DIP Episode 137 - Next Best Step In Management Series 1

Okay, welcome. My name is Divine. I am a resident. This is episode 137 of the Divine Intervention Podcasts. And this podcast is going to be kind of like a unique one. Again, I've got in this request a couple of times, but again it's just time constraints that just again make this really difficult to do. Well, this podcast I would hope is one, especially because I've been getting a, in fact, like more recently, like a lot of requests, thankfully the website has been a little more popular. And you know, this is like step two CK month for people that want to try to, you know, get in those scores for the applications. So this podcast, I'm going to call it the next best step in management podcast. And I am going to try to go through a very large number of pathologies. And talk about what your next best step in management should be for those pathologies. I think that should help you quite tremendously on exams. And again, this is obviously not something that again one can cover in one podcast, but I will try to be as, I will try to be as, you know, as comprehensive as possible. I mean, again, within limits of reason, right, I would not want to make this monster podcast that, I mean, it would be great to make, but again, there are time limits and I also have unfortunately other other commitments. Okay, so what if they give you, so we'll just jump right into it.

So what if they give you a question about 55 year old guy and this guy, he comes into the, he comes to the doctor's office and says that yesterday he lost, he lost vision in one eye. It kind of felt like a curtain was coming down. And within five minutes, his symptoms resolved. What is your next step in management? Your next step actually in diagnosis will be a carotid ultrasound, right? I know you may want to be saying, oh, divine, it's a stroke. So let me do a, let me do a non-concity. Don't do that. If a person has like neurologic symptoms that they completely recover from, right, essentially like a TIE, your next step in diagnosis on an NVME exam is to perform a carotid ultrasound. And then after that, your next step in management will be to treat those people with an anti-plitlet agent, very high auto-notes with an anti-plitlet agent. So you want to treat them with drugs like aspirin or you want to treat them with drugs like diperidomol or drugs like pleopidogram. Okay, you may say divine, why can I not use things like haprin and warfarin? You can. But those things are really correct for TIE's on NVME exams. The only time that they'll be correct is if they tell you expressly in the question that the patient has a history of a fib or has like some kind of like prosthetic valve, then under those circumstances, if they have TIE symptoms, the smart play will be to give them an anti-quagulant like haprin or warfarin.

I mean, obviously it would likely be warfarin, but you just sort of bridge them with a haprin. Now, what if they give you a question about a 55-year-old guy, okay, and this guy comes in complaining of the worst headache of his life, right? The worst headache of his life and he tell you that this person, you know, this worst headache started like 30 minutes ago and then they try to trick you in the question by saying that this person has no core rigidity and he may even give you like a mild fever, let's say like a 100.9. What's your diagnosis here? I hope you're saying this is a sub-archnoid hemorrhage. So what is your next best step in diagnosis? Right? For this person, obviously, you want to proceed with getting non-conscious head CT, right? But if that is equivocal or you don't get the result you like you still strongly suspect the sub-archnoid and the non-con-head CT is negative, right? The next new procedure is to get a lumber puncture because you're looking for an example chromium, right? And then your next best step in management for a sub-archnoid hemorrhage will be to to control blood pressure. So you want to keep those people's blood pressures low, right? So you want to give them things like labidolol or nitro-perside. Usually labidolol is the safe bet on NBMS, right? You want to give them like labidolol to lower their blood pressures and then you also want to give them my Modepine, right?

So that they don't get an ischemic stroke on top of the hemorrhagic stroke they just had. Now, what if you get a question about a 55-year-old female? Comsign says that she's been having like headache, kind of like look a light to like one side of her head and she tells you that over the last that like two weeks ago she had trouble like chewing with her jaw, right? So obviously this is job-lawdication and this person has like a concomitant temporal arthritis. Your next step in management for these patients is to proceed to giving high dose corticosteroid so like a high dose glucocorticoid and then after that you can then consider doing a temporary biopsy to sort of help with your, I mean to figure out exactly what's going on and since we're talking about a temporal arthritis I will just go ahead and dovetail into polymyalgia-romatica, right? Remember that presents as like proximal, shoulder pain and the ESR will be elevated in those patients and really your next step in management is low dose, not high dose, high doses for temporal arthritis, low dose corticosteroids for polymyalgia-romatica so you give them low dose corticosteroids and then in addition to that you also do a temporary biopsy. So you may see, hmm, divine but this person is not complete of temporal aderitic symptoms. I promise you it's high you to know this.

If a patient has polymyalgia-romatica you need to perform a temporary biopsy because they may not be having symptoms, they may actually have inflammation of their temporal aderis going on at the same time as the apolymyalgia-romatica and then what if they give you a question about a 60-year-old guy comes in over the past 24 hours, he's been altered, he's been you know confused, he has a temperature of 102 and he has no core gdt on exam. So obviously this is meningitis, so your next step in management will be to your next step in management depends on two pathways. The first one will be do they have signs of elevated intra-cranial pressures?

If for example the patient has like popular demon exam or they have any signs of elevated intra-cranial pressure, then your next step will actually be to proceed to antibiotic therapy and I'll talk about with antibiotic therapy means in a second, but if you don't see that as an answer, if they don't have any signs of elevated intra-cranial pressure on exams, then your next step in diagnosis actually for this people is to is to pursue obtaining an alarmber puncture and then right after that you empirically give them antibiotics and the empiric antibiotics you want to give to an old person right, a person more than the age of 50 that's coming in with essentially meningitis right, you want to give them a combination of safe triaxone, then comisine and I'm ampeicillin, so safe triaxone, then comisine and ampeicillin, I'll repeat that again, safe triaxone, then comisine and ampeicillin, they're giving safe triaxone to cover like strep pneumo as the cause of meningitis or even my sermeninjivis, they're giving the vancomycin to cover inadvertent merse meningitis and then you're giving the ampeicillin to cover the stereo, remember whenever you see a person that has meningitis and they're young like super young like a unit can a deal or they're old if the person is more than 50 years old, you almost always want to add ampeicillin to their drug regimen.

Now what if they give you a question about about a patient that comes in and they have like you know like a red hot swollen joint, they've been having like severe knee pain, they've been having like you know like severe knee pain and they have a temperature of 102, what is your next best step in management? The next best step in management will be to perform an atro synthesis, okay, because you would want to analyze that joint fluid, right? If you see less than 2000 white cells, you know you're likely dealing with osteoarthritis, right? But if you see like you know like 2010, 30,000 ish white blood cells, you're probably dealing with maybe like some kind of rheumatoid arthritis and then if you see like you know very high white counts, more than 50,000 white cells, you're probably dealing with more like you know like an infectious process or like septic joint kind of deal or you may be dealing with maybe dealing with like a crystalline arthropathy, right? So like out where you'll find like the negatively by the the needle shaped negatively by refringent crystals or CPPD where you have the rhomboid shaped positively by refringent crystals. Now what if they give you a question about 55 year old guy, okay?

This guy over the last three months, he has lost a lot of weight and he you know he's been he has lost like 40 pounds over the last three months and they tell you that this person has smoked two packs of cigarettes every day for the past three years and then they tell you that on chest x-ray you find like you know you find like a like a module in the left upper lobe and they tell you that the person has a large left-sided plural of future. What is your next best step in management? I would hope that you're telling me that you would for those patients you want to proceed with getting you want to proceed with getting getting getting a getting a thoracent thesis, okay? You want to go ahead and get a thoracent thesis because if you find my ligament cells in that thoracent thesis that's the four that's the end of the row, right? You're pretty much that's the fall on cancer that is really not what you can do beyond that. Okay now what if they give you a question about a patient that you know they drink like two points of vodka I don't know if that's although I'm not really good with these are alcoholic measurements but let's see this person drinks two points of vodka every day and they come into the hospital and like maybe they're wife or relatives bring them to the hospital.

See this person has been altered for the last few days this person has been summer length and you know has the classic size of chronic liver disease he has like the spider angiomas has the gynecomastia has the asteriscus and all that stuff and they tell you you know kind of has a low-grade fever like a hundred point nine sort of deal and then they tell you that on abdominal exam you notice that he has you know like mild abdominal tenderness shifting doneness with like a fluid wave and they ask for your next best step in that nocy so in management right I would hope you are thinking about performing a paracent thesis the next thing you want to do is a paracent thesis that paracent thesis you're looking for essentially more than 250 white neutrophils right that tells you the person has spontaneous bacterial parietalitis and under those circumstances you want to go ahead and give them a third generation cephalosporine like septriaxal nocephal taxil okay and then after they recover you need to put them on fluorocuinolumperphylaxis you know relatively for a relatively long period I won't worry about exact timelines but for a relatively long period and remember that SBP is something that can arise in patients with like chronic liver disease you can arise in patients that have spontaneous I mean that have a parietal nocephalysis right those are patients that can have those problems you can arise in a person that has like botquiaris syndrome or like a porovine thrombosis kind of deal okay so those are all how you'll think you want to keep at the back of your mind and then what if they give you a question about a 55-year-old guy and they tell you that you know he had an MRI like three days ago or he had and he has like a history of e-fib and he tells you that over the last two hours he has been completing on of severe sodium onset leg pain right like left leg pain and he tell

you that his legs appear you know pale to the touch and they're like cold and all that stuff right off the bat I would hope you're telling me that this person has an acute limb mischievous your next best-fipping management is to proceed with giving that person heprin right and I've been fusion of heprin okay you would not want to make the costly mistake of maybe like trying to do like I don't know like an uncool breechial index or whatever no your next-spin management is to provide to give a heprin infusion and then after that the second thing you would do is to obtain vascular surgery consultation right so that you can go and explore the leg and maybe bypass the leg or whatever because time is limb right within like six hours that person's limb is essentially done and they gave you a similar patient population again recent MI or history of e-fib and then they tell you that this patient is complaining of severe abdominal pain and they tell you that his abdomen is explicitly tender to our patient and would hope again what you're thinking about on other circumstances are like acute mesenteric ischemia your next step in management is actually to perform angiography right so that you can find the vessel that they've uploaded with an embolic phenomenon that's usually the superior mesenteric artery right so you do angiography because that maybe that's diagnostic and that's also therapeutic now what if you get a question about a 65-year-old guy and this guy comes in to you know his PCP's office and says that for the past six months he has not been able to like go to work regularly because he's been having like severe bilateral leg pain and they tell you that he has smoked three packs of cigarettes every day for the past 40 years right I would hope if you saw something like that you'd be thinking about a peripheral arterial disease your next step in management in that situati

on will be to obtain an uncool breekyl index okay to obtain an uncool breekyl index if it's less than 0.9 you have your answer the person has PD alternatively in the tell you that the person's ABA that was measured is like 1.5 it's like super high but they have all these symptoms you're like this person probably is like a diabetic and they have something called like Monkerberg Talsifica sclerosis so under those circumstances your next step will be to obtain a tow breekyl index okay a TBI a tow breekyl index to establish the diagnosis and then your next step in management for those people is you know supervised exercise program like a supervised walking program you would also want to consider doing things like you want to consider doing things like what is it called you know if the supervised walking program is not caught in it you can do things like recommend selloster zone remember selloster zone is a first for the history inhibitor that visual that like a visual deli that deli is the salt right so you can help under those circumstances if that's not caught in it then you need to do and need to do some kind of bypass or before you do that bypass you need to do some kind of at-eography okay now what do they give you a question about 30-year-old guy right and he tell you that this guy you know has a history of you know hearing voices and he tell you that this person whenever he takes whenever he whenever he takes his that you know that he has had multiple hospitalizations in the past and whenever he's hospitalized and studied on his anticycotics he gets better what that he you know well upon this charge he stops taking his meds and his symptoms come right back and yes for your next step in management your next step in management on those circumstances will be to give that person something called hallow paridol the cannoli remember that's the depot form of hallow parido

l right it essentially lasts for a month you just give that intramuscular injection and that tight is the patient over for a month now what if they give you a question about a patient that was recently studied on an anticycotic and they tell you that this person their face is kind of like their face is a kind of face in one direction it's hard for them to move like one of the extremities and the ask for your next best step in management right for those people you want to go ahead and give them like dichotomy or you can give them bench troops and remember dichotomy is an anti-histamine that has very powerful anti-colonial activity so you give those people a knife and hydramine to treat their acute dystonia what if they give you a similar patient population and they tell you that the patient feels like the piece body wants to jump out of his skin he bases all around the exam room doesn't want to stay in one place and under those circumstances where you should be thinking about at aphasia right and for aphasia your first your next step in management will be to give a better blocker bit of blockers and first line for the management of a catagia and then second line for the money men of a catagia is a benzodiazepine and then what if they give you again a similar scenario you know patient with a history of schizophrenia and this patient they tell you that this patient you know is having like you know like resting tremors is having like trouble like moving right so it has like really kind of Asia under those circumstances I hope you're thinking about Parkinson's like Parkinsonism and under those circumstances your next step in management will be to first line administer a most chronic antagonist like benzodiazepine or like trihexy phenodil your second line agents will be to consider giving dopamine receptor agonist like bromo cryptine or carburegulin or like epomorphine or l

ike a rapinero for example and then if they give you a question about a patient you know the phenol like anti-psychotic for a while and then they tell you that oh this patient is now having like you know like repetitive movement of the tongue or like their head or whatever then I hope that under those circumstances you're thinking about tired dyskinesia your next step in management is to stop the drug okay your next step in management is to go ahead and stop the drug and then after you stop the drug you then switch them to an atypical anti-psychotic like a orthyapine or something along those lines now what if you get a question about a patient that has a history of let's see so this patient they tell you it's like a 35 year old female she has a BMI of 40 and they tell you that whenever she comes into the she comes to the PC Bs of assess she's been having like morning headaches like for the last like you know for the last like three weeks and so when she wakes up in the morning she kind of has like a lot of blurry vision and they ask for your next step in management I would really hope that your next step in management for those people who will be to you know get like some to get like a lumber puncture because those patients have a idiopathic intracranial hypertension which is also known as a pseudo tumor cerebride so under those circumstances you want to go ahead and give those patients give those patients like acetylomite or you can then go ahead and consider cereals therapeutic lumber punctures to fix their problems and other potential next step in management for those people may be to stop the doxycycline that they are taking or to stop the acne medication like the vitamin A analog that they are taking because those things all exacerbate pseudo tumor cerebride and then wouldn't they give you a question about 35 year old guy right this guy you know comes in says he's

been having you know just terrible terrible headaches for the last like three months right he has them almost every day it has like a pulsatile sensation he has to rest in a dark room and all that crap to feel better and it's preventing him from you know getting to work all the time under those circumstances your next step in management will be to put that patient on a chronic migraine medication right and your options on MDM is a things like proprenolol right again if a person has like a history of asthma proprenolol maybe not the best idea in the world because remember right that bitter-to-visual bronchoconstrictive effect from a bitter blocker and non-selective bitter blocker like proprenolol and other thing you want to do on that those circumstances is to you could also consider to pyramid okay remember to pyramid is associated with nephrolatitis and then the third thing you could also consider on those circumstances at the tricyclic and tithy presence okay remember the classic tithyl sign on MDM exams of tricyclic and tithy present of Cicity is a white QRS on an e-kg but if a person is acutely having my green symptoms your next step in management will be to administer so much attempt okay it won't go ahead and administer so much attempt I remember or you can give them like an ergonomic derivative okay that can abort the headaches are relatively quickly if they give you like a similar question you know person patient having like you know you know lateral headache right or yeah so like you're not a headache right or yeah like conjunctival injection I hope you're thinking about cluster headaches and the ask for your next step in management you want to go ahead and give them you know like a hundred percent oxygen that will usually abort the headache up relatively quickly and then what do they give you a question about okay so let's assume you get a question about yo

u know like 30-year-old guy you know he's sure of like trip and resistance as schizophrenia and they tell you that you know two weeks ago he was studied on a new medication but they tell you that over the last 24 hours he has been having like pretty high-fever's so his temperature is like 103 and he's so his temperature is like 103 and you know they give you like CBC results and you notice that his total white blood cell count is like 2000 and like 20% of that on these neutral films right and then they ask for your next step in management your next step in management will like dlibilo stop the drop right to stop the clasping that he been placed on because they have it when it was a tosses but after that the next thing you want to do is to place them on an antiso domino agent okay on an antiso domino agent because this patient essentially has me a tropinic fever okay this patient essentially has me tropinic fever so you place them on an antiso domino agent you'd want to do something like you know like like like like Merri Panem right or you'd want to do something like Amy Panem or you do basically you want to essentially do something that covers your harmonies okay something that covers your harmonies remember they can also give you a similar question in a patient that you know has been on chemotherapy and then they have like a neutral panic fever from that or they can give you a fairly similar question in a patient that you know is on has a history of like graves disease or whatever and is on an antisoid medication like PTU or methamazon now what if they give you a question about they give you a question about you know like a patient that has been you know like a long-term smoker and they come into the hospital and the tell you that over the last seven days they've been having they've been having like they've been having like increased freedom production, shortness of

breath and all that whatever right and then they ask for the and this person is a long-term smoker and they ask for your next best step in management your next best step in management on the other circumstances is to strongly consider placing them on IV critical steroids because that patient is going through a COPD exacerbation right so you want to go ahead and you know please him on IV critical steroids if they've already done that in the Q-stem you could consider placing them on like bronchidylators right so you want to place them on a anamosclerinic receptor anamosclerinic receptor antagonist right like like an Ipertropium or tyotropium right and then if those things have already been done in the question you can consider placing them on an isitromycin okay because it has like some anti-inflammatory properties that help in the setting of a COPD exacerbation and then what if you get a question about you know like like a 60-year-old guy you tell you that this guy has you know a pretty long history of of like heotic re-gurge and then he tells you that over the past like three days he's been having like profound sharpness of breath he's had to sleep on multiple pillows to be able to like catch his breath and all that stuff he has like dyspion exertion and he tells you that he has like an S3 heart sound kind of deal and then they ask for your next step in management I would really hope that the answer you're going after with that is to is to consider giving that patient like IV phyrosamide okay IV phyrosamide to treat the CHF exacerbation right and really for CHF exacerbation you give like an IV diuretic like again an IV looked diuretic I mean if it was a patient in the question that has like a sulfur allergy then you can consider doing something like like like ethycrenic acid that would help on that those are circumstances although remember ethycrenic acid is like sup

er nephronautotoxic so you want to maybe you know think twice before pulling a stunt like that right and then other things you can also do you can place those patients on you know you can give them nitrates nitrates are actually very good at relieving the dyspnea from pulmonary edema and I guess since I'm sort of talking about dyspnea from CHF if they give you a question about a patient that has like cancer that is terminal and the patient has dyspnea and they ask for your next best step in management you'd actually want to go ahead and place them on morphine morphine is the drug of choice for the treatment of dyspnea in a patient that has a cancer that has like terminal cancer or like some kind of terminal disease and they're dyspnea okay again I promise you these are all things next best steps in management that you'd want to know for sure for you exactly now what do they give you a question about you know like a 75 year old guy you know this guy has smoked a ton for the past like I don't know like let's say four bucks a day for 50 years right that'd be a little over to talk though never seen a person smoke that much but anyhow so that's like a 200 back here smoke in history and then this guy he comes to his PCP and says that over the last like you know like six weeks you've been having like a lot of pain in his fingers and his legs right he tells you that he's having like a ton of joint pain kind of study like six weeks ago and he has tried taking like NSAI Ds and they have not helped at all right and then they tell you that one physical exam you notice a lot of finger clubbing and they ask for the next best step in management your next best step in management for this patient is to go ahead and obtain some kind of chest image usually on MBM is you'll be to get like a chest extra chest CT right because this person has something called a hypertrophic pulmonary osteoa

rthropathy right so those people have they essentially have the essentially have a lung cancer right so for those people remember the hypertrophic pulmonary osteoarthropathy it's apparently a plastic phenomenon so if you observe it in this patient you know the smart thing to do will be to go ahead and obtain and obtain some kind of chest image and to look for the lung cancer that they have now let's assume you get a question about a patient and let's say it's like a 50 something year old female she tells you that she's been having a lot of trouble at work because she's she falls asleep a lot and she says that she's having a lot of trouble sleeping at home because she feels like there's this crawling sensation in her leg while she's asleep right and then they ask you for your next best step in management your next best step in management for this patient will be to go ahead and prescribe a dopamine agonist like a primary pexol or a pinnacle right or alternatively on MDM Es because this is something they've sort of started like you know throwing in non-exams is a given a drug like primidone primidone is a babitri it right this patient essentially has a wonderful thing this patient essentially has a restless leg syndrome right so on other circumstances you place them on a dopamine agonist like primary pexol or a pinnacle or you can place them on a babitri it like primidone okay you can see why primidone would be a high value answer for the MDM Es because it's something that most people don't know and it does not sound like most of the babitri it's that people know so that's what you do on that those circumstances and remember that remember that remember that remember that restless leg syndrome has an association with the iron deficiency and immune so that's something again you want to keep on the back of your mind for exams now what do they give you a question you know abo

ut like a 30-year guy they tell you that you know over the last like six months this guy has been having you know he's worrying about paying the bills worrying about doing willing his grad classes worrying about providing this for his family worrying about crushing the USM in the step one and step two secants the three exams are calling one day you know he's worried about everything in life right so what's your diagnosis for this personal hope you're telling me I generalize anxiety disorder right and the ask for your next best step in management your next best step in management will actually be to consider obtaining I mean consider prescribing an SSRI right remember SSRI is a first line for the treatment of generalize anxiety disorder if you don't see an SSRI as an answer choice then you want to you know maybe proceed with a drug like a bospiro remember bospiro is a partial serotonin receptor agonist it's like a five-hth to a receptor agonist that can be used to treat generalize anxiety disorder now what if they give you a question about the give you a question about like a 25-year-old female right you know this person you know has a history of depression and they tell you that where this patient was placed on you know vanilla vaccine or sexually like two weeks ago I mean like four weeks ago and then this patient comes in and says that they want to stop the drug that you know they've been having like they've been having let's say it's a man and if you're having trouble like getting it up with his wife and stuff like that I mean if you see that kind of situation what is your next best step in management I hope on an MVME use you you choose the answer choice that involves a switching to bupropian remember bupropian is an NDRI it's a Mary Peniferin dopamineria of taking inhibitor and it's one of those side drugs right that those depressant anti depressants that does not

have a sexual side effects remember it's also good at helping with like smoking sensation it's also good with helping with things like you know like weight loss right but remember you don't want to give it to a person you know that has like problems that we predispose them to seizures so like an erection or Rosa or Bolinia right you want to avoid it or if a person has like any history of seizures or like high-pony trimial or something you don't want to give them those things right so if a person has like a history of SIDH that'll be a very unique way to you know not give those people a bupropian on an MVME exam and then what if you get a question about you know like a 50-year female she comes in they tell you that you know over the last you know two months she is you know Felgio Tiaman everything in life she no longer enjoys things that she's to enjoy she slips 14 hours a day she you know she endorses like a low mood and they tell you that you know she feels like she has low energy all the time and then they give you some vitals and you notice that the one of the things you tell you is the person's like heart rate is like you know like 49 beats per minute what's your next step in management and we really hope that your next step in management is to obtain a TSH right because remember TSH can cause like pseudo depression especially if you see that pretty cardio pretty cardio is a very specific finding on MVME exams for hypothyroidism so the next step in management for that patient will actually be to go ahead and go ahead and obtain a TSH okay now what if you get a question about about you know like a 45-year male he tells you that you know for the past two weeks he's been having competitions and he's lost like 10 pounds and the detail of physical exam his blood pressure is like 1.8 uv 90 and his heart rate is like 190 beats per minute and irregular and then he tells

you that all of a sudden the patient you know kind of becomes like some lens almost becomes comatose becomes altered and the answer for your next step in management I hope you are choosing to give that patient a propurnal law right this patient is essentially is in thyroid storm remember the most common arrhythmia in patients with hypothyroidism is a theft right so your next step in management will be to to administer propurnal law that is the always the first stroke you administer in a patient that has a thyroid storm and then after that you give PT you PT is the second drug you give and then after that you can knock yourself out whatever you want to give you can give steroids you can give a super saturated solution of potassium iodide sometimes on MVM Es they call that low-golds solution right those are the things you'd want to do on that those are those are those are the things you want to do on that those are circumstances and then what do they give you a question about like a seven-year-old guy they tell you that over the last like one year you know he's been like you know he's but forget to turn for forget to turn off the stove forget to he does not remember friends he's had for years he loses his will coming back to the you know from the grocery store and then they tell you he cannot repeat zero sevens and all that crap and then they ask for the next best step in bag no sis you'll actually want to go ahead and obtain an MRI of the brain this person likely has Alzheimer's right so you want to go ahead and obtain a brain MRI usually if a person if you suspect those I'm as that buys that patient a one brain MRI right you go ahead and get a brain MRI and then after that you are next step in management will be to give like a job like don't let Brazil or galantamine or investigation remember those are surgical industries inhibitors right they are indicated for the tre

atment of Alzheimer's disease remember in Alzheimer's right the Bisonucleus of minor is destroyed so those people have like no acetylcholine alternatively they can have like dysfunction of cooling acetylchransferies right remember that's the rickety and enzyme in acetylcholine since the synthesis now what do they give you a question about about let's see what do they give you a question about you know like a 35 year old guy this guy let's say drink two points of what every day and then it comes into like the emergency room you know we sit over the past like two days he's been having like severe like pain in his like his meet up the man kind of going to his back and then they ask for the next best step in management right the next best step in management will be to administer IV fluids right you administer those IV fluids because this person has pancreatitis right likely has you know pancreatitis from like alcoholism so next best step in management to be you know quite an mystery fluids and make the patient like NPO right so IV fluids NPO being control and that's pretty much all you do they will try to trick you on the exam to get you to you know pick like give it antibiotics do not do that I mean it's very rare antibiotics are very ready the correct answer for the treatment of acute pancreatitis and I remember in acute pancreatitis right those people's lipis is will be greater than their greater than their I mean they're the lipis is more specific for the diagnosis of pancreatitis than than amylase and then what did they give you a question about like a 40 year old female you know she has like a two year history of like serious disease that is well controlled with with methemazole and then they tell you that she comes into the emergency room because she's been having like politicians for the last like two hours and then they give you some vitals you know the person's

heart rate is like 220 beats per minute and then they tell you that her pulse is irregular and then they tell you that the patient becomes altered or becomes like comatose or luscious consciousness or whatever or you know what let me know go that for let me just say the tell you that the patient appears confused and they have a lot pressure suddenly drops to like 70 over 40 and your friends at the mbmi has for the next best step in management under those circumstances the next thing you want to do believe it or not is to actually perform a synchronized cardioversion I know a person listening to this maybe saying what I promise that's the right thing to do whenever a person has an arrhythmia and they are hemodynamically unstable your next best step in management is always to perform a synchronized cardioversion and remember there are many other terms for synchronized cardioversion like direct current cardioversion DC cardioversion direct current counter shock those all mean the same thing okay so the person has a fit and the hemodynamically unstable resist the temptation to pick a given a beta blocker or non-dihydroperidine calcium channel blocker or immuter on or adenosine no no no your next step in management for those people is to perform a synchronized cardioversion you want to go ahead and perform a synchronized cardioversion and then but I guess if you're thinking about all there like you know like a fifth decision trees you know if a person has a history of a fifth and you know you just want to manage them right yeah the right thing to do will be to you know like a fifth and you know they are like relatively stable you can go ahead and you can try like your big home and overs massage the carotid don't feel your head in cold water you can tell them to blow into a stroke and a deal you can try all those things but if for example you don't see that as an as an answ

er choice you know you'd want to maybe consider putting them on like a beta blocker right or a dihydroperidine a calcium channel blocker like a verapimilodil tires it and just as a high yield factor remember that verapimil is associated with a hyperprolactinemia so that's just one weird thing you want to come into memory remember in a favorite you can post you like a rate control strategy or rhythm control strategy the rate control strategy is again basically beta blocker or non-dihydroperidine calcium channel blocker like verapimilodil tires and or the joxin remember the joxin is a most grainy receptor agonist in addition to blocking the sodium potassium ETB spawn so under those circumstances you can actually use the joxin for for e5 and then rhythm control is a mutual-run essentially right now what if you get a question about you know for like a 25 year old guy you know he comes in palpitations he tell you that he's heart rate is 20 or 50 bits per minute he has like the irregularly regular crap that's e5 and then they also tell you that he has a histone wolf Parkinson white and he has for your next best step in management under those circumstances you want to go ahead and prescribe a prokenamite okay remember the patient has wpw syndrome and they have a feb you always want to go ahead and treat those people with a prokenamite you absolutely positively do not want to use an evinodo blocking agent so things like beta blockers are big no no non-dihydroperidine calcium channel blockers like verapimilodil tires and our big no no the joxin remember the joxin slows down conduction through the evinode right because it's it's also has most conic receptor agonist activity that's a big no no a denocene which slows conduction down the evinode is a big no no because if you're doing your those things you'll essentially see like open pathway to go straight through that access retr

act from the entrance to the ventricle and you convert that patient's e5 to v5 and then you have a very big problem on your hands under those circumstances so you're absolutely positively do not want to do that on an mbm x now let's assume they give you the give you a question about 40 old female okay they tell you that okay let's make this because I have a variation I want to introduce this is a 30-year female comes into the comes to the you know PCP's office says that she's been having like severe like abdominal pain for the past like three months and they tell you that on par patient of the abdomen you know you'll pop it the uterus it kind of feels soft and globular and buggy right and then they ask for your next step in management your next step in management is actually to prescribe the myerna IUD this person has abnormiosis but if they give you the qualify and the cue stem and you're likely being like a person that's a little older like in like early 40s and the give you the qualify that the patient doesn't want to have kids anymore then and like the title of the pain bloody bloody bloody blood then under those circumstances you'd want to consider proceeding with with a hysterectomy okay that's the definitive treatment for abnormiosis and if they're asking you for the diagnostic test for abnormiosis you actually want to go ahead and perform an MRI of the abdomen okay like a uterine MRI essentially if you don't see that as an answer choice go ahead and choose like a laparoscopy that's the only way you can definitively diagnose abnormiosis in fact if you work the question this way and say which of the following is the gold standard test or if is the definitive test or it's like the test that can confirm the diagnosis they essentially are saying what's gold standard that's actually diagnostic laparoscopy that's how you ultimately are able to diagnose some abnormal

myosis and then what do they give you a question about you know like a 45 year old female she has a BMI of 40 comes into the hospital she says over the last two days she's been having like severe pain in our you know like an upper right abdomen and you give you vital certain temperatures like 101 and you know she has like a white count of like 12,000 and then they ask for your next best step in management right or hope you're telling me you get a right-uproachial ultrasound but let's assume that the right-uproachial ultrasound is negative or it's equivocal right and you still strongly suspect obviously right this patient having a acute colostitis the next your next step in management under those circumstances be to proceed with a high-discan right and then after the high-discan confirms what you want BMI say oh at 60 minutes or whatever there is non-visualization of the non-visualization I mean if you want to be like super accurate is more like oh like after four hours there's no visualization of a cobladder if you're like one-gen whites for don't worry wonder about whites four hours I'm just seeing that to be accurate if you're wondering as canaryologist friend you have what basically they say oh non-visualization of the cobladder of four hours after a high-discan that tells you the patient has acute colostitis your next step in management you will be to perform and a colostitis take to me but what if they give you a question about a patient you know being in the hospital for like you know like two weeks severely ill completely not right-uproachial pain has like a fever has a lucositis and let's say you perform the so do you say next step in excuse me next step in management you're like oops if acute colostitis you get a red-uproachial an ultrasound and then let's say that a red-uproachial an ultrasound you see like dilation of the wall of the cobladder you see peric

olacistic fluid but then the adding the qualifier that there is no that you do not see dilation of the cystic dot or you do not visualize an obstructing stop and then the ask for your next step in management your next step in management for those patients is actually something called a percutaneous colostitis trust them okay you actually want to go ahead and perform a percutaneous colostitis trust me they would try to trick you by giving you an answer choice that involves uh get performing an acute colostitis take to me that's a terrible like you don't want to do that right you want to go ahead and perform a percutaneous colostitis trust me because essentially that patient has a calculus colostitis right so under those circumstances you want to perform a percutaneous colostitis trust me performing an acute colostitis like a colostitis take to me has like high mobility and mortality in a calculus colostitis now let's assume you get a question about a patient that let's see how do I want this question so let's say the you know give you a question about like a let's see we give you a question about you know like a 17 year old kid okay this kid wakes up with like morning headaches they have headaches all the time and then they tell you that the kids be am I like 40 and in the tailion physical examiner's respiratory it is like eight and then they give you like AB Gs you notice the spacial tree is like six right and the next step in management I would really want to add those circumstances that you're considering a police on some nogram right like a sleep study this kid essentially has like OSA or maybe like if you're I guess if you're being like super particular this patient has obesity hypogencylation syndrome for I mean if a person has OSA OHS if a patient has marco lepsy right so falling asleep falling down when he loves all that crap right those things your next step in

management is always to perform a police on nogram right a sleep study to make the formal diagnosis of whatever is going on now what if they give you a question about six month old I'll tell you that this patient the parents notice that like this patient has been having like over the last two weeks the patient has been having like just seizures all the time like generalized like whole body seizures and they tell you that on physical exam this kid has like high propagmented marco's on the skin and then they ask for your next best step in management right your next best step in management for that kid will be to administer ECTH right so this kid has an infantile spasms right like West syndrome remember it's like the seizure disorder that you find in kids with a tuberous curiosis so the thing you do on that those circumstances is to give ECTH and remember on if you get an edging those kids you'll find the classically described a hypsi-rhythmia okay you'll find the classically described okay and again you treat it with ECTH if the real one of misdruid your head on an exam they can give you something like like a like a vibabatry now what if they give you a question about like 23-year-old guy they tell you that you know he has a b-my of like 18 and they tell you that over the last um over the last um I don't know like um like uh three days he's been having like severe bloody diarrhea and then they tell you that on exam he has like you know like severe abdominal distension rebound garden and then they ask for your next best step in management I would really hope that you are choosing exploratory laparotomy right this patient has a toxic mega colon from like all three different lightest right so under those circumstances once you saw spec toxic mega colon you always want to proceed to performing an exploratory laparotomy so an exploratory laparotomy is typically on MDM is th

e next best step in management in people that have like toxic mega colon from like CDIF toxic mega colon from like all three different lightest toxic mega colon from like type of no somark for the eye um well if a person has like penetrating trauma to the abdomen right so if a patient for example has um um like a stab wound to the abdomen or going to the abdomen um you want to go ahead with exploratory laparotomy another classic one is if you perform an extra you see free air under the diaphragm right you also want to again proceed with a x-lap um yeah you want to perform with a x-lap the thing is your friends on the MDM instead of seeing exploratory laparotomy they be called exploratory ciliotomy it's one on the same thing now what if you get a question about uh uh you know like uh you know like a nurse and they tell you that um she gets stuck by a needle um from like you know some patient and they give you like you know serologies for the patient the hippie surface antigen is positive so you're like oh crap this patient has hippie and then they tell you that this nurse um has you know like had the hippie vaccine like two years ago um and was confirmed to be immune and that's for your next step in management your next best step in management under those circumstances is no further action right no further action because remember that um um if a person is immune to hippie then you don't need to you don't need to do any kind of post exposure for relaxes but if they're non immune your next step in management will be to give the hippie vaccine right and then to give the hippie immune globulate okay those are actually very high your things you want to keep at the back of your mind for instance and then um what if you get a question about a patient that you know has a history of HIV and they tell you that this patient cili 4 counts is like you know like 600 so you know doin

g pretty well he's on highly active antirithro viral therapy they make this like a super non-descript question and then they ask for your next best step in management um if it's in the fall you want to go ahead and give them the influenza vaccine that'll be your next best step in management um if it's like not in the fall and you don't see like an influenza vaccine as your answer choice the next best step in management will actually be to give them the pneumococcal vaccine right remember the pneumococcal vaccine you tend to give it to people that have like especially people that are under 50 you give it to people under like I guess let me be a little more specific people under 65 you can give them the pneumococcal vaccine if they have like chronic conditions right so like chronic kidney disease or cirrhosis or they're like smokers or they're diabetics or they have like csf leaks kind of deal and those people do deserve getting uh getting uh what is it called they do deserve to get um um uh come on the one thing they do deserve the pneumococcal vaccine okay and again obviously if you over 65 you do need a pneumococcal vaccine that's just kind of like a high-of-end to know now what do they give you a question about uh like uh uh uh 22-year-old like you know G1 P1 female and let's say let's say G2 K1 female and she's at like you know like uh 18 weeks gestation and let's say like at a prior doctor's visit obstetricians visit the notice that the maternal serval for fetoportals invaded and they did like an ultrasound and it was negative um and then they say that oh a decision is made to pursue an amuse synthesis and then you perform the amuse synthesis and you obtain samples and then the ask for the next best step in management i would really hope on that those circumstances that you're considering um uh giving a rugam okay remember whenever you have anything that can mix mom

and babies blood you always always always want to get rugam okay you always want to get rugam always want to get rugam right uh because uh you want to make sure that mom is not as sensitive okay now what do they give you a question about uh about like uh 37-year-old female you know um they tell you that she's been having like heavy menstrual bleeding over the last like three months and they tell you that a BMI is 35 and she she has a means he's every like 70 days something weird and then be asked for the next best step in management i'd really you want to go ahead and place that patient on OC Ps like a combined OCP well let's assume a combined OCP is not an answer choice one nifty answer choice your friends at the MbMI slow down an exam will be to actually do an endometrial biopsy or like endometrial sampling because that patient actually has a pretty high risk i mean obviously this patient has PCOS so that patient has a pretty high risk of like endometrial hyperplasia endometrial cancer so under those circumstances you're strongly strongly strongly want to consider um um getting endometrial sampling in those uh in those uh circumstances um so it means he'll divide but she's less than 50 here's the thing if a patient is less than 50 and they have like a very high risk of endometrial cancer so like a patient that has like a history of PCOS or a patient that has a long term history of Tikin Tamoxifen and he present with like bleeding that's kind of like all of the ordinary for them you want to go ahead and get an endometrial biopsy okay and then let's assume you'll get a question about uh uh you know like a 25 year old guy he he just came back from like spring break and you know maybe had sex with like a 12 women and he used condoms in consistently and then they tell you that oh on his penis you find like a pinless well circumscribed lesion with hip thop borders and tha

t's for your next step in management the next step in management that I hope will be to obtain like the RPR or the VDRL test right that this person has a specialist essentially um and um um um um after that right here next step after that will be to get like the you know the trapponimo test remember RPR VDRL those are non-trapponimo test they are for screening um the next thing you want to do to confirm that diagnosis will be to get those trapponimo tests they have like red names like FTA ABS and uh MHATP okay so that's what you do on that those are circumstances and then um remember syphilis remember a secondary syphilis russian the palms and souls and syphilis obviously if you want to treat you give IV penicillin where you give penicillin G you don't give penicillin V penicillin V but idea that's or open penicillin G IV penicillin good idea okay good idea now what if they give you a question about um they give you a question about uh you know like a 35-year-old guy and this guy um is going for like you know like icerge or whatever and then they say like 20 minutes after induction this patient um the anesthesiologist notices that he has like stiffness in all his extremities his temperature is 105 and the answer for your next best step in management the next best step in management I hope your scene is to go ahead and obtain uh I mean to go ahead and uh administered dantrullin the thing is your friends at the nbm is so seen administering dantrullin demisi administer or calcium channel blocker that will also be the correct fans remember and dantrullin is in fact a calcium channel blocker right because this patient clearly has a malignol hyperthermia and in malignol hyperthermia it's all the zomodominant inheritance those people have like mutations in the dihydroperidine and the ryanodine receptor the ryanodine receptor mutation is more common so those people have like

too much release of calcium from the cycoplasmic reticulum so they have like a craptonomoso contraction so the thing you would do is to essentially give like a ryanodine receptor antagonist like dantrullin and now fix the symptoms right because now prevent the release of calcium from the cycoplasmic reticulum now what if you get a question about uh 20 year old guy you know he's an iv drug user and we tell you that um you know he he admits to um um um um hope i make up this question sorry i'm just a literally like sitting on a couch and talking through these tens um you know i don't know the question has just disappeared from my mind so i guess uh we will have to uh move on from that i will try to keep this to like an hour or maybe like just a the tinge of smidge up over an hour uh again i'll make many next best step in my event podcast it's just literally like if i literally have to sit down and conjon conjure all like everything i have in my mind on next best steps in management i'll probably make like uh 40 hour podcasts from that that's obviously not practical right and uh the resident so i clearly have to you know do like you know resident things like you know like sleep for example um so i'll have to make all the podcast in the future on this um in fact um since we're kind of like you know coming up on an hour and you go ahead and pause here um so as i do at the end of every podcast i do offer one on one tutoring for the for many exams right step one two ck two cs step three pre-cleaned cool med school exams 30-ish off exams if you're medicine resident i actually tutor to the internal medicine board so like the ebam exam i tutor to the internal medicine training exam um if you're a college student and you need tutoring in like physics, gen-cam, o-cam, bio-cam um physiology, astrology, offer tutoring for all those states and then um again there's this thing i've b

een doing fairly recently um that a lot of is also i guess it's not what we have been doing recently i've done it for a while but i'm beginning to get like more people um sign up with me for this is longitudinal tutoring um so i've done this especially with like med students like med students like studying now med school the thing i do is i tutor them for all of their class exams right and again as i'm tutoring them for all their class exams i'm infusing step one knowledge along like along the way so that essentially when the heated dedicated periods they're like super ready for their tests um and i've again i've had like very strong solid results with these um same thing with like people studying now 30 year like again longitudinal tutoring i kind of like again tutor them for all their shelf exams and then i tutor them with their dedicated periods again i've had people do very well with this i typically end up meeting these people for like two to three hours every week but essentially over the course of that year i prepare you very strongly uh one on one for your for the u sml exam that's going to essentially be coming up at the end of your bit either 30 or second year if you're if you're pretty clinical as student um i've started actually doing this with some internal medicine residents as they're going through their rotations i tutor them based on like the stuff that's commonly tested so if you need any of those things or you know anyone that needs any of those things feel free to send them my way um you can either go through the website or you can send me an email at divine intervention podcasts with an srb at gmail.com so i hope you gain a lot from this podcast um again i know it was a long one but it's a very high-owned one so i wish all the best have a great rest of your day god bless you i'll see you next time

Carotid ultrasound (to screen for carotid stenosis).

Lumbar puncture (LP), looking specifically for xanthochromia.

Ceftriaxone + Vancomycin + Ampicillin (to cover Listeria).

Benztropine or Diphenhydramine.

Ankle-Brachial Index (ABI) < 0.9.

Endometrial biopsy or sampling.

Carotid ultrasound (to rule out TIA source).

Lumbar puncture (LP) to check for xanthochromia.

IV Heparin infusion + Vascular surgery consultation.

TSH (Thyroid Stimulating Hormone).

Angiography.

Percutaneous colostomy tube placement (to avoid perforation risk).

Benztropine or Diphenhydramine.

Carotid ultrasound (to rule out TIA source).

Lumbar puncture (LP) to check for xanthochromia.

IV Heparin infusion + Vascular surgery consultation.

TSH (Thyroid Stimulating Hormone).

Angiography.

Percutaneous colostomy tube placement (to avoid perforation risk).

Benztropine or Diphenhydramine.