very heavy for at least 5 of the 10 days. With periods like this I am anxious for menopause. She also reports frequent fatigue and occasional insomnia but she attributes these symptoms to having 3 teenage children. She has not had this menorah, this parrhenial vaginal discharge. Medical history is unremarkable. She does not use any medications and says that she does not like to take pills. A family history is positive for colonic polyps. The patient has been separated from her husband. For 5 years she is occasionally sexually active and always uses condoms. Pelvic examination to do discloses no abnormalities. Except for an enlarged uterus, approximately 8 weeks gestational size, which is unchanged from a previous examination. Autro-synography 2 years ago disclosed a mahyameras uterus. Servicose cytology and appropriate cultures are obtained and complete block-downs and serimlybid profile are ordered.

Which of the following is the most apparent diagnostic study at this time? We see this person. She is a lady, she is in her 40s. She seems to have abnormal vaginal bleeding. When she is abnormal vaginal bleeding in a woman that is like over age 30, just in general, always try to roll out endometrial cancer. Always try to roll out endometrial cancer. Honestly the only answer that makes sense here is option D endometrial biopsy. Especially women that have risk factors. Women that are obese, women that may have signs of insulin resistance, women that may have PCOS. But honestly just in general, if you see a woman that is in her 30s or more has abnormal vaginal bleeding, you really, again, it kind of depends on the context of the question. But you generally want to try to roll out endometrial cancer in those populations. So if you look at the other answer choices, so on ACES, co-poscopy, right? Co-poscopy is going to be done based on the results of the pap smear. And the thing is we don't have pap smear results. So we cannot make any judgment calls on co-poscopy. So that's going to be wrong. And they're measuring FSH and LH. So that's what you're going to do if you're worried about menopause. And the thing is for now, again, this does not necessarily look like a menopausal picture. This doesn't necessarily look like a menopausal picture. She's having heavy bleeding and all these things. So again, I'm not going to go there.

It's just that the question there were so many resources to talk about this bleeding. That's just a more important issue to deal with than being so up in the about menopause. Mergencer are proletting that's wrong, right? We don't really see many signs of hyper-proletanimemia. These are the right answer I would imagine. And then historoscopy is something you do when you're worried about a person having anatomical problems in the uterus. Anatomical problems in the uterus of alopian tubes. You can do historoscopy many times. You can inject like some contrast into the uterus. So it's just a nice way to see anatomical problems within the uterus. That's not what's going on here. At least that's not the most likely thing that's going on. All right. Question 42 says, a 58-year-old man who is recovering in the hospital two days after an uncomplicated, elective right, total knee, atroplasty suddenly develops left-sided chest pressure without radiation. The patient was able to amboly to his assistance earlier today. Medical history is significant for hypertension, type 2 diabetes, dyslebedemia, and osteoarthritis. His routine meds are enalapril, metoproloma, and forminareosuva-statin since admission is routine medications have been continued except for medforming, which has been replaced with sliding-scaling insulin. An occipering was added for DVT. The patient is that afraid. Temperature is 90.6, pulse is 100, respiration is a 20 per minute, blood pressure is 90 over 60.

Auto-sad is 92% on room air. Jogolovinus pressure is 15. Longzer-Cleodol scotation. Cardiac examination discloses an S3 and a grade 2 out of 6 murmur. Her best at the right second intercostal space with no radiation. ECG shows sinus-tactic cardio with two millimeter ST elevations in leads to 3 AVF V1 and V2. IV hairprin, 325, 325 milligrams of aspirin, and sublingual nitroglycerin. Why would he do that with those ecagies? That's not wise. Sublingual nitroglycerin administer, after which the patient's histone blood pressure immediately decreases to 72. Well, not a big surprise. We shall find the most likely cause of this patient symptoms. If we look at this question, this person clearly has an MI. Obviously, elevations in two, three V Fs. That's clearly an RC infarct. Again, when a person has an REC infarct, those people are the right hardest is gone. Those people are going to be very preload dependent. The big thing you want to avoid in those people are Vinodiliders. Vinodiliders. Vinodiliders will kill your preload. If your preload is killed, then you're going to get in some hot water. It's not a big surprise. ST elevations in two, three V Fs. That's clearly an RC infarct. Yes, there's the V1, V2. I know some people will be shaken about, but this is clearly an RC infarct. Don't give a nitrate. Nitrates are Vinodiliders. They're going to crush your preload. That's why this person's blood pressure decreased significantly. This shouldn't have done that.

They should have maybe used metform, I mean morphine instead. I'm going to go with an option D here, actually, right? Ventricular infarction. A kid mitral regurg. Again, that's going to present as a systolic murmur. It's going to be heard best at the left fifth intercostal space. This person's murmur is at the right second intercostal space. That's not going to be mitral regurg. Percardia tamponade, again, GVD, morphine heart sounds. An EKG will show like a low voltage. Low voltage EKG or electrical alternance. We don't see that here, so that's wrong. PE. Again, don't get me wrong. PE, you can see sinus-tacky cardiac. Actually, that's actually the most common EKG finding. A PE can ultimately lead to our adventchial infarction, but again, what's the thing we have direct evidence for in this question? We have direct evidence for an RC We have so many pieces of proof for it. It makes no sense to start picking PE. And then option E, viso-vigil. I'll hope a viso-vigil reaction doesn't cause the ST elevations and all those things, right? That's pretty ridiculous. Usually those people, the faces will turn white, they'll be sweating and all those things and then they pass out. That's not what's going on here. All right, so for this, I'm going to say what option D, and again, 41, remember, of set option D.

Okay, question 43 says, a study is conducted to assess physician use of bitter adrenergic blocking agents, a stripping for heart failure, a random sample of 5,000 practicing physicians is selected and surveyed. Oh, they're doing a survey. Yay! Using a 10 item validated questionnaire, researchers stratify the current prescribing patterns by age of physician and by location and type of practice, which are the following most accurately characterizes this study design. Right? So what did these people do? It was pretty straightforward. They literally took a bunch of people at a point in time and then they were like, hey, can you answer this survey for me? Please, please, please, please. Right? That's a point in time study. You can probably get a lot of good prevalence information from here. So let's see the answers. Right? Option A says case control study. No. Right? A case control study, you start out with the outcomes. Right? And then you work your way backwards and ask the people about exposures. That's not what they did here. That's literally not what, not what they did here. Right? That's not what they did here. So it's not a case control study. It's not a case series either option B. In a case series, you pretty much take a bunch of food to have a similar condition and just like right up is like a descriptive thing. You're right up their cases. Right? It's like just a case report of many people. This is not a clinical trial.

They didn't do like intervention x versus placebo intervention x versus standard of care. So that's wrong. Cross sectional study option D. Yeah, I like option D a lot. For this, this really does sound like cross sectional study. It's a point in time study that literally surveying people and just getting information from them like right there and there. I think this is a cross sectional study. I'm good. Good option D. Option E says perspective cohort study. Again, a perspective cohort study, you start off with people that have an exposure and people that don't and then you follow them for a period of time. This study that is described here is a point in time study, not follow you over a period of time study. And in a retrospective cohort study, this is not a retrospective cohort study either because in a retrospective cohort study, you take people to have an exposure and people that did not have an exposure from back in the day and then you look forward and see what happened. Again, notice for a cohort study, you're looking forward from exposure to outcome. The exposure may be a current exposure. That's a perspective cohort study or an exposure from back in the day. That's a retrospective cohort study. A case control study, you're studying at the end, you're studying with the outcome and working your way backwards to the exposure. So the answer here is going to be option D. This is a point in time study. This is a cross sectional study. Right.

So you're getting prevalence information but not incident information. All right. Question 44 says, 28 year old man comes to the office because of a three day history of increasing pain on your nation. He says, I'm worried that I might have a sexual disease. He has been married for the past seven years and he says that his only sexual relation since then have been with his wife. Medical history is on remarkable and the patient takes no medications. He works at a gardening center. Vital signs that within normal limits abdominal examination discloses shotty by lateral linguineol lymphatic anapathy. Examination of the penis discloses a minimal amount of water urethral discharge. The testes appear normal. The remainder of the physical examination shows no abnormalities, which of the fullings the most appropriate diagnostic study had this time. Okay. So option A says, Gramsstein ovary throught discharge before and after prosthetic massage. It's kind of weird. Option B says PCR tests for a nice year in Columbia. Hmm. Seems reasonable. Keep that for now. See says your analysis. D says your incontrointrance sensitivity. Ocean E says, no study, penile revolution of sexual history. You've got in the sexual history. What do you want to do it again? That doesn't make any sense. That makes absolutely no sense. Right. Well, this guy, see what's going on here. Right. He has this urethral discharge. And he's having pain on your nation. Again, could this be a UTI? Sure.

Well, we're seeing this person having a urethral discharge. Right. This kind of sounds like urethritis. Again, on the USMLE exams, stop going for things that are way off base. Just ask yourself, what's the simple thing that this thing may be? That's usually going to be the right answer. The simple thing this thing may be, maybe urethritis. Right. And we know that urethritis can be caused a lot by nice hero, chlamydia. So we're going to go with option B here. Right. And you see how they put two answers just to really embellish this urine. Your analysis, urine, culture, and sensitivity. Don't be too uppity because we're increasing pain on your nation. You can get that from urethritis as well. Right. I can just go with a simple classic thing. And you're not going to get in trouble on your test. All right. So I'm going to go with go with option B here. Right. PCR PCR PCR PCR for gonorrhiana chlamydia. Right. And obviously, if they discover it, then this person is going to get like septraxone and doxy. If they don't know exactly what's causing it, but if they figure out what's going on, if it's going to cockle, only give septraxone alone. If it's night, if it's a chlamydia only give doxycycline or is it through my skin? Doxycycline will be more, more first line in that case. All right. Okay. Grams staying after the person. Why would you do a prosthetic massage when you have like a discharge you can look at? That's pretty ridiculous. Right. And this person needs a study.

All right. Because you don't want him to pass it off to some other person or whatever. Okay. Question 45 says, 72 year old woman comes to the office because of one year he's trying to be sure of worsening shortness or breath and occasional chest tightness and nonproductive cough. Right. Chest tightness and nonproductive cough. All right. As symptoms are very in intensity, but she has had several periods of worsening symptoms during the past six months. Medical history is not remarkable and she takes no medications. She has smoked the pack in a half of cigarettes daily for the past 50 years. Wow. That's a 75-pack of your smoking history. I don't think your lungs are going to be very grateful for that. She does not drink alcoholic beverages. She works as a florist. Of course, they'll put that to as a nice distractor. Oh, maybe this person has some environmental exposure. Let's continue. BMI is 22, vital signs are within normal limits. The patient is not in respiratory distress. Oskotation of the lungs discloses a prolonged respiratory phase. Cardiac exams discloses no abnormalities. There are no rushes or lesions or results of spirometry done in the office as shown. So baseline, FVV-1 is 60% predicted. FVC is 82% predicted. FVV-1 to FVC is 0.55. Post-bronkow-di-later. FVV-1 is 65% predicted. FVC is 82% predicted. FVV-1 to FVC is 0.62. Right. They are putting this pre-ampost bronchow-di-later as if they can kind of trick you into asthma. Come on.

They are not going to be giving asthma to a 72-year-old. That's pretty ridiculous. That makes no sense. And these changes are very minimal. This is not asthma. If you pick an answer that is asthma-related, you have yourself to blame. This is not a classic presentation of asthma at all. Okay. Chestics ratio. Which of the four is the most likely underlying cause of dyspacience condition? Option A says bacterial colonization of large and medium-sized theirways. That sounds like bronchiectasis. But again, people that have bronchiectasis, they have tons and tons of cough. Tons and tons of fast-buedin production. We don't see that here. So that's wrong. Option B says bronchial constriction in response to environmental allergens. Just to make you think of asthma. No. When you have asthma, when you give you a bronchodial leader, you're going to see a big, big, big, big change. Big, big, big, big change. Big, big, big, big change. Big, big, big, big, big change. That's not what's going on here. So just scratch that. Again, option C says destruction of our viola was living to in large amount of air spaces. This person has COPD. This person probably has infeasimum of some sort. That's definitely the right answer. I'm going to go to option C here. Option D says diffuse patch interstitial inflammation on fibrosis. I don't know. IPF. But again, why would it be testing IPF when they've spent so much time on the question, given all this pretty much, this 75-pack year smoking history?

I remember IPF is a kind of restrictive lung disease. Your FFU1 to FVC should be normal or increased. We're seeing numbers like 0.55 and 0.6 to here. That's not what's going on here. An option E says it's an ophilic infiltration of the pulmonary interstitial. No. That's not what's going on here. Again, this person doesn't have an allergic thing. This person has smoked a lot. That's why they are long-signed trouble. If you look at this chest x-ray, it clearly shows a ton of long hyperinflation. The answer to 45 is definitely going to be option C. All right, definitely going to be option C. All right, we're going to go to question 46. So patient information. This is a 16-year-old male on-specivitis or ethnicity being seen in the office. All right, let's jump in. The patient is brought for a well-child visit. The patient's model is concerned because his grades have declined from B's and C's to C's and D's during the past year. She says he has been having difficulty concentrating in school and asked the physician to write a prescription for methylphenidate. Medical history is unremarkable and the patient takes no medications. The mother has a history of MDD, Trito-setraly. The patient's maternal grandfather, uncle and cousin Havah Kohol used the sorter. The physician has the patient's mother to leave the examination room. When alone with the physician, the patient says he has smoked cannabis at least three times weekly during the past six months.

He often smokes with friends in the morning before school starts. He does not drink alcoholic beverages or tick prescription drugs or the substances. Physical examination shows no abnormalities or mental status examination. He reports no depressive symptoms or thoughts of harm in himself. Your detox screening is positive for a Delta 9 tetrahydro cannabino. That's weird, marijuana. After the examination, the patient becomes distressed and says you cannot tell my mother about the marijuana. This is confidential. Which of the following is the most appropriate initial physician response? All right, okay, this boy smokes weed. It's affecting his school performance. He's like please don't tell my mom. All right, Ojonee says I'm worried about your cannabis use. So I recommend that you decrease your cannabis use and see me again in four weeks for repeating your intestines. Okay, so you're recommending a decrease. Okay, let's let's look at the other answer choices here. FX is one of those things where you really just roll out answers. You have to look at everything. Ojonee says I can give you a telephone number for enrollment in a substance abuse treatment program. Ojonee says cannabis is bad for your brain. So let me tell you how 12 step programs can help you stop using cannabis. Ojonee says because you are not actually unsafe. I don't know if that's true. This discussion is between the two of us. And the option E says we need to discuss how cannabis affects your functioning.

How can I help you tell your mother? Right? So the thing is if you look at the context here, the context is this boy uses weed. It's an issue of drug use, substance use. So the thing is characteristically issues of substance use or reproductive healthcare or whatever or like mental healthcare. You generally do not have to disclose to the parent. However, one classic exception to be aware of is this when a person, and again, you have to look at the particulars of the question, when a child is using drugs and is beginning to affect their performance in where it may put them in an unsafe situation, like you see this child is not perspiring academically. And we can see that this is almost certainly being caused by the marijuana. There has to be some way for the parents to know. There has to be some way for the parents to know. And the thing is in this case, you as the physician, you should not be the one. You should try to have the child tell the parents. But honestly, if that does not work out, then you need to tell the parents yourself. So this is just kind of one of those contests where the first line thing you should do is that you should encourage the child to tell his parents himself. But if the child does not tell his parents, the parents have to know in some way. So Blanket say, no, we're not going to tell the parents. That's not going to be the right answer. So I'm not going to go with option D actually. And the thing is option C does not address the primary problem.

This person is not doing well at school. We need to deal with that. We can just say going to a treatment program. No, you need to address like, okay, this is what's going on. This is how it's affecting you academically and things like that. Option B says, oh, I can give you a telephone number. If you notice, the problem with options A and B actually options A, B and C, you're just saying, okay, let's deal with your marijuana. We're not talking about the parents concerns. You need to address the parents concerns. Again, answers that are as all in compassion as possible in ethics are usually better. Right? Option E, B and C just addresses the weak problem. It doesn't do anything about this boy's academic issues that his parents raised. His mom raised. You got to deal with that problem. And option D, again, this thing is affecting this child. That is not addressing the cannabis and the parents issue. So I'm going to go with option E for this. This is actually a pretty controversial question, but I'm definitely going to go with option E for this one. I like option E for this. So I'm going to go with option E for this one. I'm going to go with option E for this for this one. Okay, let's go to question 47 says, a 77 year old man is admitted to the hospital because of a two week history of gangrene of the right foot three years ago, you know, on the went left, transmitted a tar cell amputation during hospitalization.

He received intubation and mechanical ventilation for two weeks because of sepsis. He then spent two months in an acutery hub. Medical history includes type two diabetes, preferred vascular disease and hypertension. He takes insulin, herb, satan, HCT, and aspirin. He's weird leaves alone and keeps in contact with these two sons. He has a living will and his younger son is his designated healthcare proxy. He's a lot of fully oriented. He has a fever. His pulse is 90 per minute and regular. His risk version is a 12 per minute blood pressure is 156 over 90. Also, 696 percent of room air, 5 by 6 centimeter also in black margins over the plantar service of the right foot. A lot of us white green X to date and visible boating the center of the ulcer. They need to cut this off right. Propriety of false impulses are decreased and posterior pulses are absent. Antibiotic therapies are begun. The patient is informed that he requires an petition of the right leg being low. He declines an petition saying, I don't ever want to go through when I went through before with my left foot. He's told about the potential risks for not proceeding with an amputation. These are things like loss of the entire rightal or extrubinary and death. He still refuses the procedure. I wish I would follow his the most appropriate action for this physician to take. This is a classic example of a patient refusing medical care.

When a patient refuses medical care, your next step on the exam is to explore their reasoning. If you explore the reasoning, explain the risks and benefits to them and they're like, no, I don't want this procedure. Yes, it's tough to lose an extremity but then you'd have to honor their wishes. This mind is not alterating any way. So you got to respect these wishes. So on actually I'm going to go with option A here. Just abide by his wishes, right? Consult the whatever department never never do that. That's always a bad idea on your exams. Obtain consent for amputation from anybody. No, this guy is still lucid. Even if you have a healthcare proxy, if you're still lucid, you can make decisions for yourself. Even if you have a healthcare proxy, even if you have a living well, whatever. So CD and E are all wrong. And then option F says review any additional instructions. No, the instructions are pretty clear in the question. Again, when you start reaching beyond the boundaries of a question, when you start going into all these mental gymnastics, that's how you get in trouble. We've been told that he has a living well. That's it. Again, just go with the simple thing and leave it at that on your exams, right? Live well enough alone. Live well enough alone. Really nice role of thumb to fall on the USM. All right, question 40 says a 63 year old woman is evaluated in the hospital two days after shows admitted for management of left-standard pain.

Left-standard chest spin and high-pertensive emergency with a blood pressure of 195 over 110. Workup included CT and geography of the chest, we should know evidence of her PE. During the past six hours, she has had decreased her in a pot of blood catheter, yielded only 50 milliliters of urine during the past three hours. She has not had abdominal pain. Medical history is remarkable for hypertension, also a Threadiesand Stage 3 CKD with a baseline serum creatinine of 1.7. Routine meds are like syno-pril and low-deepin and HCTZ. The chest spin she had on admission as resolved. Temperature is 99.7, Balsy Z7, Prominular Respirations at 18 and Blood Prishers 147 or 87. Physical examination discloses no abnormalities, results of lab studies obtained on admission and today are shown. Sodium is also sodium as risen by like three points. Potassium as risen by like point nine points from 4.2 to 5.1. Her chloride is largely the same bicarb, largely the same BUN, the same creatinine from 1.62 to 2.4. So this is clearly an EKI. Glucose barely changed. If you look at the remaining labs honestly they look pretty good to me. And then she has Modibrand Casse. So a kidney is bad. She has Modibrand Casse. We should fully infact this patient's history. Most increase her risk for developing occurring complications. This person has EKI and you see Modibrand Casse. So this is probably a cutablinicosis of some sort. So, Obtion E says bladder calf. Bloodarcaf is not going to cause a cutablinicosis.

If anything bladder calf is just going to help you out better and stuff like that. I'm not going to pick that answer. That's wrong. CKD. Yeah she does have CKD or Togiasda history. And if you have CKD you're not going to do very well with other illnesses. Other illnesses can very quickly through into acute kidney injury. So I may actually pick that answer. Let's keep that for now. And then option C says on controlled hyper hypertension. Okay she did have a hypertensive emergency. Don't get me wrong hypertensive emergency can cause a person to have EKI. But as you treat the hypertension the person's EKI should resolve and stuff. This hypertension has resolved but the kidneys have taken a hit. So I don't think I'm going to see the hypertension in the cause. But let's keep that for now. Use of lysinoprell. No she has been on lysinoprell for a long time. And lysinoprell actually is pretty helpful in people that have CKD. The only people shouldn't give it to. Although that's actually no longer the case. A people that have bilaterinal anaesthenosis these days you can actually give an acin inhibitor to people that have bilaterinal anaesthenosis. Although the USML is still largely shy away from that. And then option E says volume depletion. This person does not look volume depleted. This person is I don't think we have much evidence of volume depletion here. So I'm not going to pick that answer. So honestly I'm good to go to option B because again she clearly has ATN.

She clearly has CKD from this question. Right. And we see modibral casts. Right. So those she had an illness. Right. And this illness caused her kidneys to fail. So honestly I think that's what's going on here. That's just the most likely answer compared to uncontrolled hypertension. Many times if you have uncontrolled hypertension you have the nasty nasty high creatinine. And then as the high blood pressure is being controlled your creatinine should decrease. But this one is like the blood pressure has been controlled and creatinine is actually rising. That's a problem. Right. So I'm going to go with the CKD here. I'm going to go to option B for for this one. All right. Let's go to question 49. So around the mice placebo control trial is conducted to assess the efficacy of deloxetine in patients with severe rheumatoid arthritis. What currently true? The method tracks it. Patients who have six or more joints that are actively inflamed, swollen or tender to power patient eligible for inclusion in the study. The primary outcome measure is the number of joints that are no longer inflamed after four months of treatment. 150 patients enrolled and randomized to deloxetine group. So any equals 75 or the placebo group, any equals 75. The main number of involved joints is 12. Okay. Did I show that patients in the intervention group? Huh. This question looks kind of weird. Huh. Okay. Let's keep going. The main number of involved joints is 12.

Did I show that patients in the intervention group have a mean of seven joints that are no longer inflamed at the end of the trial? Okay. It's pretty good. Patients in the placebo group have a mean of two joints that are no longer inflamed at the end of the trial. Okay. Wow. Okay. The deloxetine seems to be helping a lot here. Seven joints no longer inflamed into the deloxetine group, too no longer inflamed in the in the placebo group. All right. Okay. Results of a total TTS show P of 0.2. So the results are clearly statistically significant. It then says which of the following is the most appropriate conclusion to draw regarding the clinical and statistical significance of this study? Well, this study is clearly statistically significant. The P is less than 0.05. So we're going to cross-off options A and C easily. And then we're left with B and D. And we see it's like, wow, seven joints no longer inflamed versus two. That seems pretty big. Again, the thing is on you exams just be a big picture thinker. Right. We clearly see that, wow, it's like five more joints no longer inflamed. The deloxetine seems to be helping a lot. It seems to be almost like almost like half of the joints are no longer inflamed. That's amazing. I'll see if this is clinically significant. So then I'm going to go to option D for this one. This thing is both clinically and statistically significant. All right.

So question 50 says our last question of physician would like to evaluate the benefit of a new super-rosis medication in preventing fractures in women age 40 to 60. Huh. That doesn't make any sense. Well, do you want to be giving a answer? I mean, it was great for super-rosis women over 65 for a reason. For you 60, why would you study that kind of population of osteoporosis? That makes no sense. All right. But anyway, okay, a total of 300 women age 40 to 60 years with osteoporosis. That's not very wise. Documented by dexter scan, I enrolled in the study from general gynecology clinics. The patients are equally randomized into two groups. Group A receives the new osteoporosis medication and group A receives placebo. That's a problem too. Like, yeah, drugs for osteoporosis. Why don't you stand out of care? Why are you doing placebo? Geez. Okay. Results show that the blood bone density of patients who receive the study medication is unchanged and the bone density in patients who receive placebo decreased by 2%. P equals 0.01. So that's statistically significant, but there are too many problems with this study. The physician concludes that the new medication decreases the risk of fracturing women age 40 to 60 years. As not very wise, doctor, which are fully the most appropriate conclusion to draw from these data. See, there's two problems with the study already. Number one, when you're studying something, you've got to study it in the population that is at risk.

There is a reason why with screen women, osteoporosis, when they're like in their 60s, 40 to 60, that doesn't really make any sense. That's number one. Number two, a 2% decrease. Gee, that's pretty low. That's not much. Yes, we may see statistical significance, but man, I'm not really seeing the clinical significance here. Honestly, I'm not very accepting of these results. These results look like a wash to me. So let's look at the answers. So option A says, option A says, the impact of the medication on bone density may not correlate with the risk for fracture. Yeah, this women's risk for fracture is pretty low. They're just not in the good osteoporosis age range. I'm going to keep that answer actually. Option B says, the lack of a change in bone density among patients who receive the study medication, suggests the presence of a confounding variable. There was a change in bone density. That's option B is not true. Option C says, the lack of a change in bone density among the treatment group. So just that the medication regimen is too complicated. No, again, there was a change in bone density. Oh wait, let's see. Result sure that the bone density of patients who receive the study medications unchanged. Oh, okay. Okay, okay, I take that back. Sorry. So, both have got the study medication, their bone density was unchanged. People that receive placebo, their bone density decreased by 2%. So, okay, but again, it's not a big change. It's not a big change.

Okay, so option B, lack of a change. Okay, so let's let's go back. Again, I'm keeping option A for sure. Option B says, the lack of a change in bone density among patients who receive the study medication, suggests the presence of a confounding variable. Not this is really this thing seem to do what you set out for it to do. It prevented you from developing osteoporosis. Your bone density did not change. Option C says, the lack of a change in bone density among the treatment group suggests that the medication regimen is too complicated. Again, I don't know if I'm going to call this a complicated medication regimen. They basically just chose the wrong patients. And the effect we're seeing is just way too tiny, way too tiny. And the thing is, honestly, we're not necessarily seeing any benefit from this drug, right? You know, yes, we're seeing that the bone mineral density kind of stabilizes, but I don't see much of any benefit from this drug. Option D says, the lack of women younger than 40 years of age is makes it difficult to evaluate the long term benefit of treatment. That makes absolutely no sense, right? Like again, the only people under age 40 they usually get like these problems are like osteoporosis. I would use like a ton of steroids or put off eating disorders, right? That's what's going on here. I'm like anorexia, for example. Option E says, selection bias is likely because the patients were also elected from general gynecology practices.

Actually going to general gynecology practices is a good thing. You're getting like a representative sample, but again, they choose the wrong population. See, this question just has this study has too many problems with it. I think I'm going to go with option A, right? The impact of the medication on bone density may not release with the risk for fracture. Right? The risk for fracturing women is 40 to 60. It's very, very, very small, right? Your risk goes up a lot once you hit menopause and stuff. So honestly, like there's quite a bit of bias in this selection bias here because they use the wrong patient population for this study. That's one. And then number two, the effect is too tiny. So I'm going to go with option A here. I'm going to go with option A here. You're seeing almost no change in a very lorror group. That's a bad study. It's not a good study. So I'm going to go with option A here. Again, options B and C are maybe true statements, but the thing is confounders. Again, we don't really know much about confounders here. Right? An option C, this medication regimen does not seem overtly complicated. Again, like the thing is option B and C are kind of decent answers for the or for the answers. They just know that it's good as option A. Option A tags along best with what the question is describing. All right, so we're going to go ahead and stop here. Again, if you're interested in any of my classes, I have a bunch of classes that are coming up in the month of January.

I have a test taking class for step one to step three. I have a bio-stask class for step one to step three. I have a social sciences and ethics class for step one to step three. And then I have a 20-hour step two step three class on a three-hour last minute review. So if you're interested in any of those classes, just reach out to me via email. Again, many people are taking these classes and have done extremely well on their exams. If you love the way I teach, I love to make integrations, I love to teach people context, I like to explain pathophysiology. And again, the class really does reveal a ton of information that's very necessary for you exam. And again, these things have updated very frequently to keep in lockstep with the NV Me. So if you're interested, shoot me an email. Also for also a 4111 to learn for all the USML exams and all the complex exams. And then I have these podcasts on Apple, Google and Spotify. And you know, you can also check out my You Tube channel where I post the videos I make, Divine Intervention, USML Podcasts and videos. And then finally, I have another website called Divine Intervention Lifelessens.com. Every week I post about one to two podcasts, Divine Intervention Lifelessens.com. We're from a biblical perspective, you know, many of you know, I'm a Christian. From a biblical perspective, I discuss a life lesson. There's almost 300 episodes on there.

There's actually an Apple podcast associated with that called the Divine Intervention Life Lessons Podcast. So just check that out. And also help with Eras applications, mock interviews and things of that nature. So if you're interested in any of these things, shoot me an email and I can give you some more information. So thank you for joining me today. I'll see you in a episode 558. Have a wonderful first of your day. God bless you and bye for now. Thank you.

Endometrial biopsy, to rule out endometrial cancer.

Vasodilators (e.g., nitrates), as they can cause precipitous hypotension by reducing venous return.

Cross-sectional studies measure prevalence at one point in time; cohort studies follow subjects over time to determine incidence.

Neisseria gonorrhoeae and Chlamydia trachomatis.

A low FEV1/FVC ratio (obstructive pattern).

Autonomy; the patient's wishes must be respected.

Endometrial biopsy (to rule out endometrial cancer).

Nitrates are vasodilators that decrease preload; RV infarction patients are preload-dependent and can crash hemodynamically.

Cross-sectional study.

PCR testing (NAA Ts) on urethral/swab samples.

Airway obstruction, characteristic of COPD or asthma.

Respect the patient's autonomy and refuse to proceed with the procedure.

Endometrial biopsy (to rule out endometrial cancer).

Nitrates are vasodilators that decrease preload; RV infarction patients are preload-dependent and can crash hemodynamically.

Cross-sectional study.

PCR testing (NAA Ts) on urethral/swab samples.

Airway obstruction, characteristic of COPD or asthma.

Respect the patient's autonomy and refuse to proceed with the procedure.