DIP Ep 647: USMLE Free 86 Series 9 (Q77-86, for Step 2/3)

Alright, welcome. This is episode 647 of the Divine Intervention Podcasts. And into this podcast we're going to be finishing the series on the free 86. This is going to be series 9. Alright, so we're going to pick up from question 77. A 50 year old man comes to the office because of a lesion on his lower lip. That developed nine months ago. He has not seen a physician during the past five years and says, "My wife made me come to see you today. Physical examination of the lips discloses the findings shown in the photograph. The lower lip is fixed to the anterior aspect of the mandible, which of the following is the most likely diagnosis. Right? So we see this lesion, right? Looks like an ulcer. Looks like an ulcer. It's kind of around the lower lip. Right? This looks like cancer. Right? This is probably going to be a scrimal cell skin cancer. Right? So we're going to go with option E. It can be option A, B, cell cancer because we're not seeing like those telanget tissues and things like that that we see with B, cell cancer. And then this is not a carado, a canthoma. A carado, a canthoma typically is going to be a raised lesion with a central critter. Right? So it's like a raised lesion with a central critter. In fact, many times it's regarded as a kind of scrimal cell cancer. So that's wrong. Look up, Blakey. I remember we tend to find that in immunocompromised patients HIV patients. It will be a lesion that is on the lateral tongue or on the tongue and it doesn't scrape off with a tongue depressor on like, on like a candidate. Right? And then melanoma tends to be a flat lesion. Right? So the red answer is going to be option E. Now, a 10 year old boy, so 78, a 10 year old boy is brought to the ED by his father because of left flank pain and tenderness. About four hours ago, the boy was hit hard on the abdomen during a carate carate match. Abdominal CT scan shows a large splinic tear in the pediatric intensive care unit is blood pressure is stabilized and is hematocritis 45%. Which of the following is the most appropriate immediate step? So option E says, so let's look at this. So this guy, this, this child has a splinic tear, right? A splinic laceration. But now he's blood pressure stabilized. His hematocritis fine. So what should you do? What should you do? Option E says continue, Paul some blood pressure monitoring. So this child is pretty stable. So I'm going to go with that option because the thing is, see, if you can avoid removing somebody's splin, try everything you can to not remove it because the splin has a very robust immune function. Right? So if you can avoid removing a person's splin, especially if the person is stable. If a person is suffered splinic injury and they're stable, try not to remove their splin. So I'm going to go with option A. Option B says do silly auto me and splinectomy. No, no, no, no, no, no, no, no, no, this child is stable. The hematocritis fine. Just watch him. So that's wrong. Option C says order diagnostic abdominal parasyntesis. Again, we do parasyntesis when we're worried about a person having like spontaneous bacteria peritonitis. You know, so say for example, they have like a side is right, but this child does not have a side is and then option D says order intravenous urography. Well, intravenous urography is something you use to analyze the kidneys, the uterus, the bladder, the urinary system. It's like a CT scan right or an X ray is basically a radiograph with contrast of the urinary system. This person doesn't seem to have any urinary system troubles. And then order radionuclide scan of the spleen. You don't really need to do that right. Radioluclide scans on the USMELs tend to be like ryu scans for the thyroid or you can do a new ligate scan for mechals that are particular. So I've talked about thyroid disease mechals that particular also for some cardiac stress tests like the technician tests. Yes, those are those are radionuclide scans. All right. So we're going to go to question 79. 42 year old woman with a history of MS comes to the office because she had a sudden loss of vision in one eye in the right eye right. She has no history of diplopia. So ocular movements are normal but fundoscopic examination shows power of the optic disk. This patient's condition is most likely a result of demyelination of which of the following. We see painless sodium cell vision loss in a person that has multiple sclerosis right. It's going to be optic neuritis. It's a cranial two problem. Right. So the problem is an optic nerve problem. The optic nerve is cranial two. So the right is going to be C option a the M. L. F. The media longitudinal fascinus right that SWAT causes interneucleophthalmoplesia when you have it up interneucleophthalmoplesia you're going to have an adduction a dd auction a dd auction nice statness on horizontal conjugate gaze right. You're not going to have vision loss right. So this is not an M. L. F. problem right. Oculomodon nerve that's wrong right that's cranial nerve three. Remember your oculumodon nerve is derived from the peripheral nervous system is not derived from the CNS the only cranial nerve that's derived from the central nervous system is cranial two is the optic nerve. So it's the only cranial nerve that is generally affected in multiple sclerosis right. So so it's not the oculumodon nerve. Remember the optic nerve is an outgrowth of the diencephalon but every other cranial nerve is derived from the from the neuro crest but cranial two is derived from the diencephalon is derived from neuro tube. It's not a factoid many resources talk about was actually pretty high yield to know for you exams and then the trigeminal nerve that's wrong right. It's not going to cause vision problems option a visual cortex that's going to be like cortical blindness that's not what's going on here right. So we're going to go to question number 80 going to go to question 80 right. So a 28 year old woman who is known to be HIV positive comes to the ED because of a one week history of increasing headaches right sided weakness and this orientation. A generalized tonic clonic seizure occurs shortly after admission following the seizure vital signs are normal there's no no core rigidity fundoscopic examination shows papilladema there's also right hemiparosis and ephysia which of the following is the most likely diagnosis right. So we see a person that has HIV and this person seems to have increased intracranial pressures right increase intracranial pressures this doesn't look like many types of this person doesn't have no core rigidity this person seems to have increased ICP right. So the person probably has some kind of space occupying lesion in the brain some kind of space occupying lesion in the brain right. Space occupying lesions in the brain should make you think of a few things right like what toxoplasmosis or what a primary CN is lymphoma right. So the thing is this space occupying lesion is kind of concerning right is probably something that is like a mass or ring and hands in lesion or whatever so I'm going to go for toxoplasmosis here. I'm going to go with option D right meningioma right is not is going to be more of a chronic mass right and it doesn't really present with signs of increased ICP I'm an ego coco meningitis again the person is going to have fever the person is going to have you know very high fevers that have no core rigidity we don't see that here on neurocifilus right we're going to see things like tb strsales right we don't see that here we don't see tb strsales we don't see many of those signs of neurocifilus so that's wrong right to record us meningitis again if you have meningitis you have no core rigidity you have high fevers you have you have abnormal vital signs meningitis is pretty deadly so you're going to have abnormal vital signs right so so the answer is going to be option now. option D. Remember we're going to treat that with Pyramethamine and Sofadysine and we're going to give the person a look of una as well so they don't develop a bone marrow suppression. So question 81 says five year old girl with a lumbar Mylomenin goesil is brought to you and remember Pyramethamine Sofadysine those are fully synthesis inhibitors. Again, please don't mess this up. The way we treat toxoplasmosis is with Pyramethamine and Sofadysine. Okay, the way we treat it but the way we prophylaxe against it right if your CD4 count is under a hundred is with Psyramethoprymsofathoxysone. Alright, so question 81 five year old girl is with a lumbar Mylomenin goesil is brought to the office by her mother for a priority-health evaluation. The girl has little motor function and no sensation below the waist. She has a neurogenic bladder requiring intermittent catheterization and she also requires daily suppositories to eating bowel movements. She does not have hydrocephalus but can walk only with the eat of braces and crutches. I am pleased with how well she is doing says the mother but I'm so worried about what might happen to her later on. Which of the following is the most likely late complication in this patient. Right, so think about this. This person has a Mylomenin goesil. Right, so this person has bladder dysfunction. Right, when you have bladder dysfunction, think about it. You pretty much have like a functional obstruction, a functional obstructive neuropathy. Right, that obstructive neuropathy over time is going to cause problems with renal failure. Right, it's going to cause problems with renal failure. Right, because you have obstruction. Right, so you have like these increased pressures within your collecting system and whatnot that can ultimately lead to renal failure. Again, I know you may have never heard of this before but it doesn't mean you cannot get this right. Right, all you literally need to do is ask yourself, what's the answer that relates to what the question is talking about? The question clearly tells you that weight. This person requires daily suppositories. The question tells you that the person has a neurogenic bladder. Right, so it has to be linked to one of those things. Right, so question. One of the bladder is wrong. Right, remember the biggest risk factor for bladder cancer is smoking. A COPD is wrong. She's not a smoker. Corpo monali is wrong. Right. Remember, corpo monali. Corpo monali typically happens when people have it is basically like right heart failure because of a pulmonary cause. Right, is typically a right heart failure because of a pulmonary cause. right heart failure because of pulmonary cause, right? This person doesn't have like 65% bruises or anything like that, right? So that's that's not what's going on here. All right. And then Nstetrenal disease is the correct answer option. E says, "Ostia my light is of the femoral head." No, right? We tend to find that in people that have like cushing syndrome, for example, right? Or people that are taking steroids. Sorry, whoops, that's osteonecrosis of the femoral head. So osteomyelitis of the femoral head, osteomyelitis is an actual infection. No, that's not what's going on. This presence, there's no reason to develop that. So please, whenever people have steroids access, they develop osteonecrosis of the femoral head, osteonecrosis of the femoral head. Please keep that in mind. All right. So a 26 year old man is brought to the ED by his family because he has been telling them that he's been followed by gangsters and that they are going to kill him. The family states that he has a history of drug abuse. His temperature is a hundred. Pulse is 110, right? So he's tachycardic, right? He's very hypertensive. His blood pressure is 160 over 95. His pupils are dilated. The remainder of the physical exam discloses no abnormalities, which of the following drugs most likely calls this reaction. So we see this person has a popular mitriasis, right? So he's probably in a sympathetic state. We see the blood pressure is really, really high, right? This is probably going to be cocaine, right? Remember, cocaine increases the amount of caracol that means you have at adrenergic synapses, right? So the answer has to be B, right? This cannot be alcohol, right? Alcohol, you know, you have like disinhibited behavior and things like that. It's not going to cause your blood pressure to rise. It's not going to cause popular mitriasis. So that's wrong. Diasa pamper, it's going to cause respiratory depression. It's going to cause respiratory depression, right? Heroin, right, is an opulent, right? So it's going to cause respiratory depression and population illnesses and population illnesses. We don't see that here, right? Methacolone is actually kind of a-- is not about bitri, but it works just like about bitri. It modulates GABA receptors. You know, back in the day, believe it or not, this stuff was actually a prescription. I was called a Quillews, but they banned it because it has a pretty high abuse potential. It kind of works like a Bavitarate, it modulates the GABA receptor. So that's wrong, right? So again, cocaine increases the amount of caracol that means that the adrenergic synapse. So that can cause you to have things like-- that can cause you to have things like, you know, very crazy high blood pressure because of alpha and mediate viso-construction. It can raise your heart rate so it can become a tachycardic because of bit-on-ones demolition, right? It can cause you to have my dryness because there's alpha and receptors in the eyes, well, right? Another thing that can cause a similar presentation is methamphetamine, right? But there is a reason why it didn't pull that as an answer as well. All right, so now question 83 says, "A several patients with hypertension whom you have treated for many years have recently had strokes." You are first treated by this outcome and review the literature on the efficacy of anti-hypertensive treatments in preventing stroke. A large multi-center randomized trial shows that a particular anti-hypertensive medication lowers the five-year risk for stroke, right? Lures the five-year risk for stroke. From 8,000 patients to 6,000 patients, right? Providing a relative risk reduction of 25%. Based on this study, the number of patients with hypertension who must be treated to prevent one stroke is which of the following, right? So this question is asking about the number needed to treat. How many people do you need to get? Give this anti-hypertensive to prevent one stroke. Well, remember, if we took calculate absolute risk, I mean, took calculate number needed to treat first, you need to find the absolute risk reduction and then take the inverse of it. Find the absolute risk reduction and then take the inverse, right? And the absolute risk reduction is a difference in risk, right? So it's like 8,000 minus 6,000, that's 2,000, right? That's the absolute risk reduction. And then just flip it, take the inverse, 1,000 divided by 2 is 500, right? So the NNT is 500. This drug has basically no clinical significance, right? No clinical significance. The NNT is 500, right? Like literally to prevent one stroke, 500 people have to get this drug. This drug has no clinical significance, right? So remember, NNT is a very good way to gauge clinical significance on the USMLA exams, right? All right. And also in the real world. All right, now question 84 and 85, 48-year-old Native American construction worker who sustained a comminuted fracture of his left TB and fibula four months ago. He's transferred from the rehabilitation facility to the ED because of a three-hour history of Disney and chess pain. During the past three months, he's sustaining the fracture. He has recited in the rehabilitation facility with his left-low extremity fully mobilized. That's not good. He now describes an aching discomfort over the right superior anterior chest and the right scupper lapostero. That's not good. Family history is strongly positive for heart disease. All right. So we see a person that is like fully mobilized, right, for weeks, come on, right? This sounds an awful lot like a PE. All right. So let's look at 84. He says, in questioning the patient father, an important point in the history would be the relationship of the pain to which of the following. A says change of position, B says deep breathing, C says eating, D says swallowing, E says walking, right? Remember, one common presentation we find in people that have PE's, pulmonary embolus, is a pleuritic chest pain, pleuritic chest pain, right? So I'm going to go to option B for this, right? Change of position, that's probably going to be more perioditis, right? Get worse when you lay back, when you're supine, gets better when you lean forward, right? Eating, that's probably going to be some kind of a so-for-joe problem, swallowing, probably some kind of a so-for-joe problem, walking, maybe like, engine or something like that, right? So now the presence, question 85 says, the presence of a right pleural effusion, right pleural frictionerop in this patient will suggest which of the following, right? So pleural frictionerop, right? Again, this is probably a PE, right? Probably a PE, right? So again, I'm not going to pick pulmonary embolus, right? Pyracoditis is again, gets worse when you lay back, better when you lean forward, not going to be pneumonia, right? Numonia is, it's going to close chest pain, but you're going to have fever on all these things, right? Neumothorax, you're going to have decreased breath sounds, you're going to have decreased breath sounds and things like that. And the pneumothorax is pretty sodded, pretty sodded, right? PE with infarction, yeah, I'm going to pick option D, right? Because remember when you have infarction, infarction hurts, infarction hurts, infarction hurts, right? It's just kind of like when a patient has an M.I. their chest hurts, right? So when there's an infarction, it's going to hurt your plur, right? So option E says PE without infarction, that's probably not as accurate. So I'm going to go to option D for this one. All right, so last question of the free 86, whoo-hoo! A 68 year old woman who underwent flexible sigmaidoscopy six hours of going to the office as part of routine screening returns to the office because of left lower quadrant abdominal pain fever nausea and vomiting. Uh-oh, that's not good. Now during the procedure, three centimeter polyp was found in the sigmoid colon and was removed. Vital signs are temperature of 100.6. So that's a fever. So 30.1 degrees Celsius. She's tacky cardiac, she's the kipnic, blood pressure is 120 over 60. Abdominal examination discloses bowel sounds and tenderness and guarding. Whoa, in the left lower quadrant, right? So that those are signs of peritonitis. Rectal examination shows no stool and tenderness only superior. Which of the following is the most appropriate next step, right? This person has signs of peritonitis. That's an indication for exploratory laperology, right? So let's look for the X-lap answer. Option A says, obtain an geography to roll out in testneless ischemia. That's not X-lap, that's wrong. Option B says, obtain immediate consultation with a surgeon. Yeah, that's the person that can do X-lap for you. I'm going to go with option B. Option C says, past a soft rubber recto tube under fluoroscopy. When you have peritonitis, you've probably ruptured something. Do you think it's a good idea to pass a tube into a person where something has ruptured? That's not a smart idea. I'm not going to do that. Option D says, repeat the flexible sigmaidoscopy to evaluate the operative site. No, again, when a person has potentially ruptured their bowel, you don't introduce tubes into the bowel, because that can cause very significant infection and death. Option E says, start hydrochlorizone intravenously to decrease any inflammatory response. No, don't do that, right? Go and do exploratory laparotomy. All right, so that's it. Again, if you love the way I teach, again, if you notice, I explain pathophysiology. I show you how things present on the exams. I make integrations, right? Many people have taken my classes and don't extremely well on their exams. I really put everything I can into truly helping you understand the content, into truly helping you understand the material, right? And many people have run through my courses and don't extremely well on their tests. So if you're interested, I have a last minute review for step two, step three, taking place today. And starting tomorrow, I have a 20-hour comprehensive step two, step three review. And then in the month of June, first two weeks, I have a 50-hour step two, step three class. And I also have a series of other classes I'm going to be teaching in the month of May. So if you're interested, shoot me an email. I can give you some more information. I also offer one I want to learn for all the USML and complex exams and medical exams. And I help with errors, applications, personal statements, more interviews and rec letters. And then this podcast on Apple Google on Spotify, so check those out. I also have a YouTube channel, Divine Intervention, USML podcast and videos where I post the videos that I make. And then I have another website called DivineInterventionLifelessens.com. DivineInterventionLifelessens.com. Many of you that listen to this podcast know I'm a Christ follower, right? So every week, I post one or two podcasts where from a biblical perspective, address a life lesson. There's actually an Apple podcast associated with that, called the Divine Intervention Life Lessens Podcast. So thank you for listening to me today. Again, I think you listen to this podcast, you find them to be helpful, share with your friends and your colleagues. And I wish all the best on your exams. Have a wonderful day, have a wonderful week. God bless you and bye for now. Thank you.