DIP Episode 523 - 2024 USMLE Step 2CK Free 120 Discussion Part 6

Welcome to episode 523 of the Divine Intervention Podcast. Into this podcast we'll be continuing the series for the step 2 CK 312, the 2024 312. This is going to be part 6. We've done the first 40 questions, so we're literally going to roll into block 2. So it's going to be question 41. Let's get right to it. A 40 year old man comes to the office during the summer. Because of a 3 day history of fever, the fused muscle aches, fatigue and sore throat, he has had no sick contacts. Medical history is unremarkable and it takes no medications. He received the influenza virus vaccine this year. Ten days ago he returned from a trip to Malaysia, where he says he enjoyed the local food and nightlife. Temperature is 38.8 degrees Celsius, that's 101.8 degrees Fahrenheit. Pulse is 90 per minute, respirations are 16 per minute, and blood pressure is 126 over 70 millimeters of mercury. The remainder of the examination shows no abnormalities. Results of laboratory studies are shown. So he's hemoglobin is 10 grams per deciliter. Okay, I'm not going to run through all these labs, but he's hemoglobin is low. He has an anemia. His white count is also low, so he has a leukopenia. His platelet count is normal. His retinal distribution with appears to be normal as well. Although I don't know the normal value for them, I'm not going to waste time looking at that. Monospot test result is negative, which of the following is the most appropriate next step in diagnosis?

So option E says, cytomegalovirus, serologic testing. Option B says, ebsten bar virus, serologic testing. Option C says, hemagglutinin inhibitionase. Option D says, HIV RNA polymerase chain reaction testing. Option E says, serum, hebbi surface antigen testing. Well, let's look through these answers. So this person has sore throat. This person has malays, fatigue, fevers. You know, and this person has leukopenia. Person has anemia. And the person also has leukopenia. The platelet count though is fine. And this kind of seems to have a reason to acute. Looking at something like this, if we look at the answer, option E says, hebbi surface antigen testing. So I know you may think, oh, wow, local food. But the thing is, how do people get hebbi? Blood transfusions, sexual contact, IV drug user. We don't see something like that here. So let's cross that off. Option D says, HIV. With this person, you have HIV. Yeah, they could actually. This could be an acute ritual viral syndrome. So let's kind of keep that answer for now. Option C says, hemagglutinin inhibition, hemagglutimation inhibitionase. This is just pretty much a way to see how you, if your body is having given an antibody response to a viral infection, that's not going to be very helpful here. That's not going to help you figure out too. It's not going to be helpful here. Let's skip that. Option B says, hebbi, serologic testing. Well, the monosport test is negative. This person probably does not have hebbi.

And option A says, CMV serologic testing. Again, remember, CMV, what does he do? CMV causes a monosport negative, mononuclosis like syndrome. So what hebbi, CMV here, he code. But the thing is, CMV, they're usually going to give it to a person that is immunocompromised. The person is either a transplant patient or a person has HIV. And the person will have like some CMV manifestation. Either the CMV colitis or the CMV red nitis. We don't see any of those. So I don't think I'm going to go CMV. I think I'm going to go to option D. HIVR and Polymericine reaction testing. This person obviously has HIV. You went to some country, you enjoyed the local food. Honestly, the USM is wanted to be kind of nasty here. They could put an option F and throwing hip A. I almost bet that many people would jump on that answer. And it will be wrong because this person doesn't have jaundice. We don't have any AST. We don't have any ALT. You can not just create that information on your own. So that's wrong. So it's not HIVR. Remember, HIVR has a bunch of stages. There's the incubation period where you get the infection. And then there's the acute retroviral syndrome where you basically have like, a few days to a month. You see those people who have monolike symptoms. So you notice that they will have FIV Rs, Malays, Myalges. They'll have all these issues that you kind of see with people that have mono. But you'll notice that the mono spot test will be negative.

So you're just going to keep that at the back of your mind on exams. And then after that obviously they'll then go to the lead-to-the-feast, which usually lasts for anywhere from a few months or a few years. And then before they go the way to AIDS. So this person probably has an acute retroviral syndrome. So we should go ahead and do PCR. That's really the way we check for HIV these days. Okay. Now question 42 says, 22-year-old man is brought to the ED by his girlfriend. 30 minutes after she found him unconscious in his home. She last saw him yesterday and he appeared well. He has a history of cocaine and heroin use. And also use of prescription or cortic agents. And now, Jesus, sorry, that he obtains from friends. On arrival, he's lethargic. Temperature is 35 degrees Celsius. So that's 95 degrees Fahrenheit. So he's hypothermic. His pulse is normal, 60 per minute. Respirations are 8 per minute. So that's pretty low. And blood pressure is 96 over 50. That's also low. Postoxymetry in the air shows an oxygen saturation of 96%. The left lower extremities are notic and cold to the touch. The remainder of the examination shows normalities. Results of serum studies are shown. So his potassium is 5.5. That's, I believe, high. Yeah, that's high, actually. That's high. He is bicarb. Although potassium is 5.5, I think that's kind of like the upper limit of normal, actually. His bicarb is 18. That's low. So he's got a metabolic acid. He's going, it's creatinine is 1.

So his kidneys are not filled yet. His creatinine kind is 50,000. So the question then says, this patient is at greatest risk for which of the following conditions? Option A says acute kidney injury, option B says acute liver failure, option C says cardiac arrhythmia, option D says hypocalcemia, option E says hypophosphatemia. So what does this person have? This person, obviously, obviously, right, think about it. What do you think this person has? You see they have this left lower extremity that's notic and cold to the touch. This person has a rubbed on my alvases. This person has a rubbed on. And we know that a rubbed on loves to torch people's kidneys. So because remember that myoglobin can accommodate within your renal tubules and mess you up. So he can cause an acute tubular necrosis. Remember those people, your analysis, you're going to see blood on your analysis, but you won't see an offer it cells on your microscopy. That's rubbed on my alvases. That's why the way you treat a rubbed on is with fluids. You're almost feeling flush on that myoglobin through the person's kidneys. So I'm going to go to option A here, option B, rubbed on doesn't really have much of any relationship with liver failure. So I'm going to cross that out. Credit career with me. So the thing is this person has a potassium of 5.5. Again, I can't remember the exact number, but I'm pretty sure that's like the all per limit of normal or pretty close.

So I'm not worried about at least based on the data I have in the question, not the data I'm kind of manufacturing, data having the question. I'm also worried about that. So I'm going to get rid of C. I'm sure this is hypocalcemia. I don't have hypocalcemia with the rubbed on. If muscle cells are dying, but again, I'm just going to go with I have data for. I can see the creatine kinase is right there. 50,000. It's pretty high. That's going to mess up a person's kidneys. The person clearly has rubbed on. So I'm just going to go work with what I have data for. I don't have enough data for option D. Hypocalcemia. Although don't get me wrong, that's a fine name or rubbed on. But again, I just don't have calcium data in this question. And hypophosphatemia. I'm going to rub to tend to have hyperphosphatemia. All that phosphate that's released from the muscle cells that are dying, it's going to raise your serum phosphate. So I'm going to go with option A here. That's just the more classic thing that the USML is tend to test with rubbed on my analysis. Kidney injury. Again, question 43 says, 62-year-old woman is brought to the emergency department by her husband because of a three-day history of increasing confusion. She has a 20-year history of bipolar disorder, well-controlled with medication. Okay, for the past five years, her husband forgot to bring her medication bottles and cannot remember which medication she takes. He never remembered the medication.

He reports that she has recently had mild headaches and has taken a seduminoffin as needed. On questioning, he says that there has been no particular change in their routine. But during the past two days, they have been outside plain tennis more than usual because of the onset of sunny warm weather. While in the ED, the patient has a generalized tonicronic seizure lasting two minutes. She is 163 cm, so that's five foot four inches tall. And weighs 72 kg, that's 160 pounds. Her BMI is 27 kg per meter squared. Her pulse is 104 per minute. Respirations are 18 per minute. And blood pressure is 140 over 90. Examination shows dry mucus membranes. ECG shows a second-degree V block. Which of the following is most likely responsible for this patient's confusion? Option A says a seduminoffin, Option B says bupropion, Option C says lefium, Option D says resparidone, Option A says to pyramid. All right. So, the thing is, this person clearly, you know, has had a seizure, this person has dry mucus membranes, so they're probably hypoglymic. And the person is, is tachycardic, you know. And we see that this person has been, been in the sun more, you know, playing more tennis. But they have bipolar disorder, that's being well controlled with medication. So, if we look at all the answers here, again, I just don't know how a person can not pick option C lefium. This person is on a seduminoffin, but how does a seduminoffin have a seizure?

So, the doctor says, this person is on a seduminoffin, but how does a seduminoffin work on exams in terms of toxicity? It causes problems with a person's liver. Remember that any PQI that can cause the liver failure, acute liver injury, this person doesn't have any liver anything going on here. So, we're going to cross that off. And bupropion is not used to treat bipolar disorder, so we can cross that off. Respiridone is not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. It's not used to treat bipolar disorder. If your kidneys don't respond, then you will not be able to hold free water. So, you're going to be losing a lot of free water in your urine. So, your urine or small arity will be low. Your sermons are going to be pretty high. And that can cause hypernatrhymia. And then think about it. This person is also going out more often. And so, that can volume the pleated person. So, the person is going out in the sun. It's probably sweating more, losing more fluid.

That can actually potentially help you to hypovolume and make things worse. So, this person has lithium toxicity. I'm definitely going to go to option C for this one. It's just a simple easy thing. Question 44. A 32-year-old, nolly-gravid woman, comes to the office because she has been unable to conceive during the past 12 months. She and her husband have unprotected sexual intercourse three times weekly. Two years ago, she was involved in a motor vehicle collision. Cities can have the time-should absence of the left kidney. Okay, that's useful to know. She has no other history of serocelness and her only medication is a prenatal vitamin. She has no known allergies. An envidocyanis are within normal limits. Pelvic examination shows no abnormalities. Histero-sopping golgophies shown. When this patient conceives, she's at greater risk for which of the following pregnancy complications. Option E says phyramacrosomia. Option B says multiple gestation. Option C says oligohydramneus. Option D says preeclamsia. Option E says preterm labor. So, this question, there's obviously an image attached. Again, it's a preterm. There's obviously an image attached. Again, many of you that have listened to my podcast, you're probably pretty conversant with this. I don't stress out too much over images, audio, video, and all those things. Like the Throne Exams. Most times, if you just read a question carefully and know your information, you're going to be pretty, pretty set.

So, again, I'm not going to stress out over this. I'm showing some people that are trying to like analyze and over-analyze and do all these things. I just know in this question that one, this person is infertile. And two, this person doesn't have a kidney. Whenever you see a person that doesn't have a kidney, always think of those people having an atomic problems of the reproductive tract. I'm going to say that again. In a woman, this is a classic USMLE concept. You see a person that does not have a woman that does not have a kidney. Always think of an atomic problems of the reproductive tract. And I mean, if you look at this person's uterus, this person's uterus does not look normal at all. If you look at the image, but again, I don't really care for the image. This person is going to have a uterine abnormality. Many times, those people will notice that, wow, they have like weird shapes of the uterus. Or the uterus may have all these anatomic issues. And whenever you have issues with the uterus, even if a child implants there, there's probably going to be problems with that pregnancy. Either you may lose the pregnancy, or you may have a preterm labor, things like that, right? Because think about it. If your uterus is smaller than normal, right? Then that baby may not be able to grow enough all the way to like 37 weeks or whatever, for it to go into labor. So you're probably going to preterm labor. So I'm going to go with option E here, no question.

Now, let's look at some of these other answers, right? So option D says preclamsia. Well, usually people get preclamsia when they've had preclamsia in prior pregnancies. And you're going to see certain antecedents like hypertension, proteinuria, we don't see any of those here. So that's off. Oligohydraminus. We're usually going to find oligohydraminus when mom has, I mean, there are many causes of oligohydraminus. So let's say there's renal agenesis in the fetus. But again, we don't know that about the fetus. We know that mom doesn't have a kidney. And if, you know, mom has like placental abnormalities, there doesn't appear to be any of those problems. This is a uterine issue going on here. So that's off. Option D says multiple gestation. Multiple gestation, usually going to get that way you have like these assisted reproductive technologies. We don't see that here. So that's off. Option A says fetal macrosomia. Mom has to have diabetes. Mom has no history of diabetes. So I'm going to worry about option A. All right. Let's go to question 45. Ah, okay. It's a HPI question. So let's kind of scan through these. These questions are many times these HPI questions are really pretty easy to be honest with you. I think you've hopefully got in that sense from the one we've already done. The one or two we've already done. But basically again, I just tell people, come through these things and ask yourself, what are the things that so read the whole thing?

We're already very fast and ask yourself what jumps out at you. So this person is 14. She's female. And why did she come? She feels lightheaded. Okay. So for the past one week, she's been feeling lightheaded. All right. Okay. Almost lost consciousness. Okay. And then an experienced tunnel vision almost fell when getting out of bed. Right. So this person seems to have a lot of orthostasis. And this person was evaluated at 10 days ago for ADHD. Clothed in therapy and he cheated. I wonder what this person has. Okay. Let's continue. Sister is currently hospitalized for meningitis. A patient has been receiving prophylactic rifampin. Makes sense, right? If you're exposed to a person that has been in gochokom meningitis, you should be on prophylactic rifampin. Or safe tracks or stuff like that. But rifampin is fine. And then, past medical history, she has moderate persistent asthma, well controlled. And last time, she was a week ago. She was placed on steroids. Okay. And so, maybe having an adrenaline, she's an angol there, but whatever. And then ADHD, that knows that age eight years, has been on numerous different medications. We know that she was studying and applauding in about 10 days ago. About 10 days ago. 10 days ago. Okay. So, this person is on all these medications. A bit of all flotika zone, methylphenidide, clonidine, rifampin, vaccines, refined allergies. Okay. Parents are fine. Sister has been in jade. We know that psychosocial history has ADHD.

Doesn't do drugs or any of those things. Not sexually active. I will look at the vitals. Again, what's the thing that jumps out? This person, we see orthostasis, right? We see this person after studying for five minutes. The systolic blood pressure decreases by, 20 millimeters of mercury. Remember, if your SBP goes down by 20 or more, 20 is included. 20 or more millimeters of mercury with standing, that's orthostasis. So, that's the solid goes down by 10 or more, with standing for about 30 minutes or thereabouts. That's orthostasis. So, this person kind of hits both fronts. This person has orthostatic hypertension. That's what's going on here. If we look at the physical exam, honestly, everything seems pretty fine. So, I'll verse effect on which of the four people are doing this. So, I'll verse effect on which of the following. You should probably know what this is. This is going to be, you know, they put option E, I'll be the role. It should be clonidine, option C, methylphenidate, option D, predisone, option E, right, phampine. This is clonidine. Clonidine is an alpha. It's an alpha. It's an alpha-2 agonist that's used to treat hypertension. Remember, one of the classic side effects of clonidine is orthostatic hypertension. It's a very powerful visual dilator. It can cause orthostatic hypertension. Remember, if you stimulate the alpha-2 receptor, that's going to decrease categorical amino release. It's going to decrease an open-airfriend release.

So, if you have less an open-airfriend, you're going to have less stimulation of alpha-1 receptors on blood vessels. So, you're going to have not visual constriction, but you have visual dilation. That visual dilation is going to tank your blood pressures. So, that's actually pretty high-youtuna. Again, you see this is pretty much a basic science question. So, again, those things, they've just stepped three. Don't think they've escaped basic sciences. Basic sciences are certainly still tested on the US Emily exams. Basic sciences are still certainly tested on the US Emily exams. Let's look at the other answers. A bit or all. It's a bit of a toagonist. It doesn't really have much of any side effect. Yeah, it can cause hypokidemia because it increases the activity of the sodium potassium ATP-spomp, but that's probably about it. Methylfinidate. If you make you don't want to eat or whatever, but we're not told that this person is having trouble eating or whatever. So, no, that's not it. A prednisone. A 5 D course of prednisone, I don't think it's going to eat you. And the person just stopped the prednisone, let's see. The person had an examination five days ago. Okay, she completed it. It's like an examination a week ago. No, you have to be on steroids for a long time, for weeks, for months. For you to start having adrenaline, or whatever, if you kind of stop it.

So, if you're on steroids for like three months or thereabouts, that's when you want to eat or whatever, but one week, that's not a big deal. And then rifampin, it's going to color out your secretions. Red, orange, tears, urine, sweat. It's a paradoxic, it's neurotoxic. That's not what's going on here. So, I'm going to go with option B. Again, just make sure you know your basic science details for your exams. And again, if you love the way I teach, you really should consider my review courses. I held one yesterday, actually. But I have others that start to have a bio-stats class to do for step one to three. I have social sciences, quality improvement, ethics, healthcare systems class. For step one to three on Saturday, that's tomorrow. And then I have a 20 hour step to step three class starting on next week Monday. And then in June, I have a 50 hour class for step two, step three. Very helpful class will be going through 500 multiple choice questions. If you love the way I teach, you love the way explain pathophys, you love the way I make integrations. And you love just me talking through questions, right? Then these courses will be perfect for you. They're not lectures, they're me going through questions that are very high yield for the exam. I'm talking through the concepts and showing you all these integrations. I actually have a podcast that I made on the class. So you just check that out. I think you can send me an email through the website.

I think you'll find these courses to be extremely helpful. Lots of people have taken them and passed the exams, got in very high scores on their tests. Okay, let's go to question 46. So a 51 year old woman who comes to the office for a health maintenance examination, she feels well, she has no history of serosailness and text and medications. She smoked one pack of cigarettes daily for 20 years, what quit six years ago. So she has a 28 pack of smoking history. Posts is 80 per minute, respirations are 12 per minute and blood pressure is 12, 22 over 78 millimeters of mercury. An examination, pito, pulse is an absent bilaterally. A thermal brewery is heard in the left lower extremity, which of the fluene is the most appropriate next step in management. So option A says, been toxifying therapy. Option B says, peripheral artery catheterization, option C says, seromalypt studies, option D says, warframe therapy. Option E says, no further management is indicated. So if we look at this question, this is just sort of like a screening question. The general like tell people is this, if a person has a malphurist factors, you should probably screen them for stuff. But let's look at this, right? So option E says, been toxifying therapy. So if we look at this, you know, been toxifying, what do we use it for? We use it for treating peripheral arterial disease. But this person does not have PED, that's just the truth. One, we have no diagnosis, percent PED.

So you cannot just jump, prematurely, to treat me, if not done an ankle, break a limb, index. And this person doesn't have any symptoms of intermittent clodication. This person does not have PED. You do make up stuff that's not there. So option A is wrong. Option B says, peripheral artery catheterization. That's pretty invasive for a person that doesn't have any symptoms at all. So that's wrong. The person has absent PEDO pulses by lottery. They have a femoral bruy. But they really have no symptoms. So that's wrong. Option C says, serenely pit studies. Now this person has smoked a ton back in the day. This person is 51. So this is a female that is on the older end of the spectrum. So getting serenely pit studies actually seems reasonable. So I would say option C is probably right. A warframe therapy. This person has no indication of warframe therapy. They don't have a favela a fib. They don't have mechanical heart valve. There's no reason to do that. Option E says no further management. Yeah, but we should probably screen this person for hyper lipidini. Okay. Now question 47 says, 47 year old woman comes to the office for full-up examination. Three days ago, she was brought to the emergency department because of cellulitis of her regular extremity. And tremor thorium sulfur methoxasal therapy was begun. She has had no adverse reaction to the medication. She has kept her leg elevated and her cellulitis has improved moderately.

She also has hypertension, galt and congenital heart disease. Or other medications are lysinoprile, allopyrinol and warframe, five years ago, shown the went mechanical mitral valve replacement. Temperature to these 36.7 degrees Celsius, that's 90 degrees Fahrenheit. A pulse is 72 per minute and blood pressure is 120 over 83 millimeters of mercury. Examination shows a four by five centimeter aerothematosworm rash over the right-row extremity. There is no red streaking, vesicles or pyramids. There is no rash elsewhere. Posis in the lower extremities are intact, longs are clear to asceticion. On cardiac examination, a mechanical click is heard during S1. A great toilet, six-houlosistolic memory is heard best at the apex. The remainder of the examination shows no abnormalities. Results of lab studies are shown. What do we see? Blood here, hematocritis 35%, white count is 13,000. That's fine. Actually, that's not fine. That's actually elevated. The hematocritis is fine. Plutally count is fine. PTT is... I don't know the numbers of the top of my head, but the PT, obviously, they want to be pay attention to that. The INR is 5.2. That's very abnormal. This person has warframe toxicity. Which of the fluorine actions is most likely to have prevented the near-missing of the patient? Again, this is a classic, classic, classic, basic science question. It frees me as a near-missed, it frees me as a healthcare systems question, but to be honest with you, this is a basic science question.

This is a drug-drug interaction that you certainly need to know for your exams. So, I guess I pretty much told you the answer is option A. And again, you can probably tell that option A makes the most sense. Because this person has been on warframe for at least five years. And this person doesn't seem to have had any issues, but man, we put this person on Bachterm and this person starts having issues. So, Bachterm is probably the cause of the problem. So, the answer is going to be A. Option B is wrong. Dietary canceling is not going to help with your INR. Option C, ECHO, cardiography, no. This person has a super therapeutic INR. That's the problem. Option D says, Veno is duplex, ultrasound, no. No, this person doesn't have a DVT. If anything, being this super-clog-glitter, it's probably... Super-antico-clitter is probably going to make you not have a DVT. And this is allope, no, no, no, no. So, this is... Remember, Bachterm can cause warframe toxicity. So, the thing is, warframe is broken down by a cytokron P450 enzyme known as CYP2 C9. It degrades warframe. So, Bachterm inhibits that CYP2 C9. So, if you inhibits CYP2 C9 with Bachterm, then you won't break down warframe. Warframe is going to have a super therapeutic INR. That's a high-o thing to know for you, exam. So, that's why you should, again, do these medication reviews. You should do medication reconciliation when people get into the healthcare system. So, the answer is going to be A. The answer is going to be A.

Remember, alopearinol, the thing it interacts with is six-megaphtopurin, or, you know, it's close causing is a thioprate. So, those drugs are broken down by Zanctianoxidys. Remember, those anti-cancer drugs, they are very powerful and immunosuppressant. So, they can cause boomer's impression if you have toxicity with those. So, if a person is being treated for a gout and they are concretely being treated for something with six-megaphtopurinol, is a thioprate, that alopearinol will inhibits Zanctianoxidys. That's going to decrease degradation of six-megaphtopurinol. It's a thioprate. That's going to make those drugs a complete more. You can have some very, very nasty toxicity with those. That's actually pretty high-o to know for your exams. Again, the thing is step two, step three, these days, I begin to test a little of basic science information. That's why in many of my podcasts and many of my review courses, especially for step two, step three, I focus quite a bit on the relevant basic sciences for the exam. So, just don't ignore those things. I guess it's the big message I'm going to throw out there. Alright, so question 48 says, a 58-year-old woman comes to the office for routine examination. She has type two diabetes mellitus. During the past three months her fingers ticked blood glucose concentrations have ranged from 80 to 230 mi per deciliter. Previously, they ranged from 80 to 140 mi per deciliter. Medications are metform in an aspirin.

During the past three months, she has exercised three times weekly. Previously, she exercised once weekly. She follows a balanced diet. Despite exercise and diet, she has no had any weight loss. She is 157 cm, that's five foot two inches tall. And with 72 kg, that's 160 pounds, her VMI is 29 kg per meter squared. Examination shows a one by two centimeter, a rhythmical soft lesion of the posterior plantar aspect of the left foot. So, this person probably has some kind of ulcer or something. That very foot ulcer. Sensation to pimpre can touch is decreased over the ankles and feet. Immogluene is 1 C7%, which of the following findings are most likely to be present in this patient. Says glucose, insulin and insulin receptor responsiveness. So, this question is pretty straightforward. This person has type 2 diabetes. Remember, type 2 diabetes is primarily an insulin resistance problem. Simple as that. It's primarily what? An insulin resistance problem. So, you have an insulin resistance. Your body basically does not respond to insulin. So, you know, the third column that says insulin receptor responsiveness should be decreased. I'm not even going to consider any other answers about ANC. And the thing is, again, when you have resistance to something, means you're making a ton of it, your body is just not responding to it appropriately. So, your insulin should be increased. So, honestly, the right answer here should be option A.

And obviously, if a person has diabetes, they're probably going to have hyperglycemia. I mean, we clearly see in the question that this person is a blood glucose levels or kind of vacillating in the very high, higher figures from a mixed predestinator perspective. So, I'm going to go with option A. This is actually a pretty simple question. Okay, question 49 says, a 57-year-old woman comes to the emergency department. Because of a 2-day history of fever, chills, and sore throat. She is on D6 of a 70-course of tremor-primsofome foxesol, for tributin of cystitis. She has been taking Lycino-prionitely for two years for tributin of hypertension. She has no other history of serous illness and takes no other medications. Temperature is 30.6 degrees Fahrenheit. Sorry, 30.6 degrees Celsius. That's 101.4 degrees Fahrenheit. Pulse is 84 per minute. Respirations are 16 per minute. Blood pressure is 18 over 76 millimeters of mercury. Examination shows erythema of the firing spot, no exudates. No other abnormalities are noted. Results of lab studies are shown. So, let's look at this lab. Herumatic rate is fine, 30%. White count is 2200. That's low. That's low. Right? Again, the USML is the love this, these neutropenial questions. You should probably know this stuff pretty well for your exams. So, the neutrophil, segmented 16%, bands is 4%. This person has neutropenial. Simple as that. Limfocys 64%, monocys 16%, little account 225,000. That's normal, actually.

So, this person has febronutropenial. This person has febronutropenial. Which of the following is the most likely explanation for these findings? So, option A says acute mononucleosis. You're not going to be getting more than 57-year-old, just FYI. But let's continue, let me read the other answers. Option B says AML, option C says adverse effect of TMPSMX, tremethobrimsophamethoxazole. Option D says allergic reaction to lysinopryl. Option E says mylofibrosis, option F says sepsis syndrome. Right? This is a pretty clear court question. This person has neutropenial. What's in the queue stem that goes with neutropenial? It's going to be a back trim. Right? This person studied back trim 60s ago. Now, they're having all these problems. So, back trim probably factors in again, I'm telling you this. Drugs side effects are pretty high to know for the USMT. These don't ignore that stuff. I'm telling you, one of those things that you're going to regret pretty hard if you don't know those things. Right? So, this is going to be a back trim side effect. This is going to be C. It just doesn't make any sense for this person to have AML. But don't have any hour rods, nothing. We don't have any blast cells, we don't have any microscopy, like blood smear, anything. Right? This is not my lofibrosis. But I have my lofibrosis tend to have pansideopenia. We don't see that here. Mono, again, this person is 57. They don't have mono. Let's scrub that from your brain. Sepesis syndrome.

It's kind of a bogus answer there. So, I'm going to go with an option C here. All right. So, final question we'll do to the question 50. So, a 39 year old man is brought to the ED because of a three hour history of moderate pain and swelling of his right knee and ankle. His symptoms begin after he scaled a wall during an obstacle course. He landed awkwardly on his right leg and rode his right ankle. His knee buckled. He limped to the finish line. He underwent reconstruction of a torn, right anterior cruciate ligament 15 years ago. He and his boyfriend are engaged to be married. He feels safe at home. He does not appear to be in distress. Examination of the right knee shows mild tenderness to palpation. So, mild tenderness to palpation of the mid-sagital joint line. Adduction and abduction stress test in his stable at 0 and 30 degrees of flexion. Range of motion is full. Lachman test is negative. That's a test for ACL tears. So, his presence knee seems to be pretty fine. There's moderate tenderness to palpation of the distant aspect of the fibula. There are echimoses over the anterior lateral aspect of the right ankle. The ankle is swollen. There's no tenderness to palpation of the mid-sagital joint line. Range of motion of the ankle is limited to five degrees of dorsiflexion and 30 degrees of plant reflection because of pain. We should have a follow-in is the most appropriate next step in diagnosis. So, you know, they put knee ankle. So, they put many permutations here.

Like knee ankle, option A says get an extra on both. Option B says get an extra on the knee, but not on the ankle. Option C says get an extra on the ankle, but not on the knee. Option D says get no diagnostic test in the door. So, this presence, this, again, the thing is just be a straightforward thinker with many of these questions you're going to be set. It's when you start over complicating things that you start getting in trouble. This person scaled a wall and then the busted up their knees and their right knee and right ankle. Okay, so let's ask ourselves, how does the right knee look? Well, this question goes into extreme lengths to tell us this is negative. This is negative. This is negative. In fact, the only thing wrong with the knee is that, oh, you know, this person has like some mild tenderness, mild means that is a nothing burger. So, it's nice. He's nice. Fine. So, we shouldn't be, we really shouldn't be looking at this person's knee. Okay? We really shouldn't be looking at this person's knee. So, the answer is probably going to be between C and D. Okay, but let's, let's look at the ankle. Well, this person's ankle seems to have quite a number of problems. Again, even if you don't know the exact concept that I'm going to describe, there is no reason why you should test this person, why you should not test this person's ankle. This person's ankle, notice this question is like two halves.

They spend the first half talking about how this person's knee is awesomely okay. And then they spend this other half of the question, talking about how there's all these problems with the right ankle. You should probably image that person's right ankle. So, just going with gestalt, I'm going to go to option C. I'm going to go to option C. You know, no diagnostic testing for the knee, but let's check out the ankle. But again, what do you actually need to know here? You got to know your Ottawa, your Ottawa ankle rules, right? So, if you're Canadian, I would hope you never get this wrong going exact. I'm just kidding, but you should probably not get it wrong going your exacts. Ottawa ankle rules, although I don't know if it's from some Canadian, but anyway, okay, right? But the Ottawa ankle rules is basically a series of rules that tells you, should I get X-ray imaging on a person's ankle if they hang trauma? Honestly, there's three criteria. But as long as you meet pretty much any one of them, you should get an ankle X-ray. So, let me give you the divine Ottawa rules, the divine Ottawa rules. That will just make your life a little simple. Number one, do you have issues bearing with on that ankle? If you cannot bear with on that ankle after you have the trauma, then you should get an extra of the ankle. Number two, do you have tenderness around the lateral maliolis? Yeah, you should probably get imaging of the ankle.

Number three, do you have tenderness around the medial maliolis? Yeah, you should probably get imaging of the ankle. And the imaging is going to be an X-ray. So, this person, we can see that the medial aspect of the ankle has no tenderness. But the lateral aspect has tenderness. The lateral aspect has tenderness. They're achymosis, the ankle is swollen, the person could limp. So, that means the person cannot bear with it. This person meets at least one of the criteria mentioned. So, again, the easy way to remember the Ottawa ankle rules. Ottawa, O-W-T-A-W-A-N-C-R-O-R-O-S is one, can bear with it on the ankle. Basically, if you have tenderness over any of the malioli, it's going to be super specific. If you have tenderness over the posterior aspect of the tip of the lateral or medial maliolis, you should get an extra of the ankle. So, I'm going to go with option C here. Okay, so I think I'm going to go ahead and stop here. Again, I have a bunch of review courses. If you're interested, should be an email through the website. I hope you're well worth your while. I have this podcast on Apple, Google, and Spotify. I have a You Tube channel where I post the videos that I make. And I also want to learn for all the US Million complex exams. And I also have people with ear-ass applications and resinsy applications, like personal stipends and all those things. And then I have another website called Devine Intervention Lifelessens.com.

Every week, I actually just posted a podcast this morning. I think it was episode 256. Every week, I post about two podcasts where from a biblical perspective, usually about 10 minutes long, address a life lesson. Many people have listened to those actually and found it to be pretty helpful. There is an Apple podcast associated with that called the Devine Intervention Lifelessens.com. I mean, yeah, the Devine Intervention Lifelessens.com podcast. So, just check those out. I think you'll find it to be helpful. So, thank you for listening to me today. I'll see you in episode 524 of our wonderful weekend. God bless you and bye for now. Thank you.

HIV RNA polymerase chain reaction (PCR) testing.

Fever, myalgias, sore throat, anemia, and leukopenia, often mimicking mononucleosis but with a negative Monospot test.

Acute kidney injury (AKI) due to nephrotoxic myoglobin precipitation in renal tubules.

Uterine/reproductive tract anomalies, leading to increased risk of preterm labor.

Clonidine (or related agents).

1) Inability to bear weight, 2) Tenderness over the lateral malleolus, or 3) Tenderness over the medial malleolus.

Bactrim inhibits CYP2 C9, decreasing warfarin metabolism and causing supratherapeutic INR.

Insulin resistance (the body does not respond appropriately to insulin).

Trimethoprim-sulfamethoxazole (TMP-SMX).

Uterine/reproductive tract anomalies, leading to preterm labor.

Creatine Kinase (CK) due to muscle breakdown.

Bactrim inhibits CYP2 C9, decreasing warfarin metabolism and causing supratherapeutic INR.

Insulin resistance (the body does not respond appropriately to insulin).

Trimethoprim-sulfamethoxazole (TMP-SMX).

Uterine/reproductive tract anomalies, leading to preterm labor.

Creatine Kinase (CK) due to muscle breakdown.