DIP Ep 646: USMLE Free 86 Series 8 (Q67-76, for Step 2/3)

Alright, welcome. This is episode 646 of the Divine Intervention Podcasts. Today's podcast will be continuing the 3.86 series, first step 2. Step 3. This is going to be series 8. Alright, I'm going to pick up from question 67. A 4-day-old female, Greek American newborn, is brought to the office by her mother. Because the infant developed yellow enough for skin one day after hospital discharge, and approximately 20 red spots over her skin yesterday. The infant has continued to feed well. Pregnancy and delivery were uncomplicated. Birthweed was 3400 grams. 7 pounds 8 ounces, 50th percentile. Upgrad scores were 8 and 9 at 1 and 5 minutes respectively. The mother gravita 2.2 has blood group A, Irish positive. The neonids blood group is O, Irish positive. Results of a direct anti-globulin that's a cum stress was negative. The newborn, the neonids was breastfeeding and was doing well at the time of discharge. Waits to these 3250 grams that 7 pounds 2 ounces 25th percentile. Physical examination discloses John Dessence Clare Electors. Many papules containing small vesicles with clear to slightly tributythloid are present over the newborn's face, trunk and extremities. No organometalline or adenopathy is noted. Serum total bilirubin concentration is 8.7 mg/dL. And serum conjugated direct bilirubin concentration is 0.7 mg/l/dL. So question 67 says, "In addition to scheduling a full-of visit in one week, which of the following is the most appropriate next step regarding the newborn's jaundice?" So option A says, "Advice the mother to avoid eating foods containing large quantities of chiropractic protein." B says, "Begin adbenistrine small doses of phenobarbidol to the newborn." C says, "Recommend discontinuation of breastfeeding until the jaundice has disappeared." D says, "Recommend home full therapy for the newborn." E says, "Recommend no change in child care of feeding of the newborn." I'm going to go with option A here. This child has a physiologic jaundice. Usually the arises after the first 24 hours of life. And it's going to peak within a few days and then it's going to go down. This child since his first week of life is probably breastfeeding jaundice. So typically that's just jaundice that arises because the baby is not feeding enough. He's not eating enough, which is not unusual. The old mom is still figuring out how to breastfeed and all that stuff. That's why the bilirubin is high. It's almost like a bilirubin concentration effect in a sense. It's 8.7. The child is fine. This child is four days old. That's like 96 hours old. We don't start doing phototherapy and any of that. In a 96 hour old until their total bilirubin is 20 milligrams per decilator or higher. What I'm going to do that here, that's ridiculous. Option E is the right answer. Home full therapy. Photo therapy we don't in a hospital setting, right? Not at home. And then this continued breastfeeding, no. You should actually breastfeed the child more. Give final barbitol to the newborn. No. Right to increase UDP glucose or transfer is activity. No, you don't need to do that. Advise the mom to avoid eating foods contain large amounts of carotene. No. Right? And this jaundice again is physiologic because it rules after 24 hours of life and it's indirect. Right? Remember physiologic jaundice is never direct type bilirubin. Mimi. All right. Now, question 16. It says which of the following is the most appropriate management for the newborn's rash? Again, what rash does this newborn have? It's red. You know, has an aerothymal base. You know, small vesicles. It's on the face. The trunk and the extremities. Right? This is ETN. Right? Aerothymatoxicone, your nature. Again, usually picks a few days of life and then usually with them by like two weeks or whatever it just resolves on its own. So it's not a big deal. I don't do anything here again. You see most of this question is benign. You really should be picking up benign answer. So option A says a 0.5% hydrochlorousone cream applied twice daily. Now, daily wet to dry. Povi don't iodine. Soaks with goss pads on each vesicle. No. Polymixin, ointment applied twice daily. No. Routine skincare with soap and water. Yeah, that's a benign answer. Epic D. Option A says scrubbing daily with insuphone cleanser. Firmly enough to unroof the vesicles. I've not even heard of insuphone before. I don't know what that is. You have to look that up on your own. But option D makes sense here. All right. Question 69. Six month old male, his panic infant is brought to the office by his parents. Because of intermittent swelling of his right scrotum, that is more pronounced when he cries. The swelling has never been read or stock. Vital signs are normal. Arriding when a hernia is confirmed on physical examination. In discussing repair of the hernia with the parents, you should inform them which of the following. Right. So this is panic infant. Right. Like if we look at this, this looks like an inguinal hernia. Right. And what kind of inguinal hernia is this likely going to be? I hope you're saying divine. This is probably an indirect inguinal hernia. Right. Remember, indirect inguinal hernia is a very common in little kids. And we tend to find you more commonly males. We tend to find you more commonly males. Males, people that were born preterm. And he's usually going to be on the right side. Right. Because the pathophysus we know involves persistent pretency of the processes vaginalis. And the thing is, you know, there is obviously a right process vaginalis and a left process vaginalis. And there are one on the right side tends to close later than the one on the left side. Right. So if it's patent, then the abdominal contents can come through that road. Because remember the process vaginalis. I actually think of it as a highway that connects the abdomen to the testicles. Right. So you can to the scrotum. So you can basically have like if that highway is open, then abdominal contents can come through the highway. Right. From the abdomen to the scrotum. Right. And the thing is, for this, you know, you want to fix them. The way you manage inguinal hernias is kind of different from the way you manage on the local hernias. On the local hernias, I can wait till close on his own in most cases. But I'm going to hernia. You especially in inguinal hernia in a little kid, a child that's like less than a year old, you want to try to close it electively. Right. You want to schedule the surgery because the thing is, especially in kids underage one, they have a pretty high risk of incarceration and strangulation. Right. So you want to fix it. It's not crazy high, but you want to fix it. You don't want to just leave it dangling or whatever. So you want to fix it if you can. Right. So let's look at the right answer. So option A says, "Henerofic can be postponed until each two years because many hernias close spontaneously." I'm again, the risk of incarceration, strangulation and death is high. So you don't want to do that. Option B says, "Henerofic can be postponed until each 12 years." Because so it goes permia. Does not develop before each 12. I would not do that. Option C says, "Henerofic should be scheduled at the earliest convening time." Okay. That seems like a reasonable answer. Option D says, "Henerofic should be scheduled as an emergency operation." No. Right. Deal with a mess first. Prevent a mess instead of cleaning up a mess. So deal with it sooner or later. Right. Don't wait until it becomes an emergency. That doesn't make any sense. Option E says, "There is no need to repair the herniane childhood unless incarceration occurs." No. You want to repair it. The thing is when a child that is more than a year old that has lived for a few years of life has an inguinal hernia, the risk of incarceration, strangulation is low actually. But for a child that's like less than a year old, the risk of incarceration, strangulation is pretty high. It's not an emergency operation, but you want to fix it. It's an elective procedure, but you want to fix it. All right. Now, question. So the right answer is going to be option C for that one. All right. Question 70. Three weeks ago, a 45-year-old man was admitted to the hospital because of frostbite of both feet. He was treated by rapid, rewarming and protective care of the feet. All the tools on the right's foot have turned black. That's not good. He has become slightly fabriol and progressively more confused over the last few days. Examination discloses cellulitis in the midfoot. Which of the following is the most appropriate treatment? This guy has gangrene, right? I can see many things going wrong here, like I don't know, like neck fascia, compartment syndrome, or sepsis and death. So option E says amputation, I'll probably pick that one, right? Get rid of that bad foot. Option B says, application of topical collagenase, that's like a thing that kind of breaks down collagen. That's not going to help with gangrene. Option C says, the breathing of necrotic skin. Seems like the problem involves more than the skin, so I'm not going to pick that. Option D says hyperbariac oxygen. Again, gangrene has happened necrosis of the tissues happened in it to an amputate. E says, whirlpool therapy. Now, the right answer is A, you're going to amputate that, that extremity. All right. Okay. Now, question 71 says, a 44-year old African-American construction worker comes to the emergency department because of excruciating left flank pain that reduced to his left testicle. He describes the pain as occurring waves and says, "This is the worst pain I've had in my life." And that includes closing my thumb at my, in my truck door. He's extremely restless as in, and he's in obvious pain, genitalia or normal. Abdominal examination discloses intermittent guarding with spasms of pain, plain extra of the abdomen shows no abnormalities. Results of your analysis are shown. So the pH 6.4 5 specific gravity 1.025 glucose negative protein negative of course the neglect to show us the red cells MbMEs all right, so urinary sediment is shown which of the following is the most appropriate diagnostic study Option E says CT scan of the abdomen B says CT scan of the kidney C says culture of the urine D says Determination of serum uric acid concentration E says measurement of 24-hour urinary calcium excretion This person has got a kidney stone right the abdominal film did not show you anything Well, how do we find kidney stones we find kidney stones with CTs right non-contrast CTs Remember you use a non-contrast CT because if you use contrast you'll obfuscate the stone and you'll be able to see it So option C is wrong right urine culture that's for UTI that's not what's going on here D says Checking serum uric acid concentration. He says checking urinary calcium excretion again Let me help you you don't really need to do that right you don't really need to do that like the direct way you diagnose a kidney stone Is by doing a CT so we have two kinds of CTs here. We have a CT of the abdomen and a CT of the kidneys. You're like Those two answers are correct. No, they're not Only one is correct right so remember Well kidney stones always be at the kidneys No, right there are many places they can be they can be in the kidneys They can be in the urators they can be in the renal pelvis they can be many different places So between a CT of the abdomen and a CT of the kidney which one is going to give you a more complete visualization of the urinary system I hope you're saying CTs kind of the abdomen right so the right answer is going to be option A. It's not going to be option B All right Because option B only shows you the kidneys option A shows you the kidneys and the entire in a collecting system all right Or urinary collecting system all right, so question 72 says a 52 year old woman who has had low back pain for several years Is admitted to the hospital because the pain is suddenly worsened Her crime medications include oxycodone, Amy tryptoline, perfenozine, flow oxytin and chrasodone The patient's body weight is 10% below ideal weight. Pupils are constructed and skin turgor is poor She seems sluggish and her speech is slow Neurologic examination and x-rays of the lumbar sacral spine disclose no abnormalities If a medication is responsible for this patient's mental condition the medication is most likely to be which of the following So see this person has constructed poop pills you don't say She's sluggish your speech is slow hmm all right Let's look at this option A says Amy tryptoline well. No, that's a TCA TCA is have anti-colonergic properties right so the cost Popular in my dry asses not meiosis so that's wrong Option B says flow oxytin well flow oxytin does not cause ocular findings Option C says oxycodone oxycodone is an opioid opioid skin Cospopolar meiosis because the decrease in our opinion friend released at the adrenergic synapse So that seems right. Let's keep that Per phenazine I believe is an anti-psychotic anti-psychotics Especially the first generation low potency anti-psychotics. They also have anti-colonergic effects right remember Your tricyclic anti-depressants and your first generation low potency anti-psychotics They have those anti-harm effects anti-h1 so they can cost sedation anti-alphones so they can cause orthostasis and anti-moscarinic Right anti-M1 so they can cause anti-moscarinic anti-colonergic effects right so option D will cause popular in my dry asses That's not what's going on here Trasodone Uh, Trasodone is kind of a kind of a Um, we copioid right it's kind of a we copioid Um, but again between oxycoron and tracodone which one is a more powerful opioid more likely to cause this systemic effect Um, I'm gonna go to option C right so yeah oxycoron makes the most sense for this person all right So gonna go to question 73 uh 65 year old man is admitted to the hospital after he has an inferior wall myocardial infarction 48 hours later his vital signs are stable ECG is shown The most appropriate course of action is to do each of the following All right, ACES administer atropine B says administer isoprotarinal C says begins synchronized card diversion D says insert a pacemaker he says observe All right, let's look at the ckg Okay, um, oh, okay, that kind of makes sense. So first things first, let's look at the rate right so we can see between the QR's complexes I mean the boxes do we have so one two three four five oh like About six so his heart rate is pretty low is probably about 50 so he's got a pretty cardio has maybe a pretty arrhythmia All right, now let's look at the PR intervals right because again if the US Emily is again just think in odds on your exams, right? I feel like people like to overcomplicate their lives just thinking odds on your exams If the US Emily's at testing a pretty arrhythmia, which one do you think they're gonna go for first probably some kind of AV block right so Whenever I see a person has a pretty cardio the next thing I think about on my exam is G divine. Let's look at the PR intervals well, we'll look at the first PR interval. We'll look at the second one. We'll look at the third one We'll look at the fourth one we can see the PR intervals are getting longer and longer and longer and longer and longer and then boom QR is disappears So what kind of AV block is that that's gonna be second degree which one? Mobiz one right? Winky Bach Mobiz one Do you do anything for a Mobiz one AV block? Nope, especially if they're asymptomatic if they have symptoms then yes, you can paste them But this person doesn't have any symptoms. So I'm not gonna do anything right so Um, so I'm not gonna be doing that troping. We use atroping when a person has a symptomatic bradycardia Um symptomatic bradycardia and you notice that pacing is not even a supply dancer. I'm not gonna do that Isoprotary Nol is a beta one and beta two agonist. There's no reason to do that. This person literally has no symptoms He's completely fine Synchronized cardioversion is typically for tachyroidism is not brady arrhythmias Instead of pacemaker again, that's for people that have a Mobiz two or a complete hard blocks. That's third degree and typically Mobiz two and third degree hard blocks tend to be associated with led infarts led infarts, okay? And TRIMI's Post in feroal LMI's RC infarction to be associated with Mobiz one Uh, and those tend to be transient right usually within a few days. They'll kind of go away You know as these schemia and everything results right so I'm not gonna put a pacemaker right like I'm not gonna put a pacemaker So option e makes sense right the right answer is to observe right So the answer is e all right So a healthy two-year old African-American child is brought to the office for routine well child visit The child was winged at six months of age and began to walk at ten months of age on physical examination She has mild bolex 10 degree genuvarum The parents should be advised about which of the following again. This child is fine coming for routine visit Right and then the US Emily's you know she started walking at ten months. She was she's crushing it motorwise mild bolex Guys pick up the nine answer here. Don't overthink this thing Option a says braces should be applied immediately No Option b says no treatment is needed at this time. Yeah, so I'm gonna pick option b Option c says surgical correction is necessary. Come on from our bolex. No Option d says the child's intake of vitamin d should be increased Do we see any indications of rickets in this child vitamin d deficiency? Nope. Special exercise program is needed We don't need that right now, right again most times bolex or resolve within like you know two to three years or whatever right You know this child is just a two-year old you know likely resolve. It's just a part of development It's not a big deal, you know If the person has lived for you know, maybe longer than three years they like four five-year-olds They still have bolegs or they have like very severe bolegs Then you can maybe do exercises and things like that or brace in but you don't need to do that right now This child is fine. This child is just a two-year-old chill out. I'm gonna go with option b for this for this one. All right Yeah, that's the thing. I feel like many times people over complicate the usmly exams. They actually fairly straightforward If you don't over complicate things for yourself. All right Question 75 says a three-year-old child is brought to the ed by his teenage sister because He refuses to walk okay The sister reports that she has been babysitting for three days while her parents are away on a trip What and that the boy has been fussy for the past two days Physical examination is normal except for a painful swelling of the left lower leg In addition to radiography of the leg you should obtain which of the following Man, this story is not adding up What kind of parent? Goodness gracious. What kind of parent leaves a three-year-old in the care of a teenager Okay, maybe two hours. I understand that we got to go grab ice cream or something but for three days Wow, okay, this story is not adding out. There's something strange going on here Well, let's look at the answer choices here option. He says abdominal ultrasound B says CT is kind of the abdomen C says CT is kind of the head D says skeletal survey. He says sirm led concentration So what do you think is going on here whenever you have a story in a kid that does not add up Well kind of worried about child abuse here, right kind of worried about child abuse Um, so this child has a problem in the low extremity Uh, maybe they have issues in other bones add to a skeletal survey, right? The theory is you want to be really careful about ordering CT scans in kids, right? It is a three-year old white giving that big dose of radiation, right? So So, certainly will not do options B or C And then option A abdominal ultrasound Well, the thing is again the question is directly focused on the musculoskeletal system Why don't we examine that first before we start looking at the abdomen, right? And then option E says sirm led concentration because remember led can cause abdominal pain, it can cause like wrist drop, foot drop, you can cause neuropathy and all those things. But again, it will probably not arise this suddenly, right? That doesn't really make sense. So I'm gonna go to option D for this one, right? The skeletal survey is basically like an X-ray, like a series of like 20 X-rays. I know, I know, sounds like a lot of radiation, but it's not as much as a straight up CT, right? So like a series of 20 X-rays, you assess the major bones of the body, just to make sure that hey, there's no kind of like non-acadental trauma going on here, right? So I'm gonna go to option D, right? This story just does not add up, it just does not add up. All right, now, questions 76 are last question today. A 32 year old man and his 29 year old wife come to the office for evaluation for infertility. The wife's gynecologist has reported that her anatomic and physiologic evaluation disclosed no abnormalities and that assessment of potential male factors is needed. The husband is 188 centimeters, he's six full three inches tall with fair skin and little facial hair. He has male gynecomasia and small firm testicles, no sperm as seen on similar analysis. Which of the following tests is most likely to establish the underlying cause of this couple's infertility? Well, the wife seems fine, but what do we think the husband has? Tall guy, gynecomasia, small testicles, right? Not making enough 100 genes for you, so they have like decreased baby canoxyria here. It's probably client filters, right? Client filters, client filters, right? 47 XXY. So, okay, let's see what it was gonna help us here. So, option A says, carry a type from peripheral leukocytes. Sounds reasonable, let's keep that. Option B says, serum estrogen and testosterone concentrations, no. That's not gonna be specific for anything, right? Option C says, serum FSH and LH concentrations. That's not gonna be specific for anything because the question is, which of the following tests is most likely to establish the underlying cause of this couple's infertility? Option D says serum prolactin concentration. No, prolactin doesn't explain this guy being this tall. I don't know, that doesn't make any sense. Option E says, testiculotry sound, no. This person has client filters, you're gonna see very well with carry a type in. So, I'm gonna go to option A for this. All right, so we're gonna stop here. Again, like the way I teach, you're gonna love my classes even more. So, I have a bunch of classes for this month, taking place starting on the ninth, right? So, starting this Thursday, for step one to three, there's a test taking class, bio stats class and a social science class. And then, for step two and step three, there's a last minute review on a 20 hour class. And then in the month of June, first week of June, I have a 20 hour step two, I have a 50 hour, sorry, step two, step three review. And then I guess in the month of July, if you're a person that is studying residency, internal medicine residency, or you're graduating from residency, and you're taking your internal medicine boards, or you're researchifying, I have a 50 hour ABIM review that's coming up. All right, if you're interested, I've meet podcasts where I talk about those classes and what you should expect from them. Or if you want more information, shoot me an email. Again, these classes are not lectures, I use problem sets to go over content, explain pathophysiology, make integrations, show you how that information is presented on exams. And then, also, I offer one or one to learn from all the US similarities and complex exams. And then, I also have this podcast on Apple Google on Spotify, I've got a YouTube channel you can check out. And then, I have another website called DevineInterventionLiveLessons.com. DevineInterventionLiveLessons.com. Many of you know I'm a Christ follower, so every week I post like one or two podcasts where from a biblical perspective, address a life lesson. I uploaded episode 300 and E-7, I believe, yesterday. And there's actually an Apple podcast associated with that called the Devine Intervention Life Lessons Podcast. There's actually many people that listen to those and find them to be extremely helpful, like getting emails from people all the time on those. All right, so thank you for listening to me today. I'll see you God willing episode 647, I think. And I believe that should be the last part of our series on the 3D6, so we can move on to something else. All right, so have a wonderful day. I'll see you next time. God bless you and bye for now. Thank you.