DIP Episode 529 - 2024 USMLE Step 2CK Free 120 Discussion Part 10 (Q71-80)

Welcome, my name is divine. This is episode 529 of the divine intervention podcasts. In today's podcast, we're going to be continuing the series on the step 2 cq free 120. This is the 2024 one. The one that's on the website right now. And it's going to be part 10. We've done 70 questions so far in the series. So we're going to go ahead and pick up from where we stopped. So let's get right into it. So question 71, a 22 year old man comes to the office for a health maintenance examination. He feels well and has not noticed any health issues. He's in the US Army. Two months ago, he returned from a 10 month deployment to southwest Asia, during which he started smoking one pack of cigarettes daily. The patient says he's happy to be home and has been celebrating with his friends and family. He has been consuming an average of six beers daily since returning to the United States. He has no history of metronomeical illness. He does not use any medications or the substances. His mother has type 2 diabetes militaries. The patient is 180 centimeters. That's 5 foot 11 inches tall. And weighs 72 kilograms. That's 160 pounds. His BMI is 22 kilograms per meter squared. His first blood pressure reading is 156 over 95 millimeters of mercury. Repeat reading is 160 over 92 millimeters of mercury. He says he remembers his blood pressure being normal when he had he checked in the past.

Physical examination discloses no other abnormalities, which of the feelings the most likely cause of this patient's increased blood pressure. Option A says cigarette smoking. Option B says essential hypertension. Option C says excessive alcohol use. Option D says fiochromocytoma. Option E says Rinal artery stenosis. So what factor that's present in the QSTIM tells you that this person's blood pressure will be elevated. Well, I'll show you a cigarette smoking. Here's the thing. This person was also smoking when he was out of the country. It doesn't seem like he had high blood pressure when he was out of the country. So I think that rule out option A. Option B says essential hypertension. Essential hypertension is usually going to be usually probably the most likely cause of hypertension in most people. But that's typically going to be in the person that is unhealthy, you know, obesity, which is person's not obese. Obesity, metabolic syndrome kind of deal. And again, this person is 22. It's unlikely that's going to be in essential hypertension. So we're going to get rid of that. Option C says excessive alcohol use. Well, since he came back, he's been drinking six beers daily. That's a lot of alcohol. That's going to jack up your blood pressures. That's going to alcoholism kind of raise our presence of blood pressure. So I'll probably go with option C. Option D says fiochromocytoma. Fiochromocytoma, you're going to see episodic headache and hypertension.

Remember, he has this association with MEN2, MEN2 A and 2 BSB, especially. We don't see that here. So that's off. We're not allowed to know. So you're going to be in an older person, although you can be younger people. But those people have like flung bruises and stuff. We don't see that here. So I'm not going to go with that. I think I like option C a lot here. So this person has to kind of, I know it's happy to be home, but he should probably kind of calm down on the drinking. His blood pressure will probably don't realize with that. Remember, if they give you a question about a woman that's a productive age and has high blood pressure, what's the risk factor for that? That's OCP Us, right? That's kind of high or to know for example. Okay, so 32 year, question 72, a 32 year old man comes to the office because of a three month history of a painless rush over his arms. Okay. During the past month, he also has had a seven pound, that's a 3.2 kilogram weight loss, despite no change in appetite. He has no history of syruxionus antigeno medications. He's 175 centimeters. That's 5 foot, my name is tall. And we sell two kilograms, that's 150 pounds. BMI is 23 kilograms per meter squared. Pulse is 90 per minute. All the vital signs are within normal limits. Longs are clear to us quotation. Cardiac examination shows normalities. A photograph of the left upper extremities shown, similar findings are murdered over the right upper extremity. So it's a diffuse process.

Which of the following is the most likely cause of this patient's dermatologic findings? So option A says, actinic erotosis, option B says, dermatitis for periformis, option C says, kaposis for coma, option D says, liking planus, option E says, separate dermatitis. So this is actually a pretty good question because there's not many clues that are supplied in the Q stem, but it's applied an image. So this is one of those questions where I imagine a lot of people panic with an image. Again, I think I've kind of explained this to you many times, but the image is not typically absolutely necessary to you answering the question correctly. But obviously for a question like this, if you knew what the image was asking, then you're solid. You can get this one at the tip of a hat. But again, just use the process of alienation, right? Like for example, option A, okay, let's look at what's bad in this question. This person has had this painless rash, has lost weight. It's kind of worrisome, right? Lost weight. And we see that this process is diffuse. So, and you know, it's kind of a young-ish guy. So we look at option A saying, actinic erotosis. This is usually going to be in a person that has been out in the sun for a long period of time, like a gardener, landscaper, stuff like that, right? And they're going to have it like a rash, like a sand people like rash. It's going to have like a rough texture. We don't see that here. So that's off. I'm not going to go with A.

Option B says dermatitis are pretty formless. We tend to find that in celiac disease, celiac disease. So they will give you a question stem that talks about my absorption, iron deficiency, anemia, you know, vitamin D deficiency, stuff like that. We don't see that here. So we're going to get rid of that. Caposis or coma, usually shows up with skin findings. It's a kind of malignancy. It's associated with a HHV8. Or sometimes we call that KSHV. Caposis or coma associated with herpes virus. And you know, it kind of sprites sometimes. So let's keep that for now. Option D says like in planets, like in planets, remember the piece, right? It's going to be polygonal. It's going to be purple. It's going to be like a popule or a plaque. And we should be finding that around like the wrists, around the ankles, stuff like that. This does not look like that at all. So we're going to get rid of that. And then option E says suburitumatitis. Usually we're going to see that in a Parkinson's patient or HHV patient is going to involve like heirs of hair growth, right? So like around the cheeks. Basically where there is hair, that's not what's going on here. So I'm not going to go with that. And we see this first thing losing weight and stuff, right? So that's kind of worrisome for like a malignant process. So I will go with Caposis or coma for this one. Honestly, this one is actually quite a kind of a question with very few clues.

But again, I feel like you can at least get very close to the right answer. At least get it down to one or two answers. It was just kind of got rid of the answers that make no sense, right? So I don't really really fit the bill. So I think for this one, I'll go Caposis or coma, losing weight. This skin lesion is a diffuse process, painless rash. People that have Caposis or coma, the lesions tend to be purple. This thing certainly looks purple to me. And it tends to again, it can be diffuse, right? So I think I like this one for Caposis or coma. I remember for Caposis or coma, you're either going to like, if they have HIV treat the HIV, usually they'll take you take care of the Caposis or coma, we can inject steroids into the lesion. You can inject healing to the lesion. There's many different things you can do for Caposis or coma. All right, let's go to question 73. A 42-year-old, nolly-gravid woman comes to the office because of a six-month history of hot flashes and intermittent populations. A last-nest-repeared was six months ago. Mences previously occurred at regular 20-90 intervals, but gradually had occurred less frequently during the past two years. She won the Wendtow variances'ctomy 13 years ago for a small benign territory. She used an oral contraceptive for 12 years until tubal ligation six years ago. Her mother and sister had metopause at the age of 47 and 49 years respectively. The patient has smoked one pack of cigarettes daily for 26 years. That's no-wise.

She's sexually active and monogamous with one male partner. She's 170 centimeters, that's 17-she's tall, and weighs 86 kilograms. That's 191 pounds. BMI is 30 kilograms per meter squared. Paul sees 82 per minute and blood pressure is 130 over 85 millimeters of mercury. Physical examination, including pelvic examination, discloses no abnormalities, which of the following is the most appropriate next step in diagnosis. Option A says, measurement of serum, follicle stability, hormone concentration, option B says, measurement of serum, luteinizing, hormone concentration. Option C says, measurement of serum, testosterone concentration, option D says ECG, option E says pelvic ultrasound, so what do you think? What do you think? That's a pretty straightforward question. So many in her 40s, she's having menopause like symptoms. But like, man, you're 42. Although 42 is not too early. It's kind of early, but there's no super early. Remember, we say people have premature variant failure when they're starving all these issues before age 40. But this person's past age 40. So a lot of big deal here. So what's the answer here that kind of relates to checking if a person's going to hit a menopause if they are over his beginning to kind of shovel up? It's just checking the FSH level. It's going to be elevated, right? Because essentially, these people's gonads are not working. The ovaries are not working, so they're not making estrogen.

If you don't make estrogen, there's no negative feedback. So you're going to drop in as like FSH. It's going to be elevated. So I'm going to go with option A here. I know that option B kind of looks good as well, but usually for trying to determine these things, FSH is just a common thing. They go after an exam. So I'm going to be too hamstrung by option B option C. That's where Dix usually option C something you think about it like low libido in indeed. Just make no sense here. All right. Question 74. A colleague of a 47-year-old physician who is conducting patient evaluations during afternoon walking clinic hours. Notice that the physician appears groggy, has slurred speech and smells of alcohol. Oh, that's not good. Earlier in the day, the physician had attended a celebratory lunch for the graduation of one of the clinics employees from nursing school. The colleague has not witnessed similar findings in the physician in the past. The physician is scheduled to work at the clinic for the next four hours. A physician assistant is present at the clinic and typically eats the physician with evaluating patients. Which of the following is the most appropriate action for the colleague to take at this time? Option A says, allow the physician to finish his clinic his time at the clinic, but raise concern about the episode that the next physician staff meeting. Option B says, ask the office administrator to consult the remainder of the clinic hours.

Option C says, ask the physician assistant to examine the physician's patients and discharge them before the physician has a chance to examine them. Option D says, confirm the physician and ask him to leave the clinic. Option E says, report the physician to the clinic administrator and conduct the remainder of the clinic hours without him. Option F says, report the physician to the steep medical board. All right. So this is an impaired physician. There are certain rules and principles to follow when you're dealing with an impaired physician. Number one, the person has to be removed from patient care immediately. They can keep care of her patients. They don't want them to kill somebody. This is a simple rule of thumb to follow. A simple rule of thumb to follow. And the number two, they got to get reported. It's a hazardous practice, right? So they need to get reported. So basically, let's look at an answer that helps those accomplish objective one that see. We're going to remove this person from patient care right now. And usually when you remove them from patient care, the person that does the removing is a very senior person in the organization, very, very senior person in the organization. Every hospital has like a chief of medical staff or something like that. So option A is wrong, right? Oh, keep going. And then we'll raise our next staff meeting. What about prison kills somebody from their care? That's right. That's off.

Option B, as the officer administrator counsel, the remainder of the clinic hours seems like there's people that can do the job. And again, we're literally not removing the person from patient care. You need to quickly answer the removes the person from patient care, removes the person, not the patient, right? The patient should get care, right? If you care. Option C says ask the physician assistant to examine the physician's patients and discharge them before the physician has a chance to examine them. No, you're not removing this person from patient care. I don't like option C. Option D says, confirm the physician and asking to leave the clinic. Okay, that seems like a good one. Let's keep that for now. Option E says, report the physician to the clinic administrator. I call up the remainder of the clinic hours without him. Okay, so you're a physician. So obviously you can treat these patients and report to the clinical administrator. Yes, that's probably a good thing to do. So the administrator, so presenting charge, right? The person usually is well versed in how to handle these problems. The option F says, report to the stigma medical board. No, the stigma medical board is something you're going to do down the line. The person has got to be written up, but not right now, right? So between options D and E, you know, conferencing the physician asking to leave the clinic versus report to the clinic administrator and condo the remaining hours without him.

I like option E better, right? Confronting the physician like how successful is that going to be, right? Because it's just your suspicion. The thing is many times when you suspect bad behavior on the part of a healthcare professional, such as E, this, but you got to report them, right? You need to make some kind of document dishes, some kind of record. But again, that person has to remove from clinical care. I feel like option E is just much better because in option D, you're conferencing the person, well, you're not making any, you're not lodging any complaints with the higher ups in the clinic. You got a larger complaint. It's a patient-seaf-dee event. Patient-seaf-dee events always have to be reported. Option E makes the most sense. Again, if you want to be well-versed in dealing with these kinds of colondromes, I definitely have a class that can help you. I have a five hour social sciences class. It's going to be taking place on the 20th of this month. It's for step one to step three. We have like 200 plus scenarios that we deal with revolving around the healthcare systems, social sciences, ethics and whatnot. Many people have taken the classes, found you to be extremely helpful. Also, I will say that I also have a biostat class that's far as long. It's on the 19th of this month. A test taking strategy class is two and a half hours long. These classes are not lectures. They're all like scenarios, NV Me style questions to portray these points.

They're all four step one to step three. Then starting on the 22nd of this month, I have a 20 hour step two step three class. Again, pretty much all scenarios, although I have some tables and charts that needs to go over some very high-yield information for people. That's a step two step three class. Then I have a last minute review on the 27th of this month. It's a three hour class. It's not supposed to be a deep detailed review, but I'm going to be using a lot of integrative questions to go over a lot of very high-yield things for step two, step three. Then the first week in me, literally from me first to fifth, I have a 25 hour step one class. If that's something you're interested in, shoot me an email. I can give you some more information. Again, many people have taken these classes and they've done extremely well on their exams. Let's get back to question 75. Again, if you're interested in any of these classes, they all over Zoom, just shoot me an email and I'll give you some more information. I can reserve your spot. That's 16th, Arab Women returns to the office for a full-up examination. I just let me comment on that when I four-row quick again. Remember, when you suspect a patient safety event, you've got to report it to a higher up. The person has to be removed from patient care right there. The person that's impaired has to be removed. You got to report it to a higher up because option D looks good, but you're not reporting to any higher up.

That confrontation may not do anything. You may create a variant of comfortable circumstance in the clinic that will end up causing problems. You've got to handle things clearly. I don't like option D. I like option E better. And then after you've done option E, then you do option F. Question 75. If a 16-year-old woman returns to the office for a full-up examination, one month ago, your analysis should protein during the work-up of a suspected urinary tract infection. At that time, the patient was prescribed a 3-day course of oral cephalyxin. Today, she says her previous pain on urination and urinary frequency have resolved. She has major depressive disorder and osteoarthritis, chronic medications of hemifaxine and acetylaminophen. Temperature is 37.0 degrees Celsius, that's 98.6 degrees Fahrenheit, pulse is 66 per minute, respirations are 18 per minute, and blood pressure is 122 over 66 millimeters of mercury. The patient appears physically fit. Examination discloses no abnormalities, repeat your analysis issue. So the specific gravity is 1.015. Normally it's from 1.003 to 1.02, PG6.0, that's normal. Protein is negative, blood is negative, low-side is series is negative, nitrate is negative, white cells, 3 per high-power field, that's not much. Red cells, 1 per high-power field, that's not much. I don't really hear about those. Okay, now what should I follow is the most appropriate additional diagnostic study at this time.

So option E says the termination of the urinary and abusing to creatine ratio. Option B says 24 are urine collection for measurement of protein concentration. Option C says ultrasound salography of the kidneys, option D says urine, sofosalacetic acid method, option E says no additional testing is indicated. So this person had a UTI, all right, okay, with treated person for the UTI. All right, the person is UTI resolved. All right, and the person got better, and then now all of the person's virus are completely fine. All of the person's labs are completely fine. Do you really want to do anything else for this person? Sounds like no is like the good answer for that question. Right, whenever your question is like completely like A, okay, this person needs like nothing, then do nothing. Right, I don't see why we should really consider the other answers. Your option E makes a lot of sense. No additional testing is indicated. Right, option A, urine, abusing to creatine ratio. We measure that in diabetics to screen for microabular ureia. Option B is something that relates more to like nephrodix syndrome. Right, so far urine collection of protein concentration, right, because remember in nephrodix syndrome, for example, nephrodically afraid, I guess, nephrodically less than 3.5 grams of protein in 24 hours, nephrodically more than 3.5 grams of protein in 24 hours. Kidney ultrasound, this person doesn't have any structural kidney issue.

Your insophylsilic acid method, it's actually like a very easy test that's kind of safe. Like I used to detect protein of person's urine, right? So, you like to use it in pregnant women every now and then. You just add so-fosilic acid to the person's urine, it's an acid. So, and if there's protein in the urine, it's going to denature the protein. After you denature the protein, the water is going to get turbid. The degree of turbidity will tell you it's kind of a good surrogate for like the level of protein or in a sense. But again, how likely is it you're going to test that? Almost done liking it again. Asked on what's now. We're not going to do that here. I like option E for this one. This one is pretty, pretty easy. Okay, question 76. The 22-year old man is brought to the emergency department because of severe right lower leg pain since he fell in the woods during a camping trip two days ago. The pain has worsened during the past 12 hours. He sustained a small scratch below his knee as a result of the fall. He has no history of serious illness and uses no medications or the substances. He does not drink alcohol. Post is 110 per minute. Oh, that's not good. Respecies are 14 per minute. Blood pressure is 105 over 60. It's kind of training low. Examination of the right lower extremities shows a dima, diffuse elitis, and hemorrhagic bulley. Oh no, from the knee to the ankle. Oh no, that's not good. Okay, no abnormalities of the left lower extremity are noted.

Peripheral intravenous anti-pathic therapy and infusion of two liters of crushed staloid food I began. I begone, which of the following is the most upper rib next step in management? Option E says FNA of the bulley. Option B says hyperbaric oxygen therapy. Option C says MRI of the right lower extremity. Option D says surgical deep ribment. Option E says hospital administration for observation only. All right, let's look at this. So this person was next to just below the knee as we're going through the woods. And then we see from there this person has severe pain. Look at those descriptors. The person has severe pain. Person is kind of hypotensive. You see diffuse cellulitis, hemorrhagic bulley. This is really bad, right? So I'm kind of thinking that this person has necrotizing fasciitis. Person has necfache. So they've started anti-biotics, they started fluids. Well, necfache, you got a deep brain. You got a deep brain, deep brain, deep brain. So I'm going to go with option D here. Option E doesn't make any sense. Just to observe. No, this person's process is rapidly spreading and getting worse. I'm just going to be observing. Option C says MRI. Again, that's something we'll be doing if we're going to move on to my lightest, but that's not the pressing concern now. The pressing concern now is necfache. Option B says hyperbaric oxygen. No, the person has necfache, you got a deep brain. Option A says f any of the bulley. f any of a bulley. Come on. That's right.

The answer is going to be option D. Okay, question 77. A 27-year-old woman gravity of three part two, a 12-week gestation, comes to the office for her first prenatal visit. Her first child was delivered at 41-week gestation and weighed 41-67 grams. That's 9 pounds, 3 ounces. It's a big baby. Her second child was delivered at 37-week gestation and weighed 4309 grams. That's 9-pound in ounces. That's a big baby as well. She has no e-stroke, zero-seowness and her only medication is a prenatal vitamin. Her sister has a e-stroke, delivering a stillborn infant. Her mother and father both have type 2 diabetes mellitus. Eight months ago, the patient immigrated to the United States from Mexico. The patient is 157 centimeters. That's 5'72 inches tall. She weighed 95 kilograms. That's 210 pounds prior to her pregnancy. BMI was 30 kilograms per meter squared. She has had a 3 kilogram. That's a 6.6 pound week gain during her pregnancy. Pulse is 80 per minute. Respirations are 14 per minute. Blood pressure is 110 over 60, but the muscle pressure is 10.5%. BMI examination shows a uterus consistent inside of the 12-week gestation. Autosanography confirms a 12-week gestation. Which of the following is the most appropriate next step in management? Option A says antifers-fulipid antibody screening. Option B says chest tetrahedron. Option C says fasting glucose. Tolerance test. Option D says measurement of serum alpha-phenoprotein concentration.

Option E says measurement of serum-free-thyroxane concentration. This woman is delivering big babies. And I know some of you may be like, divine, how do you know these babies are big? Can you give me the exact criteria? I can't. I literally don't know the exact criteria. But again, that's the thing I feel like. Many people pass a very over-sertined details that just don't matter for the exam. Well, these things are just you applying some wisdom. For example, I don't know the exact code of it, but I know that man, 9-pound babies like, that's just not usual. A baby that's 9 pounds. As a baby is approaching 10 pounds, it's probably a big baby. It's probably a big baby. So these two babies are big. So that's phytonmachrosomy. Well, what do we know about phytonmachrosomy? It has a very strong goths of sejor diabetes. Very, very strong as a young diabetes. So for me, just like me, what's the diabetes related answer here? Substance C. I'm going to go with that. And I know some of you may be like, but divine, we do the oral glucose tolerance test around 24 weeks. Yeah, we do. But the thing is, remember, if this person has a high risk of diabetes, which he sounds like she is, we probably want to figure out that she has diabetes now. When, you know, it's early on pregnancy, so because that fixated it now, so we can so we can prevent that macrosomy down the line, stuff like that. So don't go to oxygen C.

Option A only makes sense if we're told that, oh, this person has like recurring pregnancy losses, venous troma in body disease, stuff like that. That's the one's going out here. I don't know what you're trying to be glinging for my chest X-ray. Measuring AFPN, phyroxyl levels, doesn't make any sense to me here. So I'm not going to do that. All right. Question 28. I mean, sorry, 78. And 84-year-old woman comes to the office because of a one-month history of malaise. She has not had fever, weak lots, or abdominal pain. She has type 2 diabetes, malatrous, well-controlled, with long, actininsulin and metformin. She has missed multiple appointments during the past six months, with no reasons given. Her hemoglobinia 1c6 months ago was 6.7%. She says she has been feeling fine. Some move back into her home nine months ago because she had lost his job. The patient's husband died five years ago and she has no other children. She appears on a chemt. She is a learned and fully oriented. She is 163 centimeters. That's 5 foot 4 and she's tall. And we sell 17 kilograms, that's 170 pounds. BMI is 29 kilograms per meter squared. Her pulse is 80 per minute and regular. Respirations are 18 per minute and the blood pressure and blood pressure is 160 over 94. Minimumilers are mercury. Meagots membranes are dry. There is no throsh. The skin is dry and intact. The remainder of the physical examination shows no abnormalities. Mental status examination shows no memory deficit.

She has a normal mood and flat effect. Her fasting serum glucose concentration is 3e. Milligrams per deciliter. Results of your analysis are shown. Glucose 4-plus. That's a lot of glucose. Keytones, non, nitrites, non, glucose, rays, none. We're going to find the most likely diagnosis. Social E says dietary indiscretion. Okay, that's an interesting answer. Option B says elder neglect. Option C says major depressive disorder. Option D says pancreatic malignancy. Come on, really? Option E says urinary tract infection. Right, for a month. Come on. Okay, so let's look at this. So what's abnormal here? All person, malise, right? She has to take two diabetes that was well controlled. But now she's been missing appointments and she looks on chemt. Her blood pressure is pretty high. Dry mucus membranes, dry skin. The pressure has not been properly cared for. And I know you may think, and you just look at that glucose, nice 3e. I mean, you think that this could be depression, but she doesn't have sleep issues. Does it have loss of interest? Does it have guilt? Does it have low energy? Does it have concentration problems? Does it have poryptite? Does it have psychomotoritation? Does it have suicidal ideation? Does it have low mood? We don't have any of those things. Literally, this person essentially checks off nothing in the Ciccaps plus no mood or criteria. That's ridiculous. So it's not MDD. This person has been abused. This, again, we see a sun kind of move back in.

The sun is not pulling his weight. This is elderly neglect. It's a kind of elder abuse. And typically on the USML, we're going to see an elderly neglect question where this elderly person is no longer taking their medications, their missing clinic appointments, the look on chemt. They just don't look like they are being well cared for. Physically, they look like malnourished, they look dehydrated. You've got to call adult protective services. That's what you need to do. So the answer is B. This is elder abuse. But again, as I've said in many of my review courses, I've said to many people that the USML is these days, the trading derivatives. A person that has knowledge of financial markets would be like, divine. I've seen that the USML is of trading options and futures and all these exotic financial instruments. No. What do they do? Again, it's something I feel like came on online after they started after Anki became very popular. Is they started using non-classic descriptors of things? They put elder abuse. Many people will be like, oh, yeah, of course, that's going on here. But let's just change it around a little bit to elderly neglect. So again, I'm telling you this, for you Anki uses is nothing wrong with Anki. I know many people think that a vine is like an Anki heater. No, Anki is actually amazing. I believe Anki is really good because I mean, I don't use it, but I've evaluated it and I feel like it's very beneficial for many people.

But just make sure you're not just memorizing. Make sure you understand what's going on. Make sure that, oh, this thing that I learned, what's the context behind it? What all the ways it could be described? So, you know, option C doesn't make any sense here. This person does their prank ready cancer. No John, this no LFT, Billy Rubin labs, whatever. No, no weight loss. UTI, come on. Ditoring discretion. That's why glucose is skyrocketing. No, our son is not taking care of her. That's why glucose is skyrocketing. Looks like we were doing pretty well before our sun came. Maybe our son does kind of need to leave the home. Okay. Any. All right. Question 79. A 15-year-old boy is brought to the office two hours after he had a walk with weakness of the right side of his face. He has a two-week history of intermittent headache sensitivity to light and mild to moderate neck pain. He has no history of serocioness. His only medication is the seraminophenaz needed. He lives in New Jersey and has not traveled outside of the state during the past six months. Temperature is 37.4 degrees Celsius. That's 99.3 degrees Fahrenheit. Post-easonry per million in regular blood pressure is 108 over 70 millimeters of mercury. Flection of the neck elicits moderate pain or resistance. So like look at rigidity. The again, they could have just ready no. rigidity boy see. They described it. The right eyelids do not close completely. Oculum movements are normal. There's no evidence of tools.

The right side of the forehead does not wrinkle when the vision looks up. There is severe weakness of the right corner of his mouth of the mouth. There are no abnormalities on the left of the left side of the face. Mosul strength in the jaw, tongue and palate is normal and symmetric. There's no dysathria. Mosul strength is 5 out of 5 in all extremities. Coordination and sensation of intact gait is normal. A number of punctures performed and opening pressure is 180 millimeters of water. CSF analysis results are shown. So glucose is 60 milligrams per decilator. Total protein is 52 milligrams per decilator. White cell count is 85 per millimeter cubed. Segmented neutral fills is 30 percent. Limful sites is 70 percent. Red cells is 1 per millimeter cubed. Good shot of volume is the most appropriate next step in diagnosis. So option A says measurement of serum and retention, converting enzyme activity. Option B says measurement of serum line that's burriolabocadoufri antibody concentration. Option C says polymerizcin reaction test for cytomegalovirus. Option D says serum and tiniuclear antibody assay. Option E says serum percent electrophoresis. Okay, so this person seems to have meningitis actually. They have no corrigidity. And then we can see like one side of the face is super weak. That's Bell's palsy. Well, what's the answer? What's the thing we know that? Ooh, Bell's palsy, Bell's palsy. Bell's palsy is really going to be a sort of herpes on the exams or with Lyme disease.

Right? And remember, Lyme disease can cause like, almost like an aceptic meningitis. I like that answer a lot for Lyme disease. Right? Burriolabocadoufri is a spirochete. So I think I'm going to go with option B here. This person I think has Lyme disease. This is not CMV. CMV is really going to be in the middle compromised on a newborn that has like microcephaly paraben, traficial calcifications. That's not what's going on here. And CMV can also be in people that have had transplants as well. ANA, that's Lopus. What I'm going to do that is SPEP. That's multiple myeloma. This person is too young for multiple myeloma. Serum asactivity. That's going to be in stroke oedosis. Nah, I'm going to go with option B here. I remember this person is probably going to be getting IV-Syftriaxal. Whenever you have Lyme disease that's torching your brain or your heart, you're going to reach out for, you know, reach out for, Syftriaxal. All right, let's do one more question and then we'll call it. So question 80, a two year old girl is brought to the emergency department because of loud breathing, harsh cough and a horse cry. Since she woke one hour ago, oh, her parents state that yesterday she had a runny nose. All right, medical history is only remarkable and it receives no medication. Temperature is 30.5 degrees Celsius. That's 101.3 degrees Fahrenheit. Both is 120 per minute. Respirations are 32 per minute and blood pressure is 105 over 65 millimeters of mercury.

The amortaric supersternal and sub-costal retractions. Inspiratory strider is heard at rest. We should have learned the most operating initial pharmacotherapy. Option A says intravenous dexamethazone. Option B says nebulized abitural. Option C says nebulized blood esonide. Option D says nebulized abinnefre. Option E says oral abitural. Option F says oral pregnant zone. Option G says subcutaneous abinnefre. So those each out half. Let's see, right? So so young kid loud breathing harsh cough, horse cry. NBM is how could you have made our life simpler? You could have said things like this person has a barking seal like cough. A brassy cough has strider. Remember, an C strider tells you he's over early. They tell us the strider when he's so seen a barking or a brassy like cough, they say, loud breathing harsh cough and a horse cry. That's literally them telling us this person has a barking brassy cough. Again, both words are extinct or they are rapidly becoming extinct from the USM at least. Right? And this person has strider. This is an upper ear we think. So what is this? This is going to be a group. This person has a group. Remember a group. We also we can call it laryngo tricubron tightis on your exams. Okay? Laryngo tricubron tightis. Typically, you don't have to do any formal workup, but if you've got like a chest x-ray or whatever, you'll see that's deep all side. Kind of looks like a wine bottle in the upper ear. Okay, whenever you see an upper ear we problem.

You're going to see strider. Lower ear we problem. You're going to see whiz it. This is an upper ear we problem. And does this person and honestly the management of a group typically is supportive care. But if they have severe symptoms, let's say they have like really nasty fever, really struggling to breathe, then there's pretty much two things you need to do for them. You need to put a penifering through their earway. So you've got to give them like a penifering through the earway to open up that earway because that that closed out glottis is not good. Right? So you kind of want to open that earway. Although it's more of a subglotic problem, it's a subglotic problem. So you want to pay attention to that word subglotic. I want to open up the earway. Give something that's like a beta twaggedist. That's very powerful or rapid acting. And in typically they're going to get steroids. You can give IV steroids, but most people do well with oral steroids. Most people will do a oral steroids. But again, this person does not really seem to be in a situation to be getting oral steroids because it looks like this person's earway is closing. So you need to do something and do something quick. Okay. And steroids take a while to kick it and start working. Right? So again, we need to give that out. It's pretty severe symptoms. If we don't do anything this, this child is going to die. Basically, it's what's going to happen. So we need to open up that earway quick. Right?

Open up that earway quick. And please, I know you may be like divine. Tell me a beta twaggedist like we do for asthma or COPD exacerbations. No. Those are not very great in people that have a group. So don't do that. That's not going to be very, very helpful. Okay. So let's work through these answers. I think this is actually a pretty useful exercise to know why the answer is right. Why the right answer is right and all the other answers are wrong. Option A says IV Dixamethosol. Again, that's something we'll probably, that's something we're going to do for this person because this person's earway is closing. We're going to do that. But it's not the right first step. We need to open up this person's earway immediately. So they don't die. This person has a high fever. They're super tachycardic. They're super tachypnic. Right? We see all these subcostal, superstinal retractions. We hear strider. We need to act immediately. IV steroids going to take a while to kick in. So that's wrong. Option B says, Nebulizer, beta twaggedness pretty much have no role in the management of a group. Option C says, Nebulizer, but you're death so night. Again, that's inheld steroids. Again, it doesn't really have much of any role in the mind. You could use it in some circumstances. But again, this person seems from the pretty severe. Right? And most times in group, oral steroids are preferred as first line in terms of steroid over IV steroid.

IV steroid is something used when the person is super unstable. They can't swallow anything or whatever. Right? This person is super unstable. So even oral steroids were probably not going to do that. We're going to try IV steroids. Right? So they provide steroids. It's not really going to do much. Option D says, Nebulizer, peniferin. I like that answer a lot. I'm going to go with option D here. But let's look at the others. Option E says oral or beta wrong. Again, before he kicks in, the person may be dead. You don't want that. Option F says oral prednisone. Again, this person's earway is really open. They have strider. What I'm going to do that option. She says subcutaneous epinephrine. Now IV epinephrine. IV epinephrine is like a kind of cardiac epinephrine. That's like ECLS protocol right there. This is not ECLS. Right? IV epinephrine. You better believe that that's kind of a lot of epinephrine. What do I guess the denouncing for venus, this is subcutaneous. So give it onto the skin. Not really. Not really. Not really. Right? So this person needs to put epinephrine down her earway. That's one. And then number two, you should give this person IV steroids. If the person was not so, they don't have such a ten wall scores. They don't have such severe symptoms. You don't have to do that. Usually we prefer oral steroids. So if a person has like, again, so let me maybe address the vitamin of the group. Typically, supportive care. So what if care? One of the person is unstable.

The person has severe disease. Then that person is going to be getting oral steroids. Right? But if they're like super unstable like this person, you're going to give IV steroids. Right? IV steroids are going to bubble up and everything down their earway. That's how you manage a group. Okay? That's how you manage a group. But again, I remember another name for a group is Larry Engel, Tricu, Bronchitis. So let's go ahead and stop here. Again, I will throw these review courses for the exams. If you're interested, shoot me an email, give some more information and also meet a separate podcast talking about that. Then I have these podcasts on Apple, Google and Spotify, Apple You Tube channel where I post the videos I make. I offer one to you all the USMLE, all the complex exams, medical exams, shelf exams, and I help with applications, ERAS applications, all those things. Something I've done with tons of people over the years and I've had a very, very good truck record with that. Then I have another website called Dividing Intervention, Life Lessons.com. Dividing Intervention Lessons.com. Pretty much every week on Friday Sundays, I posted a 10 minute podcast. Typically, I use a biblical perspective, many of you know I'm a Christian. It's a biblical perspective to address a life lesson. This actually an Apple podcast associated with that called the Dividing Intervention Life Lessons Podcast.

Again, many people have listened to it to those podcasts that we have about 260 of their about. Many people have found it to be extremely helpful. So check that out. Check that out. Again, the website there is Dividing Intervention Life Lessons.com. So thank you for listening to me today. I'll see you in a episode 530. God bless you. Have an awesome weekend and bye for now. Thank you.

Kaposi Sarcoma (associated with HHV8/KSHV).

Elevated Follicle-Stimulating Hormone (FSH) concentration.

Remove them from patient care immediately and report the incident to a senior administrator/supervisor.

Barking, brassy cough, stridor, and upper airway obstruction.

Elder neglect/Elder abuse (requiring reporting to Adult Protective Services).

Pleocytosis (elevated white blood cell count) with a lymphocytic predominance.

Diffuse, painless rash; often purple/violaceous plaques.

The ovaries are failing (declining estrogen production), removing negative feedback on the pituitary gland, causing FSH to rise.

Providing immediate airway support/bronchodilation (e.g., nebulized epinephrine) and systemic steroids (IV or oral).

Surgical debridement of necrotic tissue (deep fascia/muscle).

Dry mucous membranes and dry skin; missed appointments or poor self-care.

Measurement of serum anti-Borrelia antibodies (Lyme titer).

Diffuse, painless rash; often purple/violaceous plaques.

The ovaries are failing (declining estrogen production), removing negative feedback on the pituitary gland, causing FSH to rise.

Providing immediate airway support/bronchodilation (e.g., nebulized epinephrine) and systemic steroids (IV or oral).

Surgical debridement of necrotic tissue (deep fascia/muscle).

Dry mucous membranes and dry skin; missed appointments or poor self-care.

Measurement of serum anti-Borrelia antibodies (Lyme titer).