DIP Episode 521 - 2024 USMLE Step 2CK Free 120 Discussion Part 4

Welcome to episode 521 of the Divine Intervention Podcasts. In today's podcast, I'm going to be continuing the series on the free one twenty first step two. The one that's presently right now in 2024 on the USM Lis website. We've done the first twenty questions, so this is going to be part four. We're going to start off from question twenty one. Alright, let's get right into it. A thirty six year old woman, gravita two, power one at thirty nine weeks gestation, is admitted to the hospital in labor. She reports painful contractions that occur every two to three minutes and last sixty seconds. She has not had vaginal bleeding. She has no history of serious illness and pregnancy has been uncomplicated. Temperatures thirty seven degrees Celsius, that's ninety eight point six degrees Fahrenheit. Paul sees 84 permanent and regular and blood pressure is a hundred over seventy millimeters of mercury. The abdomen is non tender and consistent in size with a thirty nine week gestation. External fetal monitoring shows a heart rate of a hundred and fifty per minute with moderate variability. Several spontaneous accelerations and no decelerations. An external to cometer shows regular uterine contractions every two to three minutes. The cervix is six centimeters diluted and a hundred percent effaced. The vertex is at zero station. Autosanography shows the fetus in a cephalic presentation. The membranes are artificially ruptured, yielding copious clear fluid.

Thirty minutes later, the cervix is nine centimeters diluted and a hundred percent effaced. The vertex is at plus one station. The fetal heart rate tracing is shown. Which of the following is the most appropriate next step in management? Option A says, advising the patient to begin pushing. Option B says, amnion infusion. Option C says, expectant management. Option D says, forseps assisted vaginal delivery. And option E says immediate cesarean delivery. And of course, they put this fetal heart rate, whatever thingy at the top. To be honest with you, I don't care about this picture. Let me just ask you a question. Let's just be real here. Look at this question, twenty one, I just read. Anything seem wrong here. Literally, does anything seem wrong here? Just ask yourself. Anything wrong with mom? Anything wrong with baby? No, there's nothing wrong. Baby seems to be doing pretty well. Mommy seems to be doing pretty well. So you know what? I'm going to pick the most benign answer possible. I'm going to go to option C here. Again, that's the thing. Many people really stress out a lot about images and audio and video that they put on the exams. Most times if you just read the question carefully, you're good to go. I'm not even going to bother analyzing this fetal heart rate tracing. Like I have all I need from the cue stem itself, which is the case a lot of the time. Option E says advising the patient to begin pushing. What I'm going to do that?

Pushing is something you do when the baby is about to come out. When the baby is about to come out. A woman does not push for all of labor. That's pretty ridiculous. If you've done any kind of woobie guy rotation, see that? It's when the woman is in like the second stage of labor. The baby is about to come out and everything. The baby is like a plus two or whatever. Don't even worry about the details here. But basically like you know that while this baby is about to come out, the woman at least has services completely faced, dilated and everything. And we see that while the fetal head is about to come out, then you tell her push, push, push, push. Usually pushing is done at the very till end of the labor process. Option E is going to be wrong. Option B says because this woman is still in the active phase of stage 1 of labor. Her cervix is 9 centimeters dilated. So you really shouldn't be pushing at that time. At least for my even just personal observations. And then a new infusion is wrong. Usually we're going to do this when we have concerns about oligone or anhydrine use. We don't see that. Or when there are variable decelerations from a vehicle called compression. We don't see that here. So we're not going to go with any of those. And then option D says 4 steps assisted. No, again, you're not going to be doing 4 steps in stage 1. Just no. Option E says immediately sees her in delivery. Everything is fine. Why you want to start cutting this woman up?

No, we're not going to be cutting this woman up. That's wrong. Okay, so I'm going to go to question 22. So a 27 year old woman comes to the office because of a three week history of nasal concession, cough, productive of spuro, intramethan moderate headache, and intramethan moderate pain over her cheeks. She has had similar symptoms three to four times a year, during the past five years. The symptoms last two to eight weeks and generally results spontaneously. She has had two episodes of bacterial pneumonia during the past five years. Both episodes resolved with antibiotic therapy. Her only coroner medication is a sedaminophilus needed for headache. Vital signs are within normal limits. Examination shows no abnormalities. Serum study results should decrease IgA, IgG, and IgM concentrations. Antibiotic therapy is begun and the patient's condition improves. Which of the following is most likely to decrease the likelihood of recurrent infection in this patient? Option A says daily inhaled to bromizing therapy. Option B says daily inhaled, daily intraniso glucocorticoid therapy. Option C says daily trimethyroprimsol from a thuxusol therapy. Option D says intraniso influenza virus vaccine administration. Option E says monthly immune globulin replacement therapy. So first thing we got to ask ourselves, what does this woman have? We see a person that they seem to be having all these infections. And he seems to have started like I guess in her 20s or something like that.

I noticed that some of my immunoglobulins are low. Or does that tell you that CVID, common variable immunodeficiency? That's a very classic presentation. It's pretty much an immunodeficiency disease. You see lots of bacterial infections. But it won't start early in life like we see for almost every immunodeficiency disease. They're starting a person's teenage years or just later in life. So this is CVID. And so for CVID, what are we going to be doing? Let's look at option A. Option E because this will keep getting infections, infections, infections. So you want to figure out a way of making them not getting infections. So option A says dealing healed to bromizing therapy. That's going to be wrong. I would only pick that answer for a person that has cystic fibrosis, especially because getting that regular to bromizing is actually pretty helpful in CF patients to reduce the risk of infection, especially like gram negative organisms. Remember, when people have cystic fibrosis overage 20, the most common cause of pneumonia in those folks is pseudomonas aerogenosis. So for those people getting dealing healed to bromizing, it's not a bad idea. Option B says dealing Chinese or glucocortico therapy. Again, we're going to be doing this for people that have asthma, asthma, asthma, asthma is the second wrong on the lottery money. And asthma, we're not going to be doing that. This person doesn't have asthma. Option C says daily TMP SMX therapy, backtrack.

Again, this person does not appear to have HIV. HIV is going to affect your CV or positive T cells. It's not necessarily going to be clobbering your immunoglobulin count. That's for people that have CV falls on the 200, right? For people that have HIV. That's not what's going on here. So we're going to get rid of that answer. Option D says intranasal influenza virus vaccine administration. I'm going to tell you this right now. This is one of those answers that is almost like consulting the ethics committee on your exams. The intranasal, there's just almost no reason on the USM at least that I can think of conceivably. Am I saying that wow, this can never happen. It can't happen. But I can just not think from my testic in experience of any conceivable reason why that would be the right answer to a question. Like, in fact, many people know that if you have HIV, you should not take a live attended vaccine. If your CD4 count is on the 200. And the intranasal influenza vaccine is a live attended vaccine. But to be honest with you, that rule completely won't break down when you're dealing with an intranasal influenza vaccine. Even if your CD4 count is over 200, you really should not be giving the intranasal influenza vaccine to force the half HIV. That's not smart. Option E, which obviously has to be the right answer, says monthly in immunoglobulin replacement therapy. So monthly IVIG, that's going to be correct. That's going to be correct. Well, why is that?

Because the thing is these people have antibody deficiencies. So by giving them IVIG, you're pretty much giving them passive immunity back. That's going to reduce the risk of having infections. That's actually the primary treatment of CVID. All right. Question 23 says, a 37-year-old man comes to the office because of a two-year history of malto-monoried fatigue. The fatigue waxes and wings without relation to activity. He has no history of serocérenes and takes no medications. He drinks three glasses of whiskey weekly. That's not too bad. He has had two lifetime female sexual partners. He uses condoms consistently. He immigrated to the United States from China 15 years ago. Vital signs are within normal limits. Examination discloses no abnormalities. Results of laboratory studies are shown. Serum creatinine is fine. You see STLT, not a little bit elevated, but I don't care too much about those. His headbeats are physician is positive. Oh, that's no good. That's no good. So that means he has a B. His anti-heb CV is negative. His anti-heb surface is negative. His IgG anti-heb core is positive. So this guy has a B. He has chronic heb B. He does not have heb C. Look at the rest of his laps. His blood is fine. I'm not too concerned about those. So without treatment of his current condition, this patient is most likely to develop which of the following. So option E says ameloidosis. Option B says essential mixed cryovolinemia. Option C says hepedocelolocarcinoma.

Option D says membrane proliferative glomerulonephritis. MPGN. Option E says pulietaritis nodosa. Option F says chugrin syndrome. Chugrin syndrome. So which one should we pick? Again, whenever you see these questions, oh, without treatment of XYZ, what is this person most likely to develop? Again, many times these are things where new risk factors is helpful. That's why you can always recommend on my website, listen to episodes 37, 97 and 184. Those are my, I think 239. So 37, 97, 184, 239. Those are my risk factors podcast. You got to listen to those before you take literally any US Emily exam. Even if you take in step one step two or step three. Now for me, I just ask myself which one is the simple thing here? I mean, this person has chronic heb B. One of the reasons we're afraid of chronic heb B is that it can cause cirrhosis, cause a parallel cellar, of course, you know, my brain. So I'm just going to go with that as an answer. That's the thing that just makes the most sense. I'm going to comment on some of these other answer choices, right? So like I'm a loydoces. I'm a loydoces, you can get it when you have chronic inflammation, right? But we typically see people that have chronic inflammation from like rheumatoid arthritis or people that have like any two or two B with metronolarythioc cancer or people that have senal amyloidosis or people that have multiple myeloma. Those are like the, you know, things that are common with amyloidosis. We don't see that.

I'm not going to pick that essential makes cryogluboliniemia. Again, we don't tend to see this have any kind of stronger association with heb B. So I'm not going to pick that option. See, I think that's the answer. I'm going to go with that one option. This is MPGN. So MPGN don't get me wrong. Does it have a heb B association? It does. But the thing is how common is MPGN. MPGN is not very common. And honestly, MPGN has a much stronger association with heb C than heb B. So honestly, here's what I will say. You will actually think of MPGN as being more of a heb C than heb B. So I'm not going to pick that option either. Option E says poleritis nodosa. So PN can be associated with heb B, absolutely. But again, which one just seems to be more reasonable. It's going to be about those that look like synoma. It's just that's like the big concern. You hear about all the time with heb B. Chronic heb B. Ooh, we got a treat so you don't get HCC for that reason. And then I'll try and F search, set, program, syndrome. I'm not going to worry about that with heb B. All right. So let's go to question 24. So he says that a 10 year old boy is brought to the office because of moderate right knee pain. He's in no distress. Medical history is remarkable for him. Ophelia A. Examination of the right knee shows warmth and swelling. There's pain with flexion. Range of motion is limited by pain and swelling, which of the following is the most appropriate or therapy for the patient. Right? So.

Option A says ADH that's visopressin. Option B says factor. E to concentrate. Option C says factor. Nine. Concentrate. Option D says ferrous sulfate. Option A says fresh ferrous plasma. So. This person clearly has a morphelia A, right? And you know, it's a boy. Makes sense because he has an excessive inheritance. And he's a deficiency of what is the deficiency of factor. E factor. So. If you're deficient in factor. E probably makes sense to give you factor. E back. So I'm going to go to option B as the answer here. Let's look at the other answers. EDH, visopressin. That'll be wrong, right? Again, remember, we're going to use EDH. Visopressin is a presser actually. That's one is is used like a second or third line presser and an accepted shock. Remember, no, I've been referring to his first line in septic shock. But another useful visopressin is if a person has from wheel-brand disease, right? If you want to increase the release of from wheel-brand factor from Wibble Palati buddies, not a bad idea to use visopressin. You know, this person is an EDH analog. All right. And then option C says factor 9 concentrate. That'd be what that's what you'll be doing if a person had hemophilia B. Hemophilia B is a factor 9 deficiency, right? Remember, like vitamin B9, think of it that way. B9, you know, the word B9. So this person has hemophilia A. So factor 9 concentrate is not going to be of more help. Option D says ferrous sulfate.

You're going to give it to a person that has iron deficiency. That's wrong. Option E says FFP. You know, FFP was the way we used to reverse warframe back in the day. We don't do that anymore. Remember, these days we're going to reverse warframe with the four factor per thrombin complexa concentrate. So that's just going to be wrong there. All right. Now, question 25 says 72 year old man comes to the clinic because of a three week history of visual changes in his right eye. During this period, he has noticed that the lines of his daily crossword puzzle look curved. Curved lines in an old person is a classic vignette. And the blinding is apartment up here, wavy. Wavy things in an old person is a classic vignette. He wears magnifying lenses for reading. He has not had pain in his eye or photophobia. He has no history of trauma to the area. This is a gimmick question. On examination, visual acuity is 20 over 200 in the right eye. 20 over 100 in the left eye. Both pupils are around and reactive to light. Partition of both globes through closed eyelids shows no abnormalities. There's no red reflects my louder. The lens is a bit clear. Which of the following is the most likely diagnosis? This is molecular degeneration. Easy. Wavy curved lines in an old person equals molecular degeneration to proven otherwise. So the answer is D. Let's look at the other answers. Option A says cataracts that's wrong. People that have cataracts, they're going to be struggling to see at night.

That's the critical thing. Lens of classification. It's usually going to be from people that have diabetes. Option B says central, right now, louder occlusion. That's going to be a sodding presentation. And those people you're going to notice that they'll have like fondle of power is like a sodding painless vision loss. That doesn't match what's in this question. Close angle glaucoma. That's a cute angle glaucoma. That's also acute. You have like a fixed red very tender pupil. Like doesn't move very much like a rock heart pupil. That's not what's going on here. Option E says temporal arthritis. Usually it's going to be in a woman in her 50s. Although it can also be an older or younger FYI. But there'll be a woman, pain with swallowing, right? So, jaw cladication, pain by the side of her head. They can have vision problems. Remember, for those people, their ESR CRP is usually pretty high. I want to give them IV steroids. And you still need to do a temporal artery, perhaps even after you study the IV steroids. So it's not a low. So that's pretty easy. That's my community generation. Okay, question 26. Ooh, okay. It's nasty pictures, man. Okay, so 20 year old man comes to the clinic because of a 2-day history of a red severely painful lesion on his left forearm. He says that he felt stinging pain as he put his shirt on in the dark two days ago. Oh no. The pain was so severe, he immediately threw down the shirt and saw a spider peronning across the floor.

Okay, seems like his body has had contact with a spider. Here, it turned yesterday from a one week trip to the mountains in the Southeast and the United States. Of course, they're going to throw in these USM Ls. Of course, they're not going to make it straightforward. This person is beating by a spider, but hey, let's sow some doubts in the minds of the med students reading this question. So you know what? Let's talk about his amazing one week trip to the mountains in the Southeast and the United States. Who cares? He has type 1 diabetes, a military with Lycino-Prile insulin. He does not drink alcoholic beverages. He's sexually active with two male partners and uses condoms inconsistently. Right? Again, let's throw that in to make these people think of HIV. HIV. Ah, vital signs that within normal limits. A photograph of the legion is shown. No other abnormalities are noted. Which of the following physical findings is most likely to appear during the next 24 hours? See, folks, this person was beating by a spider. Okay? This person was beating by a spider. This person was beating by a spider. But again, the US immediately is doing what the US immediately is not supposed to do. Right? You shouldn't just write a question where people just read it and straight off the bat, they know exactly what's going on. Right? You've got to throw in one or two sentences here or there to kind of mess around with people's minds. Well, this person was beating by a spider. Okay?

And most spider bites are not horrible. I mean, they are. It's not awesome to be beating by a spider, but see, the end of the world. Nah. So let's look at these answers. It's going to make a lot of sense. So option E says, ears of S-car at the center of the one site. Okay? Well, let's keep that. Gangrene of the distal aspect of the left extremity. No. Spiders are not that horrible. Don't get me wrong. Most spiders are venomous, but most spider bites don't require almost no medical therapy. Just clean the ear of the one. The person is fine. You should just fix the ear of the one. That's it. So no. Gangrene of the extremity. Come on. That's ridiculous. No. What I'm going to be then as an answer. Option C says generalize or extrimmody adema. No. Come on. Like, they are just some answers on the exams. Even if you don't know anything, you're just like, come on. Man. No. Right? No. This is wrong. Option D says, poppable poop or recollections across the trunk are not for extremities. No. That's something you really find in heal or chandelier and poop. You know, poop or poop below the bottom. I guess let me know, see, across the trunk are not for extremities. For HS Bs, you really below the buttocks. But again, no. Option E says rapidly spray an earthema around the one side. So we're thinking of like, neck, fasch. No. Option F says tender, erythematos streaks up to the epitrochlear nodes. You have this problem in the arm. And then epitrochlear around your face. Come on. No.

Honestly, I'm going to go with option A. This is just a spider bite, folks. Again, I hope you're kind of learning something from my thought processes. This is a spider bite. Spider bites. This sounds scary. Right? Yeah, you may be able to see some bullet from this picture. So it means that, you know, probably some tissue is going to die. But usually you're just going to have localized symptoms. It's not going to be anything beyond that. I'm not going to start stressing out anything about anything beyond option A. Option E is the answer. So let me maybe see something here. So again, you kind of notice in with these questions, when you start applying too much brain power, you start getting into trouble, right? Just analyze things for what they are in front of you. That's the first thing. And number two, if you notice from me going through these questions. As I'm reading the question, I kind of have like a story of heuristic in my mind. The thing is, many people just memorize a bunch of associations, but they don't learn the stories behind pathologies. And I'm going to encourage you to try to learn the stories. That's what's going to be super useful for your exams. In fact, I will just tell you this that many times you've heard this from many of my podcasts. When I introduce a concept, I almost always will introduce it from a story perspective. Like what's the story? Right? Because many times if you can identify the story, that makes your life a lot easier on the exam.

You can pretty much pick up very rapidly on what you're trying to test. I mean, this is something I do with my podcasts or my review courses, right? And even in my own personal learning, like try to learn the story behind something. Okay, let's go to question 27. So a 37 year old man comes to the clinic for a health maintenance examination prior to employment. He feels well. He has no history of serocelness and takes no medications. One year ago, his blood pressure was 136 over 85 millimeters of mercury. He has 173 centimeters, so 5 foot, 8 inches tall, and weighs 100 kilograms, that's 220 pounds. His BMI is 33 kilograms per meter squared. Today, his blood pressure is 138 over 87 millimeters of mercury. Examination shows no abnormalities. In addition to recommending weight loss, which of the following is the most appropriate next step to prevent cardiovascular mobility in this patient? All right, let's look at these options. Option A says, is inhibitor therapy. Option B says calcium supplementation. Option C says, dash diet. Option D says, fish oil supplementation. That's one of those also the ethics committee like answers fish oil. Don't do that on your test. Option E says, a phyasi diuretic therapy. Okay, so let's see what's going on here. So this guy's got hypertension. I mean, like, although to be honest with you, can we really see this guy has hypertension? No, no, you can't. Usually you're going to diagnose hypertension with two or more blood pressure measurements.

And typically, you want to do that over a few days. Over a few what? Days. Over a few what? Days. Okay. We have two blood pressures here, but one was measured a year ago, and then we have one today. So can we make the formal diagnosis of hypertension in this person? No. So should we be giving this person an anti-hypertensive right now? No, we can't. Okay, so that pretty much crosses off option A and E. And honestly, if you think about it, option E is a good anti-hypertensive. He's a good anti-hypertensive, but how do we know which one to pick? How? How do we know which one to pick? I don't know. I don't know. So I'm not going to be getting any of those. Cousins of the presentation is not going to be very helpful for hypertension. Fish oil again. If you pick that answer on your exams, you're kind of guarantee you'll get it wrong. Option C is the dash diet. That's going to be correct, right? That's going to be correct. Remember, the dash diet is very effective at lower end blood pressure. Remember, the most important, the most effective lifestyle intervention for lower end blood pressure is weight loss. Weight loss is number one. Number two is actually the dash diet. The dash literally stands for dietary approaches to stop hypertension. It's a diet that's pretty rich in fruits and vegetables, a lot of nuts. It can also take meat, fish, but you know, it kind of emphasizes taking too much right meat and stuff like that. So I'm going to go with option C here.

That's pretty straightforward. All right. Remember, usually blood, so let me put it this way. In terms of management of hypertension, you typically stop managing hypertension when a person's system is going to be. This systolic blood pressure is over 140 or the dashed to the blood pressure is over 90. That's when you usually start managing hypertension. Now, so if you maybe like define how about the people that have systolic between 130 and 140? Can we money the hypertension? Usually for those people, you're going to recommend mostly like non-pharmacological therapy, more like lifestyle changes like weight loss, dash diet, use your sun consumption, stuff like that, exercise, you know, stop smoking and all those things. The only people that have blood pressures systolic between 130 and 140, that we say, oh, okay, let's go ahead and put you on an anti-hypertensive. Or people that have like some organic disease related to their hypertension. So let's say for example, they have hypertension and they have like chronic kidney disease. Like the kidneys are beginning to feel or they have hypertension and they have heart failure or they have hypertension and they have like just some ortho-organic medical problem. That's kind of worrisome. They need those circumstances. Yeah, it's fine too. I recommend the lifestyle changes first, but also put them on an anti-hypertensive. This percentage does not need those criteria. So we're going to be going with a dashed diet here.

So question 28 says, 39 year old man comes to the office because of a six week history of malphatic and increased thirst and urination. During this time, he has also had a 15 pound weight loss, despite no change in appetite. He's otherwise asymptomatic. He has no history of serocelness and takes no medications. He has 180 centimeters, so 5 foot 11 inches tall and weighs 61 kilograms. That's 135 pounds. It's being weighs 19. That's weird. Okay, kilograms per meter squared. Temperature is 37 degrees Celsius. That's 98.6 degrees Fahrenheit. Palsies 80 per minute, transpersions at 18 per minute. Blood pressure is 18 over 70 millimeters of mercury. Examination shows no abnormalities. Results of lab studies are short. Serum sodium is 135. That's fine. Potassium is 4.2. That's fine. chloride is 100. I'm not going to get out of bed for that. You're in nitrogen 25. I'm not too concerned about that. Again, I'm showing glucose 570 to make per deciliter. That's really bad. We should probably concern ourselves with that. I think we're pretty more known of that. Knows this from those. He's A1c is 10.7%. That's pretty high. In addition to recommending dietary modification, which of the following is the most appropriate next step in management? This person has diabetes. Which type of type 2? I'm going to go with type 1. I mean, think about it. This person's BMI is... Is this person that's really under weight? No, this person is normal weight. This is not a story of type 2 diabetes.

Type 2 diabetes is going to be the very unhealthy person. Vary obese. If you look older than this, although diabetes become a problem in younger people in this country, with the diet in this country. But this is type 1 diabetes. This is type 1 diabetes. So type 1 diabetes is going to be money for the insulin. Insulin is the only treatment for type 1 diabetes. So that's just going to be B. I'm not going to be going with option A. That's an oral hypoglycemic. That's a softener area. Option C. That's made for me. That's a big one-eyed option. D says piochlearlydazone. Remember, don't give those to people to have heart failure. Option E says Cedar glyptin. Cedar glyptin is a DPP4 inhibitor. Again, piochlearlydazone is a p-par gamma. Yeah, it's a p-par gamma agonist. That forming is a big one-eyed. Gliburitis or softener area. It blocks that ATP-dependent potassium channel. Now we find another pancreatic beta-ILH itself to make your release more insulin. Again, this person has got type 1 diabetes. None of those oral hypoglycemic are going to be indicated in this person. So we're going to move on from that. So the answer is it's going to be B. Question 29 says two days after admission to the hospital for treatment of a fractured femur. Closed head injury, sustained in a motor vehicle collision. An ideal girl has a brief generalized tonic on exesia. C.T. is kind of the head on admission. This closed normalities. She has no history of serocelitis.

Oral acetylaminophen was initiated for pain. The patient went open reduction and internal fixation of the fracture. She receives new routine medications today. She appears drowsy. What are the response to questions appropriately? She is at the 55th percentile. For height, weight and BMI. Temperature is 36.8 degrees Celsius. That's 90.2 degrees Fahrenheit. Post is 92 per minute. Respirations are 24 per minute. Blood pressure is 106 over 64 millimeters of mercury. Postal symmetry on the room air shows an auto saturation of 95%. Popules are equal and reactive to light on accommodation. Oculomovements are full. Muscles strength is 5 out of 5 and deep tendon reflexes are normal. Results of serum studies are shown. Sodium is 122. Oh, that's super low. Case 3.8. Not concerned about that. That's normal. Already is 94. We don't know the lower side, but I'm not really concerned about that. Bicarb 24. That's fine. Glucose of 80. That's fine. Caution of 8.8. It's not great, but I'm not too worried about that. Sodium is my big concern. We should find the most appropriate next step in management. So option A says administer a bonus of I.V. 3% ceiling. That's hyperatonic ceiling. Option B says administer subcutaneous visopressin. Option C says initiate phosphenitorium therapy. Option D says initiate therapy with 0.9% ceiling. At 1.5 times the maintenance requirements. Option E says ordering EEG. Option F says ordering MRI over the brain. This person has symptomatic hyponychemia.

You have incisors. Symptomatic hyponychemia. That is one of the few situations on your exams where hyperatonic ceiling is the right call. I've got a pick up from A here. Let's look at the other answers. Option B, visopressin. Again, given this person visopressin is kind of a horrible idea actually. The person may actually die from that therapy because visopressin is an ADHD analog. What does anti-diarrhetic hormone do? Mix your reabsorb more water from your urine. If your reabsorb more water from the person's urine, you're going to suppress the sodium even more. That's not a wise idea. Option C says initiate phosphenitorium therapy. So this is something we use in building a half seizures. Remember, if people have seizures, typically we're going to start off with IV lorazapam or diazapam or something like that, like an IV benzo. But if we try an IV benzo, like a few courses and the person is still having seizures, then in that case, you're going to go for IV phosphenitoring as the next wrong on the ladder. But we're going to be doing that here because this person's seizure, we know that it's from a hyponitriamine. And it does not seem like she's actually having a seizure now. She had a brief seizure, but it looks like the seizure was kind of stopped. So maybe we shouldn't be doing that. Option D says initiate therapy was 0.9% salient at 1.5 times the maintenance requirements. No, this person is seasoning a half-hyponitriamine. That's not a good idea.

Option E and F, those two things deep-time, the patient may have died before you get through, you're done with those tests. It doesn't seem like a very smart idea at this time. So the answer is going to be option A. Okay, let's do one more question. So question 30 says 43-year-old man comes to the office because of a two-week history of fatigue and mild pain in his right armpit. Okay. He has no hat fever, weight loss, medical history is only remarkable for type 2 diabetes. Sorry, it's remarkable. So he does have type 2 diabetes and hypercholesterolemia medications I'm informing, same as starting an aspirin. He's a social worker and frequently visits clients in homeless shelters. He lives alone with two dogs and a cat and has one male sexual partner. Vido signs are within normal limits here, as well. Examination of the right-up extremity shows an irithematos axilla with a 4 centimeter mobile tender non-flop-trans axillary lymph node and a tender 1 centimeter epitroclier lymph node. Abdominal examination shows more epatoclinomically, which of the following is the most likely diagnosis. Option E says casoman disease. Option B says cat scratch disease. Option C says hydrodynamitis, superativa. Option D says T cell lymphoma. Option E says TB. Okay, so let's look at this question. So this person, this person we're told, you know, it's been going over two weeks. Feels fatigued, has pain in his armpit. And then we're told that he has diabetes and hypercholesterolemia.

And he works with people in homeless shelters. I know why they put that there, the TB, right? And then it lives with two dogs on a cat. Okay, so the cat, cat scratch disease. One meal sexual partner. Let's make them think of HIV or some relation to it. What his vital signs are completely fine. It appears well. But now look at the key thing. This person has tender lymphodonopathy in his armpit and an epitroclier node. I don't know what's the deal with this free 120 and these are epitroclier nodes. But anyhow, well, the lymphodonopathy is both of them are tender and on the same side. Okay, and this person does have a pyrospinomychle, right? So let's look at these answer choices. Let's look at option E. Option E says TB. TB again, the person is going to be coughing, productive cough. You'll probably give us something about his labs. People that have TB, they'll be very symptomatic, you know, fever's, night's, weight loss. They'll give us chest X-ray findings. They just don't give us any of those things. This is not TB. That's off. Option D says T cell lymphoma. T cell lymphomas, I used a T in T cell lymphoma to help me remember T in T majors. You should just go to shop as a medias, tynomas in a T major. And anterior medias, tynomas in a T major. We don't see that here, that's wrong. Option C says hydradonitis superativa. When people have hydradonitis superativa, we really find it in people that are obese, usually in women.

And usually it's just localized to the armpit and that's it. This person's problems are not localized to the armpit. And usually when people have hydradonitis superativa, those lesions are like weeping lesions, right? Like, they literally bring off posts on all these nastiness. So that's wrong. Option B says cut scratch disease. Cut scratch disease is caused by Bartonella, Hensley. Let me spell that B-A-R-T-O-N-E-D-O-L-A. And then Hensley is H-E-N-S-E-L-A-E. Bartonella, Hensley. Okay. Usually you're going to be scratched by a cat. And then this guy has a cat. And then you're going to notice painful lymphodonopathy on the same side as the cut bite. And many times the lymphodonopathy tends to be pretty regional. So it may not only be like in the arm, where you're bit, it may not only be there. You may see all the swollen painful. It causes tender. See, not non-tender, tender lymphodonopathy on the same side. This person kind of seems to fit that bill, right? They have this tender lymphodonopathy on the right armpit, although the right armpit. And they also have tendinopathy, aprotrochlear lymphinol. So the same region, you know, the arms are kind of close to your face area and whatnot. So I'm going to maybe go with that. I'm going to go with option B actually on this one. Option A, Castleman disease. I know that that may have caused people some grief, but Castleman disease don't get me wrong.

Though people have lymphodonopathy, yeah, but honestly, Castleman disease is one of these things that, yes, what is the classic presentation? The classic presentation is more of a generalized lymphodonopathy, not really original. But another thing with Castleman disease is, you know, most times it's going to be generalized lymphodonopathy. Although, you know, there are certain subtypes, like reading, you can really go down the rabbit hole with Castleman disease. They can have the unicentric kind, where it's like just one region of lymph nodes that's affected. One thing I'm going to say about Castleman disease is usually these people, there's going to be some kind of association with HHV8. That's kind of thrown away your exams. And again, we don't just really see that. Again, these things are out of this world. They're not typically not going to be the right answer on your exam. So I'm going to skip that. So I think for this one, I'm definitely going to see that the right answer, I think I'm going to go with option B, cut scratch disease. So let's go ahead and stop here. If you're interested in any of my review courses, I have a bunch for step one to step three starting on Thursday this week. Again, these review courses have a testic in strategies classes, two and a half hour class on Thursday, forward bios. That's class on Friday, five hour social sciences, ethics quality improvement and healthcare systems class on Saturday.

And so these three classes are all for step one to step three all over zoom. And then starting next week, Monday, I have a 20 hours class for step two, step three, you know, also for complex tour three. These classes are not lectures. If you're looking for lectures, don't come. These classes are all scenarios, all scenarios. I use scenarios to really help you understand the pathophysiology and show you how the mature will be tested on your exams. Again, many people have taken these classes and found them to be extremely helpful. If you want some more information on the classes, you can listen to the broadcast I made on them or you can send me an email through the website. And then I have this podcast on Apple Google and Spotify. So check those out. I have a You Tube channel where I post the videos I make also for one on one tutoring for all the US semiles, all the complex exams and all my school exams. And I also have a help with e-rass applications and residency applications, you know, rec letters, personal statements and things like that. And finally, I have another website called divineinterventionalifelessons.com. Every week I post about two podcasts, literally about 10 minutes long, where from a biblical perspective, I address a life lesson. There's actually an Apple podcast associated with that. So I'll see you in episode 522. Have a wonderful rest of your day. God bless you and bye for now. Thank you.

Monthly intravenous immunoglobulin (IVIG) replacement therapy.

Hypertonic saline (e.g., 3% NaCl).

Hepatocellular carcinoma (HCC) or cirrhosis.

Factor VIII concentrate.

Weight loss and adopting the DASH diet.

Seeing wavy or curved lines (metamorphopsia) in an old person.

Hemophilia A (Factor VIII).

Common Variable Immunodeficiency (CVID).

Administration of hypertonic saline (e.g., 3% NaCl) to rapidly correct sodium levels.

Chronic Hepatitis B infection.

DASH (Dietary Approaches to Stop Hypertension) diet.

Bartonella henselae; characterized by regional, tender lymphadenopathy following cat exposure.

Hemophilia A (Factor VIII).

Common Variable Immunodeficiency (CVID).

Administration of hypertonic saline (e.g., 3% NaCl) to rapidly correct sodium levels.

Chronic Hepatitis B infection.

DASH (Dietary Approaches to Stop Hypertension) diet.

Bartonella henselae; characterized by regional, tender lymphadenopathy following cat exposure.