DIP Episode 248 - New Step 2CK Free 120 Q 1-10 (2020). A sample approach to reasoning through NBME questions

Okay, welcome. My name is Devine. This is episode 240 of the Divine Intervention Podcast. In this podcast, I want to go through some of the new free 120 questions just to kind of explain to people how they should probably consider reasoning through these NV Me questions. Because as many of you know, I made a post already recently of how this new free 120 is probably the best representation of the current exam. But again, I just want to walk through a bunch of questions. In this podcast, now I almost think you can maybe think of this as like a rapid review series to be honest, I feel like maybe like series 41 or something. But basically, I'm going to be talking about the first 10 questions in the in the set. If I have more time in the near future, I'll make more podcasts talking about other questions in the set. And I'm going to paraphrase the question, the questions, right? I don't want to be reading or word forward, right? And then just as a reminder, if you're interested in participating in the in the USML East of TUSIKI high-yield review course, it's next week Saturday. Just reach out to me, send me an email either through the website or you can email me at Divine Intervention Podcasts with an sgmail.com and then we'll set something up. I'll give you some more information about the course. But basically in a 10-hour period, I will cover like most of the high-yield information that's classically tested from PEED surgery, OBGYN, IM, Neuron, and Psych.

And again, it's made a 1 D course because in 10 hours, right? I basically planted that we just also help people build in stamina, right? So basically, the way the course runs is it will be from like 6 to 10 a.m. Pacific time, known to 4 p.m. Pacific time, and then 6 to 8 p.m. Pacific time. And again, I've had almost a hundred people participate in the course. They've all had pretty good experiences with it. At least always ask people at the end of a recourse, they all do want me to improve. And again, uniformly, most people have pretty much had a good feedback with that. Okay, so let's jump right in. So question number one, so I have the 68-year-old guy, they bring him to the hospital for two days, right? So again, always pay attention to the acute of a presentation, right? So for two days, right? He's been with the thargic, having tremors, he's an alcoholic, he uses a ton of drugs, right? And you know, he has stopped using alcohol for like two weeks, has cirrhosis, right? And he takes a multivitamin, and he should drink a ton of alcohol, right? Every day. And you know, his ill, his son, the land, right? So you can see mental status anomalies. He's in February, he's, you know, also he's a hundred, he's a little too kipnic, and his blood pressure is a hundred over 60, his pulse, oxygen is fine. He has classic signs of instantiastial verte disease, you know, like, sclerolyctus, societies, edema, right? Remember, you can get edema if you have liver disease, right?

Because you're not making protein, you're not making protein, if you don't make any protein, there goes the oncotic pressure in your blood, right? So if you don't have oncotic pressures, you're going to have a edema, right? And then they tell you that, you know, he's, he's cranial nerve, the intact, his muscle strength is four of a five throughout, so not great, but not bad either, right? So, you know, when he's awake, you know, has this tremor of his forearms and hands, and then he suddenly loses his muscle strength, his speech is normal, he can follow commands, his t-billy is three, right? And he's blood and urine cultures doesn't grain even, right? So they now see, which of the following is the most likely to improve the spacial condition or movement disorder, right? So if you kind of look at this question, see that this is basically an alcoholic with mental status anomalies, right? I could onset mental status anomalies, right? So in this kind of question, you're probably thinking about like hepatic and cephalopathy, right? That's one thing you're considering. And the thing I may be considering here is a wrenky course of cough syndrome, right? And then another thing you also may be thinking about here is SBP, spontaneous abacteria parietanitis, right? So those are the three things that should be on your differential when you're approaching this question, right? And obviously there are key differences between these three disorders, right?

Like SBP, usually those people have abdominal pain, right? They'll have abdominal pain, so when you pop it, the abdominal hurt, they usually have some kind of fever, right? And you have like various subtle mental status anomalies, right? And again, this person is in February, this person has a side, but those who have abdominal pain, right? So we can pretty much go ahead and cross up, cross that off our differential. And I think you also think about here is, is a hepatic and cephalopathy, right? This person does have auto-demental status, this person does not have a fever, right? And again, for the most part, right? This person is, you know, this is just altered, some are lent, right? So this is probably more hepatic and cephalopathy, but again, to consider the last one, wrenky course of cough, right? So wrenky is a triad, right? Of a person being confused, having abdominal plezia and having an etaxia, right? So this guy's confused, obviously, right? But abdominal plezia, he doesn't have any eye findings, etaxia, he doesn't have any, like, wrenky, anomalies, right? And he's not making stuff up, right? He's not having confabulations and all those things, right? So again, you can pretty much go ahead and cross that off as well, right? So if you notice again, when I looked at this question, came up with a differential, right? And basically, like, right, like you just basically then try to play like this matching game, right?

Most of the questions seem to be struggling with hepatic and cephalopathy, so that's what we'll go with, right? And we know hepatic and cephalopathy, you can try to unlock two levels, right? Lactylose is converted to lactic acid by your GI flour, now bind up ammonia, right? And then you'll make it into ammonia, my ants, that's not really absorbed very easily. So you basically put it out, right? You're going to have a nasty diarrhea. You don't want to be sitting next to a person that's on lactylose in the plane. That's going to be a long trip out there, that right now. So, and then again, obviously, right again, if you notice, I kind of thought of this differential, where you, and actually, maybe let me see one more thing. So, refaxi means another drug you could also use. But again, look at one smart thing the MbMe did, right? Again, they put lorazapam, right? Lorazapam, they just threw that in there just to make you think about, oh, maybe this person is having alcohol, we draw, right? But again, this person still drinking alcohol two weeks ago. Alcohol, we draw something that, oh, you stop these and going, they ain't going into trouble, right? That's a very nice bogus answer there. Again, IV vitamin B1 therapy, right? That's what you give for a person that has a, like, rainy, or crystal cough, so syndrome. And then option A says IV vancensethapine, right? That's like super, very spectrum, right? Super, very spectrum.

And they're really telling the question that is blood and hearing cultures don't go squat, right? And again, if a person has a, for a person has SBP, right? So, we're going to be using a third gen cephalosporing, right? You're going to use a third gen cephalosporing, like cephotaxi, more cepatriaxi, right? So, vancensethapine is a little too broad, right? Vancray. Remember, it covers mersem, gram positives, right? So, that's not going to be helpful in a person with a gram negative infection because remember, most times SB Ps cause by, like, equalion stuff like that. Cephypym is a fourth gen cephalosporing that typically your name being exempt is used for, just for pseudomonas. Okay, let's jump on to the next one. This next question is kind of long, right? So it's like some 45-year-old female, right? Again, pay attention to the timeline. It's a three-day history of progressive sharpness of breath, having hemoptysis, she's febriol, and then over the last three months, she has been having like these peripheral neuropathy, right? No shields, and then six months ago, she was diagnosed with asthma, right? And, you know, she's taking an inhaled steroid and a bit of twaggedness, so she's fine there. Doesn't have any history of serocereocellinestics, no meds, and she's febriol, she has a mild fever, she's tacky cardic, she's the kidney, couple of pressures, it's up, but it's okay, not worried about that.

And then our other set is, is okay, it's 92%, you can hear crackles at the right long base. And then, on your logic exam, right? She has like a decrease sensation to pin prick over the lateral aspect of her left-foot extremity, right-foot extremity, she has good muscle strength, babinski's absente, had deep tendril reflexes are fine, right? And then, right, the most appropriate next step in diagnosis, right? So again, for this question, you're thinking, okay, spursin probably has asthma, okay? Well, she does have asthma, right? But the thing is, you'll kind of be weird for the imbibri to write a question where the right-foot extremity long-ass question with like 15-16 sentences, and then the pain attention to literally like, the lyrics spend one question, one sentence on asthma, right? And then like nothing else, right? So then there's something a little worse than asthma that's going on here, right? Again, most of the question will focus on what the right answer should be, right? So you see this person, if you want to summarize this question, she's got asthma, right? She's got all this peripheral neuropathy, right? And the asthma is kind of weird as well, because this one is 45. Most people that have diagnosed with asthma, get it when they're younger, right? It's kind of bizarre. So you can already begin to tell that there's something bizarre going on here, right?

So she has asthma, so let's say, oh, let me show you that, I know it's at 44, because it was six months ago, right? And then she has this fever, has these long problems, has this peripheral neuropathy. Basically, I will tell you this right now, whenever you see like a person having a disparate set of symptoms in multiple systems on an imbibri that's usually a pretty great clue that the person has of some kind of vasculitis, right? Some kind of vasculitis. So they put a bunch of answers here, right? So they put CT and geography of the chest, right? That's something you think about if a person has like some kind of PE, right? Or some kind of acureliotic syndrome, lecheotic dissection, if you have a hemodynamically stable, we don't see any evidence of that here. So we can pretty much go ahead and skip that. Determining serum is activity, right? That's something you do for a person who has steroid doses, right? Structoid is something you check the ACE levels, the ACE levels tend to be higher. Remember, those people also tend to have hypercalcemia because the macrophages, right, make one alpha hydroxylase, the epiphiliate macrophages that line those of non-chyseding granulomas, they make one alpha hydroxylase, they'll make more active vitamin D. And then, option C says measurement of seromygychocentral, let's maybe keep that for now. So pretty good answer actually. Masonteric angiography, right?

So my masonteric angiography is something you typically get older when a person has like some kind of masonteric is chiskemiether, acureacronic, right? Those people have like abdominal pain and stuff, we don't see that here, so we can cross that out. And then option E says serum antaglomerular, bismynambrane, and say, right? This is something you do for good pastures, right? Remember that linear pattern on the middle fluorescence? Good pastures is going to be in a younger person, usually in their 20s, low 30s. And I've never seen a good pasture question that is in a woman before. It's almost always in metclassically on exams. Again, these people are not trying to trick you in this test, right? So we'll go ahead and cross that off, right? And then option F says serum antanutrophil, so plasma antibody assay, right? So auto antibody assay, right? So anchor, right? Anchor goes with these vasculonities, right? So let's keep that. And then option G says a sweat chloride testing, right? That's cystic fibrosis. Usually people, I mean people with CFD can live closer to the age of 50, right? But again, this one must have had problems from when she was much younger as a kid, right? This is not CF, right? This is kind of an assay, you can easily kick out there, right? So we're between serum IgE and serum anchor, right? So again, we'll worry here about this person having some kind of vasculitis, right? So these are classics in where people kind of end up with an exam.

They're like, oh, I mean 50, 50, what do I do? Well, if you're in a 50, 50 circumstance, one smart protein thing to typically do is just ask yourself, which answer is more specific here? Like there are some vasculities, right? That has associated with anchor. You know that for a fact, right? And you know, measuring serum IgE it's helpful and fine, whatever, but the thing is that's very non-specific, right? So typically, right? Specific answers to questions that kind of hit out to what the question is kind of moving in that direction, you know, typically end up being correct, right? So this is going to be, this person has strokes, right? So this is going to be a PNK, right? Remember, your anchors, right? With your vasculities, there's like CNK or Wagoners. Remember Wagoners is now called GPA, Granolomatosis or Polyanjitis. There'll be hemoptuses, hematuria, sinusitis. We don't see that here. Another thing you think would PNK is microscopic polyanjitis. Basically, that's a diagnosis of exclusion. The rarely favorite test that on exams. I mean, I'm sure you may have seen it in the Cubans a lot, but they almost never tested on exams because the presentation is very non-specific, but truck straps, right? EGPA, right? Eosenophilic Granolomatosis, Polyanjitis. It's going to be a young person. It's going to be a person that, you know, gets asthma, like it's basically like a three phase disease. So typically, right? Those people have asthma.

First, that's the first thing that will happen in there. That in be me question. And then after the asthma, right? The second thing that will then happen is they'll then enter a phase where their Eosenophils are super high. Like, they'll have like crazy high levels of Eosenophils, not IgE. Eosenophils, right? That's why that option C is a very, that Ig concentration, whatever. It's a very nice bogus answer there. That's why I kind of kept it, right? And then after that, they'll now start going into like the almost like a systemic phase, where they have this vasculotic phase, where they start attacking the different organs, right? So, many times you see them have like peripheral neuropathy, right? So the, some of you may be worried that, oh, the way in this thing is kind of like a little non-specific. Well, let me just tell you something that will help you go towards stroke strokes or your tests, right? If a noticeable person have asthma in the question, right? But they have asthma and many other things, they're like, this is a little too much asthma. Like you see asthma, you see like crazy high Eosenophilic counts. So they may give you a CBC. I noticed that the Eosenophilic percent is like 10%, 15%, that's, that's ridiculous, right? And then you notice the person having like these pulmonary findings and then they have like all these like peripheral neuropathy, right? It can be like a mononirapathy, pulmonary apathy, if you see that, when you think about stroke strokes.

And for the most part, you treat stroke strokes with, with steroids, right? Give them little corticoids. If that's not correct, then you can go ahead and add in stuff like is a thylopryne or cyclophosphamide. Okay, let's jump to the next one, right? So this is an 87-year-old female, right? So again, it's a super old, right? We have a 6x, 6x, 24-year-old history of severe abdominal pain. She's not able to void, right? That's the problem. And then for the last two months, she'll be having difficulty emptying her bladder, right? Especially at the end of the day, 20 years ago, she got some kind of mastectomy for breast cancer. She's okay from that perspective. She's got osteoporosis. She delivered all six of her kids, vaginally. It's a tough situation there. She takes a lendronate, obviously, for osteoporosis, remember that's a bit phosphorytory, remember? Your patients should be upright for physically be straight for like 30 minutes even though they were burned to the suffigas. And then, she has, like, the tell you that the cervix is protruding from the vagina, right? Again, that's no big surprise. You've had six kids, all of them vaginally. That's going to do that to you, usually. And then, after the cervix is replaced into the vagina, a urinary catheter drains 700 cc's of urine or 700 milliliters of urine, right? And then her ue is clean, was the most likely diagnosis, right? So, it's an old person, right? And she has she has this acute onset, right?

Of not being able to pee, right? So she's almost like she's retaining her, right? So let's look at the answers here, right? So they put overactive bladder, right? Overactive bladder, again, that's that's something that those people have like the urge to pee, right? They have like the trussohypertonia, right? So they have this big urge to pee, they got to go, they got to go, they can get it to get to the bathroom in time, right? So usually for those people, you give them an anticholinergic, right? Like oxybutin or toteridine, or phynesine, so the phynesine of trospium. We don't see that here, so we can cross that off. Overflowing condinence is a good answer. I'm going to keep that for now, actually. Option C says, stressing condinence, stressing condinence. Anything that receives the intraptominal pressure, they cough these sneeze, they bear down, devils off, or they pee on themselves. We don't see that here, so that's going. Option D says urinary retention. I'm going to keep that. Then option E says UTI, right? UTI is not the tell you that urine is clean, right? So you're not going to be doing UT Is here. So we're being overflowing condinence and urinary retention because again, overflow incontinence can definitely make a person's bladder full, right? I mean like you see this person is supposed to avoid, like this person, like they put a catheter, they drain 700 C Cs over urine, that's a ton of urine, right?

So overflowing condinence can definitely give you those findings, right? But option D also says urinary retention, right? So again, classic 50-50 situation, again, whenever you're in a situation like this, ask yourself, which answer is more specific, right? We know that this woman's thing studied 24 hours ago. So if you don't set, she has not been able to pee, right? The answer that is, again, most related to that is urinary retention. Overflowing condinence is something that the person would have had for a long time, right? You don't just develop overflow incontinence in 24 hours, right? I mean you can, right? But that will be a non-classic presentation on exams again, just go specific. I always tell people this, right? Like again, when they give you a question, they say, which of the following is the most important risk factor for, as a urinary retention, in some patient they give you on a test, you know, they can give you a bird as an answer, they give you birds as an answer. Again, both of those things are pretty reasonable answers, right? But birds is just the closest, it's the most specific for, as a urinary retention, if you get birds, you're kind of knocking down the doors of a urinary retention, so just don't keep in mind there. I think question 4, right? So I have this 25-year-old female, you know, for two days. She's been February, dizzy, light-headed, having chills and shaking.

She's got hyperthyroidism, I imagine probably it's from a gravestis, remember that's the most common cause of hyperthyroidism in this country. She also has great an asthma. She ethics me a thymazole, I'm a meprizole, takes in ill-coticosteroids. She's been on those doses for a year. She's in the military, reserves, she's deploying very soon. She began like atovakuan progwonal therapy, obviously, that's going to be formalyriaparphylaxis. She also received a hippy vaccine, the yellow fever vaccine two weeks ago, right? She's not sexually active, doesn't smoke, doesn't drink alcohol, you know, she's February, she's 101.5, she's tacky cardic, tackypne, cabloper, she's 90 or 60, cardiac exams fine for the most part. If you look at her labs, the thing that's abnormal here is the leukocyte count is 1100, that's really low, right? That's really low. So if you see stuff like this, right? You see a problem, right? You ask yourself, what could be causing this problem? Your leukocyte count shouldn't be 1100, right? And your mephymazole, right? Remember mephymazole is one of those anti-thyroid drugs, right? So, her person is on those anti-thyroid drugs, P2, mephymazole, and they have like a very low leukocyte count, you're thinking about it, you're going to low cytocytes, right? So the answer here should be, I'm not even going to bother going through the other answers, but yes, the answer here should be mephymazole for that specific reason, right?

And again, you notice people kind of get hung up on these tests, right? They say, oh, she's been on the same dosages for a year, right? Well, so some people may be like, oh, divine, she's been on the thymazole for a year, why did she actually get the problem, right? But again, you see like the rest of the question just kind of flows with, this person is infected, this person has a reason for the infection. Again, they're not trying to trick you on these exams, right? So, the answer here will be, will be D. I mean, when I go through questions with people, because that's what I primarily do when I do want to want you to learn with people, these are the kinds of, I mean, obviously there's many more things we kind of discuss, but I like to kind of go over content with people at the same time, like in real time, and then also teach them testicons strategies that's specific for the particular problem that they have because med students, I mean, they have like a whole host. There's a whole host of common parents that get people into like testicons, testicons, scribbles on exams. I mean, in fact, I imagine probably one of these days in the future, I'll probably hold like I'm doing a step two CK review class.

I probably try to do like a testicons, NBME testicons strategies class actually in the near future, probably be like two, two and a half hours for like a little fee and you know, I'll have a bunch of people and I will kind of have like a bunch of NBME questions will go through like NBME style because I'm thankfully, thankfully I'm not not saying this to both, but thankfully I'm really good at writing NBME style questions. I'm actually really good at that stuff. So maybe put up like a bunch of questions, like a pretty good size number, right? And many of those questions I'll write them to, you know, obviously, illustrate like USMLE content, but maybe just illustrate common pitfalls that people getting to an NBME exam and then I'll kind of go through those in the session just to kind of get people primed. I imagine something that people will probably find to be to be pretty useful. So, okay. So this person has a thymazole toxicity, right? So you go ahead and stop the drug and then you probably want to put her on like some kind of broad spectrum antibiotic. Usually there'll be an antisoed hormonal agent on the NBME exam. Okay. Now question five, right? Talks about a 16 year old boy. I'm sort of the ED for two days against a good problem. His febrile, noch has noge of omelette and headaches, chills, fatigue, whatever. Okay. No sick contacts. His spleen was hacked off when it was 13, right? And then we notice that his febrile is 102.5.

His stagicardic, his, you know, his respiratory, his finds 14, blood pressure is 110 over 16, right? And you listen to his lungs, you're hearing scattered crackles. Again, he has a well-heeled midline scar obviously from his planectomy. And then the central foods, the most appropriate next step in management. Again, these questions, I feel like people, when people are taking an NBME exam, they kind of get lost in the weeds. You really don't, right? This person looks like he has an infection. We have a reason for that infection, right? A plausible reason. His spleen was hacked off at the age of 13. If your spleen is gone, I don't really know where you're going to get protection against all these encapsulated organisms, right? So this person has some kind of infection. We have a reason for it. Again, we don't have to get lost in the weeds here. So we'll go ahead and pick a option A, right? So here, we're going to give him an anti, an antibiotic. They put an anti-medic, right? But again, if you pick option B, yes, he's probably not getting me wrong, right? But you see how just like one sentence in the question, right? It does not very pertinent to pick that answer. CT scan of the chest, we have a reason, we know exactly what's going on. And again, if you look between, because some people may say, well, define country to like a chest CT, right? It will help us find the pneumonia. Okay. So let's ask ourselves between in C, right?

And then A is more specific, anti-biotics than doing a CT scan because you have like you, you pretty much know what's going on with this kid. So what's a CT scan going to help you with, right? And I mean, a CT scan just to diagnose pneumonia seems a little marching. You should probably have done like some kind of chest X, right? That's something a little more prudence to do, especially in a, you know, 16-year-old boy, right? Boy, subject him to all that radiation. And then extra of the abdomen, right? Again, it doesn't really have any significant problems on the abdomen. He has like mild, diffuse tenderness to palpation. And again, that's a very small subset of the question. And you don't really assure this person, right? This person is sick. You don't say, oh, I see your sick. Oh, all the best, you know, go home. No, no, no, you don't do that, right? That's not good medical practice. Now, question six, right? Talks about a previously healthy, 29-year-old woman. She comes to the hospital because again, for one day, right? She's been having like headache fever, lethargy, right? Two days ago, wisdom tooth was extracted, tics, no meds. Can't remember her vaccines. Great. Doesn't smoke cigarettes. Doesn't drink alcohol. Doesn't use drugs. So she's a pretty squeaky, clean patient, college student, right? It lives in an apartment complex with other students. It's all her meals in the campus dining hall. You can literally see the MDM shoving down your throat.

That this woman has basically lives in a community environment, right? And then they tell you the, oh, she says her study partner had a really bad fever during the past week. Patient is sleepy. She's February, one, oh, four, super tacky cardiac, high potency of nine, over 40. She has a diffuser ash, right? Over the trunk and extremities. She has no courage. I'm not even going to bother it in the rest of the question, but you pretty much know this person has meningitis, right? First, she has meningitis. But now look at their question. They say which of the following is most likely to have prevented the patient's current condition, right? Which of the following is most likely are prevented? This patient's current condition. So, option E, we talk about adhering to immunization guidelines. Let's skip that. Option B, avoidance of eating meals in the campus dining hall. Okay, let's skip that. Why not? Option C, consistent hand washing. Nah. Hand washing is something that prevents you from getting C diff and rotovire. So we're going to skip that. Isolation of water students on campus with February illness. That's a bogus answer because they only talk about one student that was February, so again, you can just create your own information to justify an answer. So that's wrong. And then option E says prophylactic antibiotic therapy. So we have option AB and E, right? Option AB and E. Now, option B, right? Avoiding, avoidance of eating meals in the campus dining hall.

That's a very nice cop out, right? Usually when you see an MBME question, you see an answer and you're like, man, this house is really unreasonable, right? You're basically like banishing this person on their own conditions. You should never eat in the campus dining hall. That kind of killing this person's college experience, right? That's just an unreasonable thing to do. You're like super infringing on this patient's rights doing that, right? So we're going to go ahead and cross that out, right? But the big discussion here is, oh, option E says adherence, criminalization guidelines, option E says prophylactic antibiotic therapy, right? So those are two very good answers. Again, classic 50-50 situation people end up in, right? But now look at the question. The question says, which of the following is most likely to have prevented this patient's current condition, right? Most likely to have prevented this patient's current condition because I know what some people may be thinking. I can just, again, I've tiered God willing, I've tiered what? Like thousands of med students in my life, right? I kind of know the way med students think. Some of them are like, oh, divine option E should be better, right? Prophylactic antibiotic therapy blah, blah, blah, blah, blah. But let me explain this to you. So think about this.

The question is, I can wish you the following is most likely to have prevented this patient's current condition because many people may be saying, oh, maybe Harumi Tasmanian Gitis, right? I mean, maybe Harumi Tasmanian Gitis, right? So, I mean, a study partner, right? So, you know, if a person is a close contact with a meningiope patient, go ahead and give them a type of liprophylaxis, right? But then option E says, to adhere to immunization guidelines, right? So think about your jogging booth, you're asking yourself, okay, do you find out right now which one is correct? If you look at it, this question is asking prevention, prevention, prevention, right? Prevention. So that's the thing like when you're picking out answers, you want to make sure that you're picking an answer that actually answers the question that was posed. Again, you can't just like, because, um, um, um, antibiotics, yes, maybe have friend had meningitis, maybe have friend had meningitis and oh, maybe if the friend had got an antibiotics and we had given this person antibiotics, shown I've got in this problem, right? But the thing is, if you actually really look through this question, a study partner again, like really bad fever, you see the way the meningitis kind of threw that in as one sentence, but if you really think about it, and this was during the past week, but if you notice, this woman's symptoms started a day ago, and two days ago, guess what?

She, the chopped out some of her wisdom teeth, right? It is actually the wisdom tooth extraction that actually caused the problem that she has, right? So the big thing I'm just trying to get at here is we are reading questions, um, just be careful that you're actually answering the question, this is a preventive medicine question. That is why sometimes when people say, oh, define, I didn't see any preventive medicine questions on my test, I usually don't, to be honest with you, I usually don't believe them, because many times the MD and the I'm not going to say, they're not going to just straight up say, oh, which of the following is the biggest risk factor for this condition? No, that's ridiculous. You know, when they started asking those questions, that's what they were doing, because they know people were not prepared for it. They know that people now are clearly prepared for that kind of situation, right? So the pretty thing they will do is they will just frame something. It'll be a preventive medicine question in disguise like this one, right? How do you not get meningitis? You don't get meningitis if you get immunized, right? And again, if you're really like pressing into the question here, you see that the question just says many things that essentially the immune is trying to get tell you that this one is going to a community environment, community environment, community environment, community environment, and she's getting meningitis.

Okay, take a step back when you're reading these questions and trying not to think too hard about them, right? Because you see how many times the shoved, shoved, shoved, shoved, shoved this concept down the throat. She's a college student, lives in an apartment complex with other students. It's all a meal, saying the campus dining hall, right? They're just literally shoving it down through that this person has had like many people, she has potentially been exposed to it. So that's, so this person has a nice sermon in jitter this, right? So if she's got in the vaccine, she will not get in trouble, right? And again, you also notice they say, oh, she cannot remember have vaccination a history. I love these kinds of questions because they have great questions to use to teach a testic and a strategy. Okay, now question seven, right? So we're going to try to wrap up here, pretty soon. So we have this 27-year-old pre-medicated woman, you know, come to our first pre-natal visit, you know, pregnancy test at almost positive. She's fine, pregnancy is okay. Use the no CP, discontinued it three months ago. Does she have any ST Is? She's a monogamous relationship with a male partner who is the father. She has had five lifetime sexual partners, has a pet cat, uterus is 10 weeks size, that's fine. So testing for which of the following infectious conditions is the most appropriate recommendation for this patient, right?

So option A, be put bacteria of aginosis, B, B, D, put CMV, C, D, put EBV, D, D, put HIV, E, D, put H, BV. This one is just one of these knowledge things, you either know, you don't know, but in general, right? You do need to test every pregnant woman for HIV, right? Because again, that will kind of guide the way you deliver the baby and all that, all that fun stuff. Okay, now question eight, yeah, that one's pretty easy. Question eight, an investigator would like to decrease the incidence of tattoo diabetes among adult patients with risk factors including obesity, not exercising, family history of diabetes. You take 200 women and 200 men and women 30 to 64, right? You try to enroll them in a regular size program for six months, nurse reviews the details of the study, you know, basically do everything you sign in from consensual blah. And then a month after you start the study, participants says, sorry, I don't want to do the study anymore. And then we see which of the following represents the most appropriate next step by the study participant. This is an ethics question, right? If a patient wants to drop out of a study, you can force them, right? I mean, like look at all the bogus answers they put here. The patient complete the study because she signed in cousin from, no, right? Discuss we draw with the IRB, no, a patient can leave at any time, it's not by force, right? C says to negotiate, I will draw the PI, I can do that.

D says which we draw until after the investigator consults in an ethics team, that's bogus, right? Option is the best answer. Go ahead and we draw the patient from the study now. Okay, question nine. Now we have the 70 year old guy. So this is an old guy comes to the clinic three days for TIG dark urine is not being clumpier urination has a low rate fever, right? He has got hypertension and osteoarthritis. He's on a lupurinal, he's CTZ, Tylenol. He's not febri, his temperature is less than 100.4, his pulse, his respiration, his pulse is fine, his tachypnec, his blood pressure is okay, he's actually hypertensive, 16, zero, 95 there. Probably should bump up his dose of his CTZ. His auto site is 97%, his JVP is fine, long heart exams, okay. Next best step in management again, we see these kinds of questions because sometimes when people come up in this situation, they tell me to find, I don't even know what this question is asking in the first place. But again, I'll just tell you this, again, I'm not going to try to say anything bad about another study material, right? But I'll just tell you this, these exams, they're literally not trying to trick you, just think big picture, big picture, that's the big thing, think big picture, right? These are an old guy with urinary problems and he's coming to the clinic, right? If you're going to the clinic, that means you're not that sick, right? You know, it's kind of like a mild inconvenience, but you know that's sick.

If your person was going to the hospital and accuse them, you're like, oh, I got to pay attention here, right? But this person is fine, right? It's an old guy with urinary problems, right? Again, notice I'm not like getting lost in the museum, just like old guy urinary problems, that's classically BPH, right? That's classically BPH, classically BPH. So if we know that the person has BPH, right, we then just need to evaluate these answers and ask ourselves, okay, which one kind of moves with a BPH here, right? So, option A says, this is a man of fin that has no bearing with BPH, so that's wrong. Give fluids. This guy is not volume depleted. That's not the problem in the question. Again, when you make sure you're picking an answer, you've got to make sure that you're answering the question that's actually being posed. Option C says, measure and pose weight or is it one? Okay, that's what we do for a person that has like incontinence, potentially. So let's keep that. Option D says oral TMP SMX. Again, they don't give us any signs of infection or UTI or anything like that. So, of course, that out, Rinal biopsy. Again, Rinal biopsy is something typically when a person has like some kidney disorder and you don't know what's going on, like lupus nephritis. There's like five or six different types of lupus nephritis. That's a classic indication on NB Ns for Rinal biopsy although if a person has an euphrodite called euphrodite syndrome, it typically will also do a Rinal biopsy, right?

So, really, all these answers, really, these is not the best question in the world, right? But if you notice, none of the other answers relates in any way to this person's like urinary tract in terms of like his urinary problems, then measuring his pose weight or is it all volume? So, go ahead and do that. So, that'll be the right answer here. And then the final question here, right? So, we've got a 52-year-old woman, two days severe pain, decreased range of motion and are ready out well. She has RA, she gets episodes of moderate pain four times a year, previous treatment with an approximate, that's an end-set, methotrexia, that's a demark and hydroxychloroquine, provided moderate relief. Trudoroprydenison was begun after a most recent episode nine weeks ago, right? So, she's on pregnant zone, so she's immunocompromised potentially. Generalized fatigue, she has not had Generalized Fatiga muscle aches, no history of other problems. She's febrile, temperature is 101.1, she's got pulse, respiration is fine blood pressure is okay, a radiobol movement is severely limited by pain, the right elbow is warm, tender, it's themed as, right? It's literally doing an FNA, gram stain, shows a local site count of 60 grand, right? 60,000 with no organisms. Now remember if you don't find any organisms on a gram stain, a person that has septic arthritis, it doesn't rule out infection, right? So, this person has septic arthritis, right?

So, basically we know that we need to do like a joint wash out or something, but we also need to give antibiotics. And of all the answer choices here, right? There's coaches scene, there's infleximab, there's kituralach, there's methylpred, that's probably what threw him in trouble in the first place, right? So, the right answer here is going to be vent, right? It's going to be vent commising. I remember the most common cause of septic arthritis, stuff, or else, right? So, empirically, want to give this person vent to cover what's going on. Okay, so, I'm going to go ahead and stop here, again, as I do, I mentioned I need the Vever podcast. I, on a limited basis, I offer someone on one tutoring for all the US Emily exams. And then again, I also do all these classes, right? Right now I'm doing the step 2 CK review class. Again, next one is on the 25th of this month, as I discussed in the beginning. And then I'll also be doing a class very soon on NV Me test-ticking strategies. So, if you want to sign up, just shoot me an email, I'll release a date very soon. And it will be held via Zoom. And please subscribe to the You Tube channel, score divine intervention, US Emily podcast and videos, subscribe to the podcasts. It's on Apple podcasts, it's on Google Play, it's on Spotify. And I mean, it's like roughly the most for some 141, 150 podcasts that are there. Trust me, I've tried every fix. It's like a Word Press rule. I literally can't, I've tried hours on this stuff.

It's a Word Press rule. There's literally no way from here around it, at least that I know of. And then please subscribe to the Word Press website again, divineinterventionpodcasts.com. And then my life lesson for today is just about the importance of being quiet, right? So, I may have talked about this before, but I feel like this is something that's especially true for med students. And in this world, we live in today, where people believe that when you're loud, loud, loud, loud, loud, everyone will listen to you. No, everyone does not listen to you because you're allowed. People listen to you because you're a commander of respect. And the thing is, when you talk a lot, you're just exposing yourself to just unnecessary life problems. I mean, there's even a part of the Bible that says that he that keeps his mouth, keeps his soul from troubles. So, I'm not saying you should just be completely mute and see nothing. No, but you don't have to talk all the time because when you talk all the time, you'll let information that shouldn't get out, slip out, or you will see things you're not supposed to say, right? You can't talk the whole day, continuously, and not let out words that will strike people down, right? So, you're not going to be choosing with your words, right? Like, like, choosing your words with salt, think before you speak kind of deal, right?

Don't tear down people with your mouth because some people really think that, oh, you know, if I tear you down, then I'll be lifted up. No, no, no, right? You're just basically making a a bad show of yourself, right? I mean, like, for example, like, Kawaii Leonard, right? Again, my best player in the world is LeBron James. And I've been a LeBron fan for four years. Nothing is going to change that. But one, one, one, one player I have like this very strong affection for his Kawaii Leonard, right? If you remember when he was on the Raptors, right? Kawaii Leonard, very quiet guy, right? Do you see him yelling, yelling, yelling, yelling, yelling? No, right? No. But everyone on that team, including people that have been there, be long before him, they respected him, right? He led by action, let your actions show what you believe, not your words, right? You don't try to talk people into your, into your point of view. That I feel like that's a very common, unfortunate tactic that's used by many people. But again, they wonder, like, man, I've shouted, shouted, shouted, nothing has come of this. People don't respond very well to shouting, right? People respond well to actions. If you want to, a kind of behavior, you want other people to respond to, people will be more likely to respond to that, right? Action speak a lot louder than words. That's why I like Kawaii Leonard. He lets his game do the talking, right? Like, you know that he's good at his craft, he's everything, right?

So even if he doesn't speak, when he does something, he's all that team he to follow. Because I noticed, Kawaii Leonard has this very stoic personality, which is not the worst in the world, right? And if you notice, he's the other members of the raptors while he was there. If you notice, that stoic personality kind of seeped into everyone else, right? So like, he didn't talk, he was just leading by example. But I feel like in this world today, many people try to lead by yelling, right? They're like, oh, let me make my point of view by yelling, by shouting you down, by suppressing your own speech. Again, it's good. It feels good when you're doing it, but you're really for the most part wasting your time, right? So again, if you want to change model that change, and then people will be more likely to follow you, right? People will more likely to follow you. That's just one of the most powerful forms of leadership that you see. So thank you for listening to this podcast. Again, I hope that by kind of walking through those questions, you can see the way to kind of approach these questions. If I have time in the future, again, I'm not making any guarantees because I'm going to have a human schedule. But if I have time in the future, I'll try to make a more podcast, kind of going through freely available, limited content so that I don't, again, I don't want to do any kind of thing that gets me like trouble or anything like that. So thank you for listening.

I'll talk to you next time. All right, we can.

Confusion/mental status anomalies, ataxia (gait instability), and nystagmus.

Spontaneous bacterial peritonitis (SBP), Wernicke's encephalopathy, and hepatic encephalopathy itself.

SBP usually presents with abdominal pain, but the patient must have a positive culture/fluid analysis to confirm it. The absence of fever or specific GI symptoms can help rule out others.

Vasculitis (e.g., EGPA).

Staphylococcus aureus.

Benign Prostatic Hyperplasia (BPH).

Fever, pulmonary involvement (hemoptysis), and peripheral neuropathy.

Anti-neutrophil cytoplasmic antibody (ANCA).

Antithyroid drugs; they can cause leukopenia/leukocytopenia.

Measuring post-void residual (PVR) volume.

Adherence to immunization guidelines/vaccination status.

Broad-spectrum IV antibiotics (e.g., covering S. aureus).

Fever, pulmonary involvement (hemoptysis), and peripheral neuropathy.

Anti-neutrophil cytoplasmic antibody (ANCA).

Antithyroid drugs; they can cause leukopenia/leukocytopenia.

Measuring post-void residual (PVR) volume.

Adherence to immunization guidelines/vaccination status.

Broad-spectrum IV antibiotics (e.g., covering S. aureus).