DIP Episode 556 - 2024 USMLE Step 3 Free 137 Discussion Part 4 (Q31-40, super helpful for Step 2!)

Welcome to episode 556 of the Divine Intervention Podcasts. In this podcast, we're going to be continuing our series on the USM Lys Step 3 3137. This is going to be part 4. We're going to be going through questions 31 to 40. And again, if you're taking the Step 2 CK exam, I will also strongly encourage you to listen to this because if you're taking Step 2 CK now, and let's say you're still in medical school, chances are before you take Step 3 is probably going to be like a year plus. These are a new 3137 would have been released. So just FYI. Now for those that are taking Step 3 specifically, there are just two quick pieces of advice I want to give you before I jump into this podcast. Number one, if you take Step 3 and you struggle bio statistics, you're going to have a very, very rough time on your exams. You need to make sure that your bio stats expert if you're taking Step 3. In fact, the one of Step 3, about almost 20% of the questions you're going to see are probably going to be bio stats questions in some way, shape or form. Second thing I'm going to tell you if you're preparing for Step 3 is make sure you're good with basic sciences. If you struggle with the basic sciences, you're also going to majorly struggle with Step 3. That's just the truth. And this advice, I'm slowly beginning to extend it to people taking Step 2 CK. If you struggle with basic sciences, you're also going to have a very rough time on Step 2 CK. Alright, so let's jump right into it.

Question number 31, it says. A 39 year old woman comes to the office because of a one year history of progressively worsening shortness or breath. She had been generally healthy and says that initially the shortness or breath occurred only after strainers exercise. However, she now becomes fatigued and short of breath after walking two or three blocks. Two to three blocks. During the past two weeks, she has noted a rapid heart rate and lightheadedness. She has not had chest pain, lower extremity, edema, orthopnea or any nocturnal symptoms. Medical history is remarkable for Graves disease, which was diagnosed four years ago and treated with radioactive iodine. Current medications include liver, oxygen, a daily multivitamin and an oral contraceptive. She does not smoke cigarettes or drink alcoholic beverages. She is 5'6 inches tall and weighs 125 pounds. Her BMI is 20. Her BMI is 37. That's 98.6 degrees Fahrenheit, pulse is 120 per minute and irregular. Respirations are 16 per minute and blood pressure is 110 or 85. Longs are clear to her scotation. Cardiac examination discloses a rapid rate, a poppable parastronol left, a normal S1, a widely split, prominent S2. There is a great toilet, a six-estolic murmur heard best over the second intercostal space. One of the low extremities discloses trace edema of both feet. The remainder of the physical examination discloses no abnormalities. Results of lab studies are shown.

So sodium is, honestly, if you look at her lab, she has a mild hypochylemia and a TSH, let's see what a normal TSH value should be. I don't have that memorized. So let's look that up real quick. TSH, TSH, TSH, TSH, TSH, TSH, TSH, TSH, TSH, TSH, TSH, TSH, TSH, TSH is pretty fine. TSH is fine. I kind of figured it was much, but you should always confirm. Okay, transplant verified. So TSH is fine. Honestly, all her labs are completely fine. So ECG shows a fib with a ventricular rate of 140 per minute and right axis deviation. This takes ratios clear long fields, no effusion and permanent pointer arteries. So we shall follow in the most appropriate additional diagnostic study. Right? So option A says CT of the chest, B says echo cardiography, C says profusion long scan, D says PFT, E says ultrasoundography of the thyroid. So we see again, let's frame this question. What's the frame? This is a young female and she's now having this shotness or breath. Right? And the things that abnormal we see that she has this widely split prominent is to her pointer arteries are more prominent. She has trace peripheral edema of her lower extremities. She has right axis deviation. Right? Basically, we're seeing, especially in a young female, this looks a lot like pulmonary arterial hypertension. So honestly, for this one, since it's pulmonary arterial hypertension, probably going to go with option B, does you only answer that mix any sense? Right?

Because that way you can measure pulmonary artery pressures. Now, I know some people may have been easily confused with a grave disease that, oh, she has graves disease. She had a histral gravest disease and the USM is they're pretty smart. They're very good at kind of throwing some of these destructors. Right? But that gravest disease has been treated at TSE. She's fine. She does not have graves. Right? So all these thyroid answers that look very distracting, that look very enticing. Don't pick that one. Especially option A, don't pick it. Right? And then PFT, right? This person doesn't have like COPD or whatever. Right? So we're going to cross that off. Prophission long scan, right? Like a VQ scan. That's what happens when we're worried about a PE. But she has been having symptoms for a year. I would really hope you're not having PE for a year. You probably did. All right. And then option E, CT of the chest, right? No, you're not going to be doing that. So this person has a pulmonary arterial hypertension. Remember, they classically love to give this to younger females on the exams. And you can arise from a BMPR2 mutation. Right? So you have like hypertrophy, you know, an increase in the amount of smoke, most of the insulin, the lumen of your pulmonary arteries that can cause pulmonary hypertension. Right? Then you may wonder some of these findings, like the one where they should have a widely split S2. Well, think about it.

If you have pulmonary hypertension, it's going to be much harder for the right ventricle to empty of blood. If it takes the right ventricle a longer time to empty, then the pulmonary, the pulmonic valve is going to close late because it has to wait its sweet, sweet time for the right ventricle to close. So remember, S2, what's S2? S2 is closure of your urethic and pulmonic valves. But again, if the pulmonic valve is closing late, the urethic valve will close early. It's not going to keep chilling waiting for the pulmonic valve to do its job. So that's why you have that wide S2, right? And again, you have these pulmonary pulmonary arteries because this person has an increase in pulmonary pressures, right? So, and you hear the systolic murmur over the second intercostal space, right? So, remember, many times when people have, and this pulmonary hypertension can lead to a right heart failure, when you have a right heart failure, many times you may not have pulmonary deem, right? So just something we want to keep in mind. I'm going to go with option B for that one. All right. Now, question 32 says, 53-year-old man is admitted to the hospital for treatment of acute pancreatitis. His temperature is 100 degrees Fahrenheit. His pulse is 90 per minute. Respirations are 16 per minute and blood pressure is 160 over 90 millimeters of mercury. Oxygen saturation is 94% on room air. The standardness and voluntary guarding in the epigastrum with hypoactive bowel sounds.

With hypoactive bowel sounds. Physical examination is otherwise shows no abnormalities. Nomadic compression devices are in place on both extralore extributees. Most of lab studies show a local site count of 18,700 serm amelies, concentration of 540, and serm lipids of 500. Other orders are written that the patient is to be given nothing by mouth. IV fluids are administered and is given fentanyl and tribunals for pain. On the third day in the hospital, he's noted to be that for adequate labored breathing, temperature now is 100.8 degrees Fahrenheit. So that's a fever, right? Pulse is 95 per minute. Respirations are 30. Blood pressure is 110 over 70. The decrease breath sounds at the left long base. The normal examination is unchanged. So which of the four is the most appropriate next step in the evolution of these new findings? All right. So option E says chest X-ray, option B says, determine cardiac enzyme activity, option C says, echo, option D says, autostanography of the chest. That's usually not a good idea except you're worried about like a tampon out, right? And then option E says, VQ, VQ scan, right? So if we look at this question, this person probably came in with less frame at first, right? This person probably came in with acute pancreatitis is not probably the person came in with acute pancreatitis, right? The lipase is, you know, pretty high. The amelies is pretty high. Wycombe was up, person has that classic pain of acute pancreatitis, right?

And then we even told the person has acute pancreatitis, right? So, but he treated the person as the issue half, right? Don't eat anything, get a bunch of opioids, get a bunch of fluids, because we'll have acute pancreatitis since we very volume depleted. But now, so the real question kind of starts in the second half here. He's like, gee, this guy is that for reddit, liberal breathing. Now he has an actual fever, right? And we see that he has decreased breast sounds at the left long base, right? So, don't examine his own change. So who knows what's going on here? This person, at least we know, just going with the objective information we have in the question, he has a fever, left long base is not doing so well, right? Decrease breath sounds. So I don't know, maybe this person has an effusion that's collected there or has pneumonia, right? Especially with this fever. I don't know if there's something going on there. So hey, it was the best way to look at the lungs. It was like an easy, easy way to look at the lungs. If you're worried about pneumonia or effusion, maybe get a chest x-ray, right? So I'm going to go with option A for this, right? Again, ultrasoundography of the chest, that's like one of the fancy, deceitful ways our friends at the MDM Es refer to an echocardiogram, because guess what? An echocardiogram is pretty much like a cardiac ultrasound, right? It's a cardiac ultrasound.

So you're going to do that when you're worried about like a period of cardiomy fusion or period of time point out, right? Because you're going to use imaging guidance to do that period of cardiocentes. So we're not going to pick up some D. Again, echo, this is not a cardiac problem. This is a pulmonary problem. B says cardiac exam activity, right? If we're worried about an MI, right? But again, we don't have any objective information here that should guide us towards an MI. And again, a VQ scan. Again, that's thinking of a PE. But again, a PE is going to be more classy. You're going to see sinus-tachycardia. You're going to see profancialness or breath. I don't see why it makes sense for them to start giving you the fever, to start giving you the decreased breast sounds of the left lung base, especially in the person that has had another infection, right? Another problem inflammatory disorder, right? Something like pneumonia or some kind of plural of fusion or whatever, probably makes more sense. So I'm going to go with option A for this, for this guy. All right, we're going to question number 33. Okay, so a 24-year-old woman comes to the office because of a three-month-his-travel in dreamy-dremendous episodes of irritability and insomnia. She says, I'll be fine for two to three weeks, but then I get so sensitive to anything my husband says. Sorry, husband. My mood will last for a few days, then I'm fine again.

In addition to insomnia, she has associated headache, fatigue and overeating during the same period. The patient married three months ago and she says her husband has become frustrated with the unpredictability of her moods. She works as a phlobautomist. Medical history is unremarkable as she takes no prescribed medication. She does not smoke cigarettes or use other substances. She now drinks one to two alcohol beverages weekly. She drinks one to two alcohol beverages weekly. A last menstrual period was one week ago. Okay, PMI is 20. Five times that we didn't normally meet some physical examination, this closes no abnormalities. At this time, specific additional history should be obtained regarding which of the following. So option A says carb intake, carbohydrate intake, option B says coito-frequency, C says frequency of physical activity, option D says histropsychological trauma, option E says stress level, option F says timing of symptoms. This is a pretty classic question. You see, basically you see a woman that for most of the month, she's fine. For a period of the month, usually about a week. That means acting kind of crazy. Right? As she has some of these physical symptoms like insomnia, they may have bloating and whatnot. This is pretty classic for pre-manstrual syndrome. Pretty classic for pre-manstrual syndrome. So remember, pre-manstrual syndrome. Many times you want a diagnosis. You're going to make those people get a symptom diary.

You want to be able to co-locate the onset of their symptoms, the onset of their symptoms, the onset of their symptoms, right around when the immensely start. You make the diagnosis, you treat it with an SSRI or an SNRI, right? So I'm going to go with option F here. You get that symptom diary. That's literally the way you diagnose pre-manstrual syndrome. Right? I'm sure in this question, they're going to try to trick you. Is this generalized anxiety disorder? But this has been going on for three months. Don't think of GED for this. Don't think of GED for this. Coito-frequency, they don't seem to say anything about them having issues with their sex life. So kind of get rid of that. Frequency of physical activity, this person is fine, right? Just chill out from that. Chill out from that. All right. He's sort of psychological trauma, hey, maybe PTSD or whatever, no stress level, no. Right? Just skip that. Again, on the USML, it's just always go with the thing that is classic and simple and straightforward. When it's nothing, you have all these complex, complex things. That's how you get in trouble. All right. Question 34. A 55-year-old businessman comes to the office for pre-employment examination. The patient's last visit to a physician's office was 10 years ago. Examination at that time, disclose no abnormalities. So his stress is not remarkable and the patient takes no medications. His father died of CED at age 66.

His 80-year-old mother was once treated for some kind of thyroid disease. The patient has a sedentary lifestyle and says, my energy level is in what he used to be. He frequently eats at fast food restaurants. BMI's 30, temperature is 98.6, plus his 82 rescriptions are 14, blood pressure is 142. The 92 physical examination discloses obesity, but no other abnormalities. Results of fasting, lap studies are shown, right? So his cholesterol is kind of high, but at least the LDL, which we're kind of worried about, is less than 190, right? So don't be thinking of doing a starting here. That's a bad idea. Right? Triglycerized 249, getting kind of high, but not a big deal. Cratin is 1.1, that's fine. Glucose. So he, and these are fasting studies. So his fasting blogger is 126. Okay. Let's keep that. Immaculate is fine. White count is fine. Results of seromy liver function tests are within the reference ranges. Chest extra and ECG disclose no abnormalities. Determination of which of the four is the most appropriate next step in evaluation, right? So this question, right? So let's, so option E says AB Gs, option B says A1 C, option 3 says 3 hour glucose tolerance test, option D says serum cortisol, option E says serum fructose. Right? So again, let's frame this question. This guy is not a healthy person, right? Pretty sedentary. It's a fast foods, right? BMI study. And you know, he's, his lipid labs are not great, but his fasting blog glucose is high, right?

This guy, just going off of the criteria for diagnosing diabetes. His fasting blog glucose is over. Remember, there are many ways you can diagnose diabetes, right? You can use A1 C over 6.5 percent or if your fasting blog glucose is over 125 or you have a positive or glucose tolerance test or there's one more. If you have the classic symptoms of diabetes, right? Like polyurepolisipcy and then your fasting blog glucose over 199, right? That tells you you got diabetes. The or glucose tolerance test part. That's usually if you, if you do the or glucose tolerance and you measure it and is over like 199. And then you follow it up with something but don't really worry about the numbers. I know many people kind of stress about the numbers, but if you need those numbers, the USMD is usually gracious enough to kind of provide those on exams, right? So memorizing those I've pretty much never done, never done that kind of a waste of time. Right? So this person has a fasting blog glucose over 125. So we could say, ooh, it's person has diabetes. But remember, before you say a person has diabetes, you need to do a two, you need to confirm it with a, with a similar test or like another test on a subsequent day. You need two positive results to say, oh, gee, you got diabetes, right? So I'm going to go to option B here, right? A1 C. But let's look at these other answers. See, you know, why they make sense and why they don't make any sense, right? So ABG's, right?

Again, when you focus on discrete tiny parts of a question, I'm going to get in trouble, right? Ooh, these guys, BMI is 30. Energy level is low. Sleep apnea, sleep apnea, sleep apnea. But again, think about it. People can have low energy for many different reasons, right? The thing is again, if the MBA needs one day to think of sleep apnea, they would make the question very pervasive about snoring and all those things. They don't give that, cross that off. Three hour glucose tolerance test. Again, many times that's done more in the setting of pregnancy, right? This person is, you know, he's a 55 year old businessman. He is not really pregnant here. Serum cortisol, again, they should have given you a cushion's presentation, moon faces, propostriase, skin hyperpigmentation, if it's ACT dependent, right? Osteoporotic fractures, you know, hypochylemia because cortisol has out those strong like properties. So that's gone. An oceanic excess serum fructose amine, right? So don't pick this, right? Members are fructose amine is one of the very rare ways you can diagnose diabetes. Many times what? Who are we going to use this serum fructose amine thinning? I mean, in times you're going to use it in people that have diabetes and they have a hemoglobin apathy because remember, when people have, we like it once in these days because your retails live for like 120 days. That's about four months, but let's say three months.

So your retails live for about three months, you know, plus or minus a few days. So you can get glycithet proteins glycithetic glycated hemoglobin, right? That's literally the whole basis of A1 C. It's like, hey, we see what your glucose status has been for like the last three months. But the thing is, if you have a hemoglobin apathy, let's say you have like sickle cell disease, your retails don't only for three months like a normal retail. So your retails die, they live fast, die on, they die very quickly, right? So your E1, your retails die very quickly, they don't live for three months. So if you measure E1 C in those people, it may be forcefully normal because you're only maybe getting like a few weeks snapshot or a few days snapshot of a retail. So for those people, you could consider using something like fructose, I mean fructose I mean, kind of tags along with your argument, but it's, you can actually glycate certain amines, right? You measure that concentration and that can give you an idea of a person's glucose status. But the thing is, it gives you more of an idea of like the person's like 20 day glucose status, about 20 days, right? It kind of tags along with argument. I'm not going to go into the deep path of this, you don't need it for your exams, but it kind of has some kind of relationship with with argument.

So generally, you know, if you check a person's term fructose, I mean concentration, it can give you an idea of what their argument status has been for like the last 20 days, right? Or what their glucose status has been for like the last 20 days. Again, we're willing to use that input of a hemoglobin apathy because their retails don't really for very long. But again, you can already begin to see logically why that may not be such a good idea in certain diseases like the ferrodex syndrome. The ferrodex syndrome, right? Your argument levels are low because you're literally peen out argument, right? So that can give you a forcely normal serum fructose, I mean concentration, right? Again, I'm just going to give you like the rest in areas where they may throw that on on an exam. But I know sometimes you may see this on some of these, you know, you may see this on some of these, you know, med school exams, you may see this on step three every now and then, step two every now and then, right? Or really they may kind of throw it on some of these specialty, but examples like internal medicine. All right. So let's go ahead and so the answer is definitely option B, right? So we're going to go to question 35. Okay, so an eight-year-old girl is brought to the ED by via ambulance one hour after the onset of a generalized tonic chronic seizure. Paramedics noted a pulse of 50 per minute followed by a 30-minute period of acistena.

When a route, the patient was intubated and oxygen therapy and an epinephrine, an utropic trip was initiated, rainy shaded. On arrival, the patient is unconscious. This is a bad story, right? Temperature is 98, pulse is 40, respiratory stress is 16, blood pressure cannot be obtained. That's a really bad story. O2 SAD is 99% and FIO2 is 1. Physical exams shows mildly dysmorphic phases, where it's probably some genetic disease going on. All right. Puppels as sluggish in response to light, lungs are clear, those quotation of insulin that sounds. Cardiac examination distorts irregularity and sinus-bredicardia. I'm the main soft and non-tender. Neurologic exam disclosis paralysis. Distoposis at 1 plus a week. Ecocardiography shows global hypokinesis with lateral inferior wall and septal lycanesis. Okay, so this person's harness kind of like died basically. Level integral function is 20%. The patient is admitted to the hospital. For these later, there has been no improvement in her condition. Life support is withdrawn and the patient dies. A road up at autopsy. Examination of the heart shows evidence of an acute MI. Which of the following is the most likely on the line cause of this patient's death? Right. So the thing is, reading a question like this, honestly. I just want to try to be realistic here. Right. This is probably a question that most people are not going to be able to answer confidently. Right. You're really discretionary like what? Right.

So when you see questions like this, right, again, the classic temptation is to say, let me see that with this question for a bit. No, that's a horrible idea. Don't do that. Right. That's a horrible idea. Finish the block first and then come back to this question. Right. The three or four minutes you spend on your first pass through a block answering this question. It is time that will pretty much prevent you from finishing the block in a timely fashion. So don't do that. That's a very dumb thing to do. So what's the smart thing to do here? Well, the thing is, let's look at the answers. Right. So let's maybe use the process of elimination. Let's use the process of elimination. Maybe ask ourselves, these answers, what are the things that they are classically associated with? Right. Because again, I think I've kind of presented this thesis many times, many of my podcasts that the USML is they are stocking trade out classic things. Right. If you're going to your exam thinking that, oh, they're going to present all these esoteric diagnoses just because of all the stuff you've seen in the Q bank, you're kind of setting yourself up or feeling on your exam. Right. So let's kind of take you from the bottom. So option E says, thickened left ventricular wall and contractile dysfunction. Right. So thickened wall, you know, maybe we're thinking of something like hookum, right. In that circumstance. But again, hookum was the classic way they're going to throw it on an exam.

It's going to be an athlete that suddenly passes out. Right. Is that what we have here? No. Maybe go ahead and cross that off. This girl is not an athlete. She's eight years old. Right. Many times they're going to give a hookum to both our teenagers, very, very young adults. So we're going to go ahead and skip that. Now, systolic prolapse of the mitrovile, right. That's mitrovile prolapse. And again, we kind of have this hint that this may be a genetic disease in this question. Right. This may be a genetic disease because we see this morphic face. Right. So let's ask ourselves that there's some genetic diseases that present mitrovile prolapse. Well, although some dominant polycystic kidney disease can cause mitrovile prolapse, our friend syndrome can cause mitrovile prolapse. Well, as that low syndrome can cause mitrovile prolapse, oxygen is in perfector can cause mitrovile prolapse. But again, does this question have any semblance to morphines? I'm going to argue, no, there's not many things here. Persons not tall. Doesn't have the ectopia or whatever, the eye, whatever issues. It's not here, right. So I'm going to skip that. Well, as that loss, hyperextensible skin and joints, yeah, yeah, yeah, yeah, it's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here.

It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. It's not here. Right?

You have all these conduction abnormalities. That can cause these very dangerous arrhythmias. And that can cause ultimate death. Right? And if your heart dies, then you're going to have this pretty much as global dysfunction. Right? The person's heart will literally die. So honestly, I'm going to go to option A for this. So what are some potential candidates here? Well, some things you want to think about. If I had to predict what this disorder is. Again, they don't give you many clues here. But if I had to predict what's going on here, I mean, think of something like gerbil and an allangineal sen syndrome. Right? So many people have that gerbil and lancinal sen syndrome. They can have a potassium channel mutation. They're going to have arrhythmias. Those arrhythmias can lead to seizures. They can lead to what they can lead to seizures. And many times, they'll also have other things. Sometimes they can have these morphic facial features. And sometimes they can actually have a... Is this thing? It's pretty high up to here. And lots they can have here in Los Angeles. And lots they can have arrhythmias. And lots they can have arrhythmias. And lots they can have arrhythmias. And lots they can have arrhythmias. And lots they can have arrhythmias. And lots they can have arrhythmias. And lots they can have arrhythmias. And they can actually have... Is this thing? It's pretty high up to here in Los. They can have arrhythmias in gerbil and lancinal sen syndrome.

And another thing that may present similarly. Although I don't think they'll have these morphic facial features. It's our Romano word syndrome. Romano word syndrome. It's kind of close to gerbil and lancinal sen syndrome. I want to be able to differentiate those on your exams. So Romano word. And pretty straights, or those are more dominant. And it just involves the hearts. They don't have arrhythmias in Los. They don't have arrhythmias in Los. They don't have arrhythmias in Los. They don't have arrhythmias in Los. And another one you may see on exams actually is this one called Timothy syndrome. Timothy syndrome is also an Orozumo dominant disorder. It's kind of a long-cutie syndrome. But the key critical thing to know about that is you're going to see like autism spectrum disorder. And many times they can have like small teeth. They can have like small teeth. That's actually kind of high up to know for, for example, Timothy syndrome. So I'm going to go to option A for this one. Again, remember seizures can be a presentation of arrhythmias in kids. And the thing that can cause seizures in kids classically is when they have like electrolyte problems. And the thing that can cause seizures is when they have fever. Remember, February, seizures. All right. Let's go to question number 3036. So a two-month-old boy is brought to the office because of a three-day history of yellow-tanged eyes and skin. Uh-oh. Okay.

He was delivered at a 41-wish gestation, pregnancy and delivery were uncomplicated. Delivery length was 21.3 inches, 90th percentile, which was 4200 grams. So 9 pounds for ounces, 90th percentile. Headstroke conference was 37 centimeters, so 14.6 inches, 90th percentile. Upgrades were 9 and 10 and 1 and 5 inches respectively. He has been formula fed and feeds every three to four hours without speeding up or MSS. He has pale bowel movements two to three times daily. He receives no medications. Current length is 60 centimeters, 75th percentile, weight is 12 pounds, 9 ounces, 65th percentile, headstroke conference for the 1 centimeters, 90th percentile. Temperature is 90.4. Sposes 130 p.m. in a regular. Restrictions of 40 blood pressure is 105 or 65. Physical examination shows diffuse jaundice and conjunctival lecturers. Cardioperminia examination discloses no abnormalities. Abdominia is soft and there is mild and paramegaly. Results of lab serum studies are short. So, his ALT and EST elevated, his total bilirubin is elevated, his ribidirubin is elevated. So, this is predominantly a direct hyperbidirubinemia. And then he's protein total is 6.6. That's fine. His abuminia is 4.5. That's fine. So, the no-lotress sonography shows a hypoplastic gallbladder and small common bowel duct. Which of the following changes is most likely occurring in this patient's liver at this time. Again, just a big picture. And also, people will be sweating all the small details here.

But this is like an infant that has direct hyperbidirubinemia. Well, what's going to be the classic cause? What's going to be the classic cause? It's probably going to be biliria atreja. Remember, biliria atreja is probably the most common cause of... The most common cause of... What is it called? The most common cause of a direct hyperbidirubinemia, like a newborn or a very early, early, early kid. Like, first few weeks of life. So, it's going to be biliria atreja. And again, you see a predominant direct hyperbidirubinemia. It says which of the following changes is most likely occurring in patients' liver at this time. So, option A says, bowel duct proliferation. Let's keep that. Because really, biliria atreja is a problem with your bilirid duct. So, that seems like the obvious answer. Option B says, central lubolanecrosis. It's kind of a liver related answer. But that's more with the hepato sites, not with the bilirid duct. So, maybe less likely to be correct. But let's keep that for now. Option C says, inculurist glycogen stores. That makes absolutely no sense. Why are you going to have inculurist glycogen stores? I'm in biliria atreja. That's not why. Don't pick that. Option D says, intranuclear hepato site inclusions. So, you tend to see a lot of intrauclear hepato site inclusions. If you would have non-acorolic fatty liver disease, I would hope a two month old doesn't have a non-acorolic fatty liver disease. So, we're going to skip that. Microversiculus steatosis.

We also find that in non-acorolic fatty liver disease. Again, I hope a two-month old does not have that. So, it can be twin options A and B. And again, because option A says, Balt is like screaming Balt dot. And we know that biliria churches is a Balt dot problem. I'm going to go to option A for this one. I'm going to go to option A for this one. So, I'm going to go Balt dot teloproliferation. So, the answer is A. So, let's actually kind of talk about this. Again, I think this question is, and I'm going to go into a little bit of a deep dive here. But again, I think one of the warnings I said at the beginning of this podcast is that, if you struggle with basic sciences, you're really going to struggle with step three. I believe there are some people that I have taking step three and also step two actually that take my step one 25 hour class. So, the thing is, Balt dot proliferation is something you actually see in, basically in many people that have liver disease. You know why? Because if a Balt dot is not working, it's almost like your body is like, oh, gee, this road is closed, this road is closed, this road is closed, this road is closed. Let's see if a hurricane happens somewhere or tornado of some sort. What do they try to do temporarily? They try to make like new paths so that, oh, okay, at least, let's use something even simpler. Road construction. You live in New York, they do road construction, and they have to like divert traffic.

So, other people can go to some place. So, if your Balt doctor or junk thop, your body is going to be like, gee, I kind of make new Balt doctor. So, at least we can redirect a direct billier of into certain plate to out of the liver. So, Balt doctor proliferation makes a lot of sense. The thing is, central lobelemnacrosis. Look at the name, central lobula. Remember, your liver is made up of a bunch of lobeals. Now, central lobula means the center of the lobeal. The thing is, if you probably remember this from step one, the center of the lobeal, they are some very specific things that like to torch that part of the liver. Like what? Like toxins, toxins, drugs. Like I said, a minofin. They can literally write an acid a minofin question, and they say, oh, what's going to be the most likely find you on histology? I'm just going to be central lobula necrosis. Toxins, drugs. For pressing out the right heart failure, if you have a schemia of the liver, it's going to go after that central lobele region. And also, another thing that had been hit, is when you have viral hepatitis, it tends to go after the central lobele region. So, again, what are the causes of central lobele necrosis? Again, toxins, drugs. Like I said, a minofin, viral hepatitis, ischemia, right heart failure. Those things love to go after the central lobele region. Again, none of those things are happening here. So, I'm not going to pick option B. The right answer here is definitely going to be option A.

Again, you're like, ooh, the fine, it's like basic science stuff. Yeah, yeah, you should know that for your exams. Okay, now, 24, so let's go to question 37. 24-year oprenum-gravied woman comes to the clinic for her first prenatal visit. Her last menstrual period was six weeks ago. Medical history of the wife is on a remarkable, and only medication is a prenatal vitamin. Family history is remarkable for gestational diabetes in her maternal aunt. The patient's vital signs are within normal limits. Physical exam discloses no abnormalities. The patient tells the physician that she would like to be screened for gestational diabetes malitis and wants to make sure the test will not yield a false negative result. Okay, several screening tests are available, and each test performance is depicted in the graph shown. Based on these data, which of the following screening tests is the most of a resource for this patient? This is an easy question, right? You will see this graph. This is a receiver or prenatal characteristic curve, right? Y-axis has sensitivity, and then the X-axis has the 1-minus specificity. Right, remember, just quick thing here. In general, so let's define these axes, right? So obviously, it's sensitive on the Y-axis. 1-minus specificity. So where do you have the biggest specificity, the highest specificity on this graph? It's actually going to be closer to the origin. Because remember, the X-axis is measuring 1-minus specificity. So, one is like 100%.

So, at a point of 100% specificity, 100% minus 100%, that will give you 0. So again, the origin of the graph is where you have the best specificity. In general, the overall best test you want to select for any person. If you want to get the best combination of sensitivity and specificity, it would be an ROC curve. You want to go for the curve that is up or almost down to the left. But you've got to be careful here. The MDM is asking about half of the question, not the full thing. So they are saying, ooh, I want to make sure that's a false negative result. And what kinds of tests are there referring to here? Screening tests. What kind of property do you desire in a screening test? You desire a test that has a high sensitivity, right? So basically, we just need to find all these tests, which one, if we look at the gradient, which one seems to cut the y-axis at the highest point? It's going to be test B, right? Test B has a sensitivity of almost like 90%. Test A, believe it or not, has higher specificity. But specificity, you do that for diagnostic tests, not for screening tests. So this question, we don't even need to discuss your other options. Option B is the right answer, right? Option B is definitely the right answer. Okay, let's go to question number 38. A two-year-old girl is brought to the office by her father. Because of a two-day history of a pain form, as well as the right side of her neck, that has been increasing in size.

The father says she cries when her neck is touched. She also has a one-day history of a fever, or a hundred point six. It's probably an infection, right? So the pain and fever have been well controlled with a sedominofin and ibuprofen. The patient has no history of serocinus and receives no other medications. An maternal first causing a had a non-hochkin lymphoma, an a paternal aunt had EML. Examination and a proper test in a donor, and the patient is diagnosed with lymphaticitis. The physician informs the patient's father of the diagnosis and prescribes amoxysine, clavolonic therapy. The patient's father questions the diagnosis and asks that his daughter be referred to a specialist. In addition to expressing empathy, which of the most appropriate physician responds? Okay, so here's the thing. Whenever you have questions like this, when you, where you are as a physician, you say, oh, this is what you're supposed to do, this is what is going on, and the family refuses whatever. You always want to try to discuss with them, right? Don't change your decision. Don't change your decision because you've clearly done your job as a doctor and you're like, hey, you got lymphaticitis. So don't be an answer that involves you changing your decision. But address the family's concerns. Don't just be dismissive of the family. So let's look at these answers. Option A says, option A here says, I don't think she needs a specialist. What would I worry about?

So the father said, I want a specialist. You're like, I don't think she needs a specialist. You're just being very dismissive. I would not pick option A. Option B says, I know you're worried about because of your family history of cancer. But I'm confident in the diagnosis. And see no need to refer your daughter to a specialist. Again, you're being dismissive. You're being dismissive. Hey, I know you're worried about, hey, I'm the doctor. I know what I'm doing. You shut up. What do you know? You're just some regular father. That's pretty dismissive. I will not pick that, right? Option C says, tell me what your greatest concerns are. Okay, you're getting more conversation going between the patient and the physician. It's pretty open-ended, right? At least you're not being dismissive. That is a non-dismissive answer. Option C is probably horrible. Let's look at option D. There's no need for your daughter to see a specialist. She'll feel better once she completes this course of antibiotics. There's no need again. You're being dismissive. Don't do that. And the option E says, why do you think that your daughter needs to see a specialist? Right? The thing is, patients, unfortunately, many times we'll have lower health literacy compared to once the physician. Right? If you address them in that dimining tone, it may make them just keep quiet. Right? But no. You're not encouraging the physician-patient relationship by doing that.

And the thing for this question, I think option C makes the most sense. All right. Now, I'm going to go to question number 39. Okay. So a 68-year-old man is brought to the ED by his wife two hours after he collapsed into a chair and lost consciousness for 30 seconds. The wife says that during the 10 minutes prior to collapsing, the patient had nausea and two episodes of vomiting. The patient's medical history is significant for hypertension, hyperlipidemia, and coronary artery disease. Okay? Medications that may too prolong a 1-mg aspirin. GD, love this, it's 1-mg of aspirin. And since the starting, a BMI is 28 kg per meter squared. The patient is awake and fully oriented. I mean, temperature is 99.2, pulse is 104.1 per minute. Our specials are 24 per minute, blood pressure is 162 over 94. Oto cyt is 95% of room air. Physical examination discloses drooping of the right side of the patient's face. That's not good. Okay. Most of the strength is 3 out of 5 in the left upper extremity. And 4 out of 5 in the left lower extremity. Hmm. That's not good. Strength in the right extremities is normal, right? GD is 8-taxic. Come on. This is pretty classic, right? So the patient has difficulty swallowing when trying to drink a cup of water. This patient symptoms a most consistent with injury to the brain in the air supply by which of the fully cerebral arteries. Right? And again, the MBMI is there, they're kind of mean here, right? They kind of do this leading. Ooh, cerebral arteries.

Just to make you kind of look off of the brainstem and just focus on the cortex. But the thing is, this is clearly a brainstem stroke, right? This is clearly a brainstem stroke. First thing is first, there is a bunch of clues here that tell us that this is definitely a brainstem stroke. Number one, we see this person has crinon nerve issues, right? This person has difficulty swallowing, right? That's a crinonine and crinonotent, especially crinonotent, less than crinonotent, right? And crinonotent is in the middle. And then we also notice that this person seems to have issues in the upper and in the lower extremity. So this person is not respecting the territorial distributions of the major cerebral arteries, right? Because usually whenever you have a cortical stroke, you're going to have issues either in the upper extremities and face alone or in the lower extremities alone. It's going to respect territorial distributions of your cerebral arteries. They're going to have ACA problems alone. That's contralateral lower extremities or MCA alone. That's upper extremities and face, contralateral upper extremities and face, right? But we see like the upper and lower extremities are affected. Whenever you see upper and lower extremities are affected together, that stroke is not cortical. There are many options for that. But at least you can say confidently that that stroke is not cortical. That stroke is not cortical.

So honestly, there's absolutely no end-picking option A, no end-picking option B, no end-picking option C, no end-picking option D, right? A posterior cerebral artery stroke, right? That's going to be, you can see cortical blindness and then you have like some issues with sensation, right? Remember the PCA actually supplies a lot of your phalamus, right? So you're going to see a lot of sensory issues, vibration, fine touch, perception, yada yada yada, right? But we don't see that here, right? So we're going to skip that. So the answer is going to be option E, right? Again, literally your cranial nerves are like a GPS of your brain step, right? This person has a cranial tainy issue. So that tells you easily that that's a cranial tainy issue, that's a medallary issue. Well, what harder is to apply the medulla? Remember your two vertebrals come together from your basil. Your basil is those supplied to your ponds.

But your medulla is supplied by your vertebral arteries and is supplied by your, you know, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like,

like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like,

like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, l

ike, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, li

ke, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, lik

e, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, lik

e like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like, like

Widely split, prominent S2 due to delayed closure of the pulmonic valve.

Bile duct proliferation, resulting from biliary obstruction.

Echocardiography (to estimate pulmonary artery pressures).

A symptom diary or tracking symptoms relative to the menstrual cycle onset.

The brainstem (medulla/pons).

Toxins, drugs (e.g., acetaminophen), ischemia, or right heart failure.

Widely split S2 and prominent PA murmur/signs.

Biliary Atresia.

To minimize false negatives (missing a case).

1) Cranial nerve deficits, AND 2) Motor weakness affecting both upper and lower extremities on the same side.

Obstruction of the biliary outflow tract.

Central lobule necrosis; because these agents often cause damage centrally due to metabolic processing or ischemia.

Widely split S2 and prominent PA murmur/signs.

Biliary Atresia.

To minimize false negatives (missing a case).

1) Cranial nerve deficits, AND 2) Motor weakness affecting both upper and lower extremities on the same side.

Obstruction of the biliary outflow tract.

Central lobule necrosis; because these agents often cause damage centrally due to metabolic processing or ischemia.