DIP Episode 533 - 2024 USMLE Step 2CK Free 120 Discussion Part 11 (Q81-90)

Welcome, my name is Devine. This is episode 533 of the Devine Intervention Podcasts. In today's podcast, we're going to be continuing the series on the 2024 USMELES step to CK 312312. We've done the first 80 questions, so we're going to start off with block 3. I go to these two, hopefully go from questions 81 to 90. Let's get right into it. A 28 year old man is admitted to the intensive care unit three hours after undergoing a reception and an asthmosis of a small bar lingerer and an infrectomy because of a right-renowned laceration, so standard and motor vehicle collision. He also has bilateral, millimally displaced, pubic remi fractures. He's intubated and mechanically ventilated. He's receiving more phenomepropyl. He responds only to painful stimuli. Pulse is 110 per minute, ventilator rate is 12 per minute, and blood pressure is 133 over 68 millimeters of mercury. The abdomen is distended and soft, and the incision is clean, dry and intact. Since the operation, urine output has been 40 ml per hour and blood. During the past hour, urine output has been 5 ml and blood. In addition to intravenous administration of 0.9% saline, which of the following is the most appropriate next step in management. Option A, C Ts can have the abdomen and pelvis, option B, repeat surgical exploration of the abdomen, option C, transfusion of packed red blood cells, option D, ultrasoundography of the bladder. Again, before we start dealing with the answers, what's going on here?

So this person basically was in trauma and the person injured their kidney and their small bowel. And the person had surgery. Now since the surgery finished, the urine output has been decreasing. The urine output has been decreasing. So think about it. If you've had surgery, again, that's the thing about not just memorizing associations. Make sure you know the stories behind pathologies. When you see a person that has had surgery and they're not peeing appropriately, well, you'll be thinking of two things that, oh, maybe those this person have like periodical acute kidney injury. But another thing that's probably pretty common on the USML is urinary retention because anesthesia can literally grind your bladder to a halt and aesthetics can literally grind your bladder to a halt. So this person very likely has urinary retention. So now that we know that we didn't need to ask ourselves what answer choice addresses urinary retention. I'm going to venture option D, ultrasoundography of the bladder makes a lot of sense because that can help you measure like pulse voiders, it will and things like that. Option A doesn't really make any sense. Why do a city scan to access for urinary retention? We can do something that's less invasive. I mean less you know less radiation exposure. And option B makes no sense. It looks like the incision and the surgery went well. Option C makes no sense. We don't have his hematocrytosis hemoglobin.

His hemoglobin at least we don't see that it's less than seven. So I don't see why we should start transfusing. All right. Question 82. A 15 year old girl is brought to the office because of a 3 D history of the fused abdominal pain fever and vomited. She has cerebral palsy, cytosine versus and severe scoliosis. She uses a wheelchair for ambulation. During previous visits transferring the patient from her wheelchair to the examination table has been time consuming and has caused the patient discomfort. Today the patient appears uncomfortable. The physician decides to conduct the examination while the patient is sitting in her wheelchair. Temperature is 38.3 degrees Celsius. That's 101.0 degrees Fahrenheit. Post is 110 per minute. Respirations are 20 per minute and blood pressure is 110 over 50 millimeters of mercury. Postoxymidine room air shows an oxygen saturation of 100%. Examination shows mildly dry mucus membranes. The physician evaluated four previous patients today who had vomiting and fever. He diagnosed gastroenteritis in all four patients. The physician attributes this patient's increased pulse to mildly hydration and fever and he diagnoses this patient with gastroenteritis. The physician prescribes on dancetron and tells the patient to return if she has intractable vomiting or if abdominal pain worsens. Five hours later the patient is taken to the emergency department after her mother finds her listless and barely responsive. It's a long question.

Temperature is 38.9 degrees Celsius. That's 102.0 degrees Fahrenheit. Post is 180 per minute. Respirations are 35 per minute and blood pressure is 70 over 50 millimeters of mercury. Postoxymidine room air shows an oxygen saturation of 96%. C Ts kind of the abdomen shows volvulus. An emergency reception of necrotic bowel is done. Which of the following best describes the error that occurred? Option A says latent error. Option B says near miss. Option C says non preventable error. Option D says premature closure. Option E says systems failure. So what do you think? I mean you can see in this question this physician pretty much kind of jumped to conclusions. You know you had seen a bunch of people gastroenteritis and was like you have gastroenteritis. Jump to conclusions very quickly. Didn't even do any kind of diagnostic testing. I mean like literally this person has drank because membranes she's uncomfortable, blah blah blah blah blah blah. She's very you know she has a fever and all those things. And this person just jumped to conclusions. Didn't even consider alternative diagnoses. That's not a good way to do medicine. I'll tell you that right now. So this person this was a pretty classic example of a premature closure. Premature closure. You just jump to conclusions pretty quickly. Literally just think of it as I jumped to conclusions too fast. That's premature closure. So the answer is going to be D. I don't believe this is systems failure.

It's not like there was any issue with the system. No. The physician just did a bad job. That's what happened. Option C says non preventable error. No. This error could have been prevented if the physician put a little more thought into what he was doing. Option B says near miss. This is not a near miss. And near miss is where you make a mistake but man the patient doesn't get harmed. It's a near miss near miss. The word is very descriptive. Legion error is when the healthcare system a no errors happened but it's almost like a mistake waiting to happen. It's almost like a mistake waiting to happen. Right. The healthcare system is set up in a way where people are more error per all right. Let's go to question 83. So the answer to 82 is 83 says a 27 year old man comes to the office because of a one month history of depressed mode and fatigue. Here reports that he takes him at least one hour to fall asleep at night. He has had decreased concentration at work and decreased interest in socializing with his friends. He no longer exercises. He has a epilepsy well controlled with levatoracetyl. I can almost promise you that but propion is one of the answers here. Like there's no reason why the MV should more write a question like this and pull but propion is an answer. And that is correct. All right. But let's continue. Physical examination discloses not normalities or mental status examination. He has a sad mode and is briefly tearful blah blah blah blah.

He has no suicidal ideation hallucinations or delusions which are the following is the most appropriate pharmacotherapy. There's a slam down questions. Persia has measured the presence of disorder. Okay. Let's look at the answers. Option A says a prozolem. Option B says a repy presale. Option C says bupropian. Option D says buspiron. Option A says mertaza pain. Mertaza pain. Mertaza pain. Mertaza pain. Mertaza pain. So what do you think? This person has depression and they have a history of seizures. What is the drug you should certainly not give them? It's certainly not give them bupropian. Remember bupropian is an NDRI. It's an repinephrine dopamine or optic inhibitor. It lowers the seizure threshold. You have a history of seizures or disorder that predisposes you to seizures like anorexics, polymix that could have electrolyte abnormalities. No bupropian for you. C is for sure wrong. Bospiron D is wrong. It's like a second line drug for generalizing anxiety disorder. RIP presale kind of works like a dopaminergic agent. You know, really going to be jumping to that as first life or depression. A prozolem is a benzene. We do use benzene as for depression. Option E says mertaza pain. Mertaza pain is an untidy present. It's an alpha-2 blocker. Remember the alpha-2 receptor when you stimulate it is an inhibitor. It's a protein-cobotor receptor that decreases neuroepinephrine production. So if you block that inhibitor receptor, you'll increase neuroepinephrine production.

Remember mertaza pain does not have sexual side effects, which is kind of great. It helps with sleep and it also stimulates your appetite. So just something to keep in mind. So I'm going to go with option E for that one. That's a pretty easy question. Question 84 with a scary set of images. Okay. A 23-year-old and oligrafid woman comes to the office because she has been able to conceive during the past year. She and her husband have had regular and protected intercourse during this time. The husband has no children. Prior to attempting to conceive, the patient regularly used depot, a drugsy progesterone. Mences are currently at regular 20-D intervals with occasional mid-cycle abdominal pain. Previously diagnosed as middle schmutz. She had a ruptured appendix at each 17 years and pelvic inflammatory disease at each 19 years. At each 21, cervical cytology showed a low-grade screen-mossing trapethelial lesion. Repetal cervical cytology won't year later showed normalalities. Crane medications are a prenatal vitamin and occasional libeprofen for mid-cycle abdominal pain. She's 168 centimeters, that's 5 foot 6 inches tall, and weighs 59 kilograms, that's 130 pounds, BMI's 21 kilograms per meter squared. Vital signs that within normal limits, physical examination discloses normal normalities, hysterosalpingographies done and x-rays obtained during the procedure are shown. Without treatment, which of the fullings the most likely clinical course for the patient?

Option E says female factor infertility. Option B says had a telephone option C says recurrence spontaneous abortions. Option D says successful pregnancy within the next year. What do you think? What do you think? And again, there's an image here. I'll talk about the image after I've answered the question. I remember I've said this so many times on this podcast. As you know, this series that many times the images are not absolutely necessary to you getting your questions right on your exams. Like for example, reading this question again, it's a classic story. If you notice with many of my podcasts, I love to use the story. I love to use the high-yield history. Like look at this question, this person is infertile, and this person has had PID. Well, people that have had PID, they've probably scarved their uterus, they've probably scarred your fallopian tubes. Right? So those things is going to make it very hard for your eggs to migrate to be met by sperm. Right? So for me, that's what I'm really thinking in mind that there is a problem with this person's reproductive tract. So I then ask myself, what's the answer that's most closely related to that? Option D, successful pregnancy? I don't think so. Option C says, requiring spontaneous abortions. No, we should see that in people that have antifusually bit syndrome or people that have like some kind of disorder, like that message of the shape of the uterus, you know, like a T-shaped uterus of stuff like that.

I had a T-teformal no, right? This person doesn't have any history of stuff like that or anything like that. So I'm going to go to option A here, female factor, infertility. I absolutely believe that's the correct answer. And again, notice, I didn't even talk about the image, but fine, whatever. If you look at the image, this is a hysterisal pingo graph. You basically, you should have contrast into women's uterus, and you're supposed to travel, go through the fallopian tubes and then X-traverse it. But notice, we don't see any extravacation of this person's of the contrast. You can just see the contrast just within the uterus, right? Alone. So that pretty much tells you something that maybe something ring with this person's fallopian tubes or something like that. So again, I'm definitely going to stick with option A here. Again, I may be wrong, but I'm fairly certain that that's what's going on here. But again, even if you don't understand the image, honestly, I could care less for the image, you should still be able to get this question right. All right, question 85 says, a 50 year old woman comes to the office for a health maintenance examination. She feels well. Medical history is unremarkable. And she takes no medications. There's no family history of serosalitis. Physical examination, including breast examination, discloses no abnormalities.

A mammography shows a cluster of 20 pleomorphic microcalcifications in a one centimeter area at the two clock position of the right breast, which other following is the most likely diagnosis. Option A says, doctor across the norma inside too. Option B says fat necrosis. Option C says fibroidinoma. Option D says mastitis. Option A says sclerosin adenosis. Again, this is an easy question. You see my crop calcifications in a person's breast. The woman's breast, especially a woman that is older, this woman is 50, kind of read about breast cancer, right? So what's the answer? That's the closest to breast cancer here. Don't go to option A, DCIS, doctor across the norma inside too. Doctor across the norma inside too. Fat necrosis usually see like a resinneachrof trauma to the breast. We don't really see that here. Fibroidinoma again, it's going to be an a much younger female that is, you know, still going through a man's ears. Mastitis is going to be a woman that has a breast infection after delivering a child. As we know, breastfeeding does not going on here. Sclerosin adenosis. Supernone specific. So again, there's just not much in the question here that tracks specifically with those sclerosin adenosis. So we're going to, that cannot be the answer. Okay. So the answer here is going to be a, all right. So let's jump to question 86. A community has created standard of care guidelines for ambulatory patients with several command diagnoses.

The community standard of care for patients with asthma is ammo, pulmonary function testing. Resin analysis of billion records from one clinic in this community shows that only 34% of patients with asthma at the clinic undergo pulmonary function tested. In acting which of the following procedures is most likely to improve this clinics adherence to the community standard of care for patients with asthma. Option A says, annual chart reviews of patients with asthma and feedback to the physicians. Option B says diagnosis driven reminders in patient charts. Option C says, placement of flyers in the clinic waiting room. That remind patients with asthma to undergo an ordinary function tested. Option D says, primary function testing of all patients examining for respiratory symptoms. Option E says, primary function testing of patients with asthma at each examination preceded by an exacerbation. Okay. So what do you think is going on here? Well look at this. This is a case of the providers, the physicians are not adhering to standards of care. That's not a good thing. Right. And the thing is again, we're human beings. We forget one of the best ways. So this is like a concept. This is a construct of wow. People are not adhering to standards of care. You don't have to penalize those people. But try to remind them more frequently. People need reminders. Reminders are very useful. So whenever you see questions like this where people like know what to do, but they don't do it regularly.

Remind them more of the that's the principle you want to keep in mind. So option B makes the most sense here. Right. Diagnosis driven reminders in patient charts. You know, option A is wrong. Animal chart reviews. You know, we'll flip back to the physicians. And only that's not a frequent enough reminder. Option C says, placement of flyers in the clinic waiting room. Now, how many people reach flyers these days? Option D says, PFT for all of all patients examining for respiratory symptoms. No. This guidelines for what I have asthma, no, but respiratory symptoms. Option E says, PFT of patients with asthma at each examination presented by an exacerbation. How frequently the exacerbations happen? That's wrong. All right. So the answer is going to be D. Or should 87. A 27 year old woman, gravity, that one power one comes to the emergency department because of a 1 D history of moderate opinion, her right breast. Three weeks ago, she underwent CZR in delivery of a healthy newborn, a term because of bridge presentation. She's breastfeeding, but the newborn is not latching properly on the right. She has no history of serious illness. Medications are a sedimental thing for both stop pain and a prenatal vitamin. Temperatures 3.9 degrees Celsius, that's 102.0 degrees Fahrenheit. Examination of the right breast shows a 5 by 2 centimeter wide-shaped ear of very thin and moderate tenderness. The left breast is normal. At the moment, examination shows a well-heating surgical incision.

In addition to beginning and anti-pirative therapy, which of the fullings the most appropriate next step in management. Option A says, application of a breast binder on the right. Option B says, like, loxacillin therapy. Option C says, floconazole therapy. Option D says, fine needle aspiration of the erythematos area. Option E says, no further management is indicated. Okay. So again, what do you think is going on here? What do you think is going on here? This person has a pretty clear cut case I would say of my status. You're just a little bit of baby. You're having difficulty with latching, right? So the baby is biting mom's nipple, blah, blah, blah, blah. These are all, you know, creatine breaks in the skin. These are all pufferous factors for my status. This person has my status. This person has my status. And when the person has my status, you're going to treat it with the most common cause I will see of my status. I think it's staphores. At least classically, that's what they go out from the accepts. Staphores. Staphores, staphores, staphores. So you want to give an antibiotic that covers MSSE, MSSE, methylsilinsensitive staphores, like, dichloxacillin or oxacillin. So I'm going to go to option B here. Option C makes no sense for lconazole. It's an antifongal. I'm not going to be doing that here. All right.

Usually, fluconazole on the USM at least is something we put people that have had crypto-coconut meningitis, you know, typically for patients, crypto-coconut meningitis, we're going to treat them with IVM for terracing, VM, five flu side was it. But for about nine to 12 months afterwards, we're going to put them on fluconazole to reduce the risk of recurrence. So that's wrong. Option D says, FNA, come on. This is my status. You're not going to be doing an FNA for you got a mileage, my status is wrong. Breast binder is not really going to help with my status. Okay. Now, I remember this one. She'll keep breastfeeding. She'll keep breastfeeding. That's a important tip. Okay. Option Eid says, a 12-year-old girl is birthed to the office by for a well-child examination. She feels well. She has no history of serosailness and receives no medications. Menarki has not yet occurred. She's at a 30th percentile for height and 40th and 60th percentile for weight. Examination of the breast shows no glandular tissue. They are really full of the skin corners of the chest. There's no pubic hair. The remainder of the examination shows not the malities, which of the following is the most appropriate next step in diagnosis. Option E says, measurement of serum FSH and LH concentrations. Option B says, measurement of serum growth hormone and virus in concentrations. Option C says, MR of the brain, boy, that looks like a lot.

Option D says, extra of the left hand and wrist to determine bone or should E says, no additional diagnostic steps are indicated. So what do you think? What do you think? Is there anything wrong with this girl? I know some of you may be thinking, oh, divine. This person has delayed puberty. But hey, what's the criteria? If you're a girl and you've hit each 12 and you don't have like breast butts, that's delayed puberty. Or if you're a boy and you've hit each 14 and your testicles are not getting big, your testicles aren't getting big enough. Usually, I measure the testicle of volume, I think like four million liters or something like that, then you have a problem. This lady, look at this, is clearly described. She's 12 years old and we see that, it's a mission of the breast shows no glendulot tissue. They are really full of the skin corners of the chest. So this person seems like, you know, is having some kind of outline of the breast. And beyond that as well, I would say, if you look at this, this person does seem to, like a lot of this question just shows this person is fine. She's fine. She's fine. She's fine. She has a good height percentile, good width percentile. Right. Don't stress about this. It's not a big deal. It's not a big deal. It's not a big deal. Right. So this lady has breasts. Right. At least, she begins to show out, ones of the breasts. So I'm not too concerned about this. So option E makes a lot of sense here. Option E, you don't need to do anything here.

Extra of the left hand and wrist, we do that for constitutional growth delay. You know, when we're worried about like growth delay, you know, if we're like, ooh, and I've talked about this in a previous series, in one of the questions for this series, if a mom is speaking, where we're differentiating between constitutional growth delay and familial short stature, where you get an extra of the left hand and wrist. And then compared to your chronological age, we don't need to do that here. We don't see that problem here. MR of the brain is a lot. Measurement of certain growth from an infiroxium. We don't see any evidence of growth from one issue of thyroid issues, measuring FSH and disemizing hormone. We don't have to do that because this person doesn't have an organic problem. This girl is literally normal. She's literally normal. All right. Let's go to question 89. A 42 year old woman comes to the office because of a two month history of episodes of lightheadedness. And lots of consciousness for 10 seconds. The episodes occur two to three times weekly at work. She leads, she says her lightheadedness resolves after she eats snacks. I wonder what rad that is. During this time, she also has had a 9 kilogram, that's a 20 pound week game. She has no history of serosyolnes and takes no medications. She is 160 centimeters. That's 5'3 inches tall and weighs 72 kilograms. That's 160 pounds. A BMI is 20 kilograms per meter squared. Vital signs are within normal limits.

Physical examination, including neurologic examination shows normalities. Serum glucose concentration is 41 milligrams per decilator. Serum CPAP type concentration is 0.5 nanograms per millimeter. Normally 0.5 to 2.5. And serums link concentration is 80. My curl eye use per meal. Normally is 5 to 20. See this kind of the abominance. Most likely the shortage of the following findings. Option A says, do not know mass with multiple liver mitts. Option B says fluid field mass between the posterior aspect of the stomach and pancreas. Option C says, low density mass in the head of the pancreas obstructing the main duct. Option D says, vascular mass in the neck of the pancreas. Option E says, no abnormalities. What do you think is going on here? So we see this person, you know, has basically weeple striad. They have like signs of hypoglycemia, we get lapse or G, we see hypoglycemia, we feed her G hair symptoms in proof. That's what weeple striad. Typically when you see this, we're like, ooh, could this be an insulinoma? Remember an insulinoma? It's going to be producing a lot of insulin. So insulin will be high like we see here. But you'll see that plate will also be high. Whenever you have excess insulin from an endogenous source like your body like an insulinoma, your insulin and your CP apply to be high. This person's insulin is high, but boy, the CP apply this very, very low. That's not consistent with an insulinoma. So this person is injecting insulin.

This person essentially is trying to fake these symptoms. Okay. This person is essentially trying to fake these symptoms. Transually trying to fake these symptoms. In fact, we can easily see this person probably has factitious disorder. They're injecting insulin. They're injecting insulin. And honestly, I'm not surprised with this week's gain. Insulin is a growth factor. Insulin causes people to gain weight. That's why this person is gaining weight. So we shouldn't find anything on the image. So the answer is, you know, they give a bunch of answers here about pancreatic cancer. But no, it's not. This is not an insulinoma. This person, he's not supposed to see anything. This person is basically just injecting an exogenous insulin. Exogenous insulin does not contain CP apply. That's why the CP apply is, is is is not commensurately high, like we see with the insulin levels here. All right. Question mindy, our hospital with a large ICU would like to improve communication among team members. Who care for patients with complex conditions? Research has shown that team communication is most effective when one clinician is designated as the team leader and as a responsibility for directing the care. The team leader ensures that all team members here are common understanding of the patient and openly discuss their views about the case. The common understanding includes the patient's diagnosis, prognosis and care plan.

This allows the team to quickly recognize when new data divide from the expected and then reassess the teams approach to the patient. We sort of find is the most appropriate method for maintaining a common mental model among all team members. Option E says conduct weekly structure team briefings and daily holdings. Option B says educate all team members on protocols for common illnesses. Option C says have the team leader discuss the case with each team member individually on regular basis. Option D says maintain a consistent team of intensivists in the ICU. Option E says maintain a disease specific ICU. What do you think is going on here? So basically this question is a very easy question. You're saying you know what can we do to maintain a common mental model among all team members? Well I want to maintain a common mental model then you guys should meet on talk. You guys should meet on talk. These are easy and why holdings if you are working in any hospital of note many hospitals these days have these team holdings right so I'm going to go to option A right weekly structure team briefings daily holdings. That's going to make sure that everybody is on the same page. Option B says educate all team members on protocols for common illnesses. Now educating no you need to talk about your actual patients. Option C says have the team leader discuss the case with each team member individually?

No that is not encouraging team among all team members not individually team members of just the mixed sense. Option D says maintain a consistent team of intensivists. You guys still need to talk. Option A says maintain a disease specific ICU. That's pretty expensive to do so and it depends on the amount of volume that you have. So I think that's it for today. Thank you for listening to me. If you're interested in new of my review courses for step one to step three I have a separate podcast I made on that. I have a bio stats class today. I have a social sciences and ethics class tomorrow. I have a 20 hour step two step three class next week and then the first week you may have a 25 hour step one review. These classes do not lectures. The big focus of many of these classes is to use scenarios because that's what's going to be more useful for you exams and I make great efforts to explain pathophysiology and also make integrations across multiple disciplines. If you love the way I teach I think you'll find the class to be extremely helpful and also devote time to taking an answering people's questions. And then I have a 50 hour class for step two step three to 500 multiple choice question class taking place in the month of June. Very helpful class and I think it's something you're going to be incredibly helpful.

And then I also have an enterprise solution that I will be discussing in a future podcast where if you know your school has dedicated peers that they put everyone through and your school is looking for a course to give to all your students like all the students for a particular year I can certainly help facilitate that I have that specifically available as a separate entity. So if you're interested in any of that you can have your school's dean or your medical student office reach out to me or you can just shoot me an email through the through the website or just send me an email through the website. So I also for one year and for all the USMAD and complex exams, Met School exams, shelf exams and I have these podcasts on Apple Google and Spotify. I have a You Tube channel where I post the podcasts that I meet. And then I also have another I also help with ER As applications and personal statements and rec letters. Basically application advice and I've done this for years and I have a legal track record there. And I've on the website called divine intervention life lessons.com pretty much every week on Fridays and Sundays I post a 10 minute podcast where from a biblical perspective address a life lesson. We have like 265 episodes on there. There is actually an Apple podcast associated with that called the divine intervention life lessons podcast. Well the actual website is divineinterventionlifelessons.com. So thank you for listening to me today.

I will see you in episode 534 I believe. So God bless you. Have a wonderful weekend and a bye for now. Thank you.

Staphylococcal infection.

Oxacillin/Diclloxacillin (to cover Methicillin-Sensitive Staphylococci).

Bupropion.

Jumping to conclusions too quickly without considering alternative diagnoses or sufficient testing.

Poor visualization of the fallopian tubes/uterus, often due to scarring (e.g., from PID).

Ultrasoundography of the bladder (to rule out urinary retention).

It lowers the seizure threshold.

Ductal Carcinoma In Situ (DCIS).

Exogenous insulin administration (factitious disorder), not an endogenous source like an insulinoma.

Implementing diagnosis-driven reminders within patient charts/EH Rs.

Ultrasoundography of the bladder (to rule out urinary retention).

It lowers the seizure threshold.

Ductal Carcinoma In Situ (DCIS).

Exogenous insulin administration (factitious disorder), not an endogenous source like an insulinoma.

Implementing diagnosis-driven reminders within patient charts/EH Rs.