DIP Episode 240 - USMLE Step 2CK Rapid Review Series 38 (Ortho and OBGYN)

Okay, welcome. My name is Devine. This is episode 240 of the Divine Intervention podcast. In this podcast, I'm going to be continuing the Rapid Review series for the USMLE Step 2 CK exam. This is going to be Series 30. And just as a quick reminder, I'm going to be holding another another 20% one day Step 2 CK class on the 13th of this month. So next week Saturday, I'm going to be 6 to 10 a.m. Pacific time. And we'll take a 12 break and then known to 4 p.m. Pacific time. We'll take a 12 break and then 6 to 8 p.m. Pacific time. And then we'll be in 10 hours. We'll review the high yields for all the specialties. We'll basically spend like an hour on psychiatry. And then an hour and a half each on neurology, OB-GYN, surgery and peets. And then we'll spend the remaining time on internal medicine, which comes to right around 3 hours. And again, the people that are 10 and before you know, found it to be really high yield. So that's something you're interested in. You can reach out to me through the website or send out an email. Okay, so kind of like touching on OB-GYN again, I feel like these dates, these OB-GYN dates, tend to be very high yield for exams. And I feel like you know, people tend to kind of miss out on some of these, like easy, easy questions on exams, right? So like the first thing I think I want to discuss is like, you know, what are you supposed to do, right?

Like many times when you're taking an OB-GYN, OB-GYN, OB-GYN, OB-GYN, you'll see something along the lines of, at a woman's first prenatal visit, which of the following is the next best step in management and all that stuff, right? So like, what are you supposed to do at that first prenatal visit? Well, in terms of the MBM Es, right? I mean, this first prenatal visit usually happens right around like eight to 12 weeks, right? Happens right around eight to 12 weeks, right? And some key high yield things you want to keep at the back of your mind are you want to check, right? You want to test the woman for, so basically the things I'm discussing now are things that your friends at the MBME hold as valuable answer choices for this first prenatal visit questions, right? So I want to check the chlamydia and gonorrhea, right? That's kind of important, right? You want to do like urine, culture and sensitivity, right? Because again, you want to detect asymptomatic bacteria, right? Remember, every other woman, right? If she has like, you know, urine is dirty, positive for leukocyte, estuaries, positive for nitrites, you see bugs and all that stuff, but she has no symptoms, you don't treat. But in pregnant women, you treat, because if you don't treat, you increase the woman's risk of pre-termal libra and delivery. And remember, after you treat, you need to do a test of cure, right? And you know, typically you also check like the HIV, you check the VDRL, RPR, right?

Rollout syphilis, right? You check the woman's headbeast status. And the thing is sometimes your friends at the MBME can be kind of evil like this where they will put like different headbeast things like they'll put a big quarantine body, a heavy surface antibody, a heavy surface antigen, blah, blah, blah, blah. And then you have to pick out who won out of all those answers, pick a heavy surface antigen, right? Because that's the thing that will tell you if they are infected or not, right? If they will tell you if they are infected or not, right? Although if you don't see a B surface antigen, the next best answer to pick is the heavy surface antibody, okay? And then you know, you check the mom's rebellious status. And then if they tell you that, oh, for example, the mom is like a DK worker or she teaches like small kids, like elementary school kids, then you want to check for the power virus like IgG or IgM, right? And then you also want to check out a very cellar status, right? And then you know, you do a CBC, you do like a blood group, you do like blood screening, right? And then again, you don't forget asymptomatic bacteria, do that urine or culture and sensitivity. So that's what typically happens at the first prenatal visit. And again, that happens between it to 12 weeks on MBME exams. Now, when you hit the 10 week mark, the thing you can do on MBME exams is something called self-ready any, right? You can do self-ready any at the 10 week mark on MBME exams, right?

Remember, all these like autosomal trisome is like, you know, trisome 21, trisome 18, it's typically possible to detect those right around 10 weeks by the self-ready any. Although remember if a woman is obese, so let's say she's like more than 180 pounds. For the most part, you're very likely going to get like inconclusive. There's just a higher percentage of inconclusive self-ready any results. When a woman is like super obese. And then between like 10 to 12 weeks, you can do something called a Chorronic Velocampal. Remember, if you do this Chorronic Velocampal, you need to give more morogram afterwards, right? Because remember Chorronic Velocampal, right? There's the potential mixing of blood between mom and baby, right? So you want to go ahead and make sure that you give her a roguam. And remember that compared to amniocentesis, CVS actually has like a much higher risk of fetal demise is like 1% versus amniocentesis that's like 1 in 300. And it's actually much lower than that in most centers across the country. And then, you know, between like, you know, like 11 to 14 weeks, you know, you can do some specific screenings, right? So you know those ultrasound screenings where you look for like no code translusancy, right? You can check those like between this 11 to 14 week period, right? Like it's like a fetal screen, right? Like it's almost like part one of that like prenatal screen, right? So you can check the new code translusancy.

Remember, the new code translusancy is increasing Down syndrome and in Edward syndrome, right? Remember, try some of it 21 and 18, right? You can also check the beta HCG. Remember beta HCG is high in Down syndrome, but it's low in Edward syndrome, which is again, try some of 18, right? And then you can check the levels of pap A like PA WPA, right? Like I think it's like placenta as placenta associated plasma protein, or something like that. It's elevated in both Down syndrome and in Edward syndrome, right? And then at this level, you can sort of kind of check the maternal serum AFP if you want, but really that's not something you'd really worry about more around this 11 to 14 week period, right? And then, so notice some saline differences I highlighted between Down syndrome and Edward syndrome, right? Literally the only difference from that like beta HCG pap A and no code translusancy screen, the only difference is in the beta HCG is high. Down syndrome and it's low in Edward syndrome, but pap A and no code translusancy is increased in both disorders, right? And then remember, once you hit the 15 week mark from 15 weeks anywhere on point of term, you can do a new synthesis, although you know, it's probably not prudent to do a new synthesis like, oh, I'd like 32 is just this. It's probably like not very prudent, right? I mean, you're kind of planning to kill the BB at that point, right?

So, so you know, but the you can do, you cannot do a new synthesis at less than 15 weeks, once you hit 15 weeks, you can do a new synthesis, right? And then again, don't forget to give a rugam when you do that, right? And one thing you want to remember is, okay, let me talk about this next one first. So if you hit like the 15 to 20 week mark, right? You know, like between that 15 to 20 weeks, usually it's around 18 weeks to do this, right? You can do like the quad screen in a woman, right? So you can check like the maternal seromy Fp, you can check the beta HCG, you can check the astrial, you can check the inhibin A. Remember, when a person has down syndrome, right? On that quad screen, the beta HCG and the inhibin A will be elevated. But the maternal serum AFP and the astrial will both be decreased contrast that would Edward syndrome with the AFP astrial and inhibin A will all be decreased, right? And then the last value is kind of like variable there, right? So again, usually do this around like between 15 to 20 weeks, right? Between 15 to 20 weeks. And again, around like that 18 to 20 week period, that's where you can do like the ultrasound to like date the fetus. I'm not saying like you want to go on a date with the fetus, but you know, kind of like figure out like, okay, this fetus is like 18 weeks a long or something like that, right? And that's where you do like the fetal anatomy screen, right?

Most remain go for this, they check the child's anatomy, make sure there's no neural tube defect, make sure there's nobody will defect and stuff like that. And then between 24 to 28 weeks, right? On MBM Es, that's where you want to screen for gestational diabetes, right? That's when you screen for gestational diabetes. And typically you don't need to remember like all you do this 2 million gram or glucose, whatever. No, you don't need to memorize that, right? Just remember that you do between 24 to 28 weeks. And then at 28 weeks, right? Typically you would repeat a CBC at that time. And then you also do a rule game, right? You also you give rule game, right? If woman is average negative. I'll talk about an RH algorithm in a second here, because that RH algorithm is actually kind of high yield to know for exams, right? And then don't forget, right? If you are between like 35 to 37 weeks, that's where you do the screen for group B strap, right? You do the screen for group B strap. And then basically, you know, when the woman is postpartum, right? At least for the first six weeks, don't give any contraceptive option that does not contain projected, right? If you give something that contains estrogen, you'll kind of mess up her milk supply, right? Estrogen basically down regulates the insertion of proteins into breast milk, right? So you're going to have like milk that is not of like ideal quality, if you know what I mean.

Okay, so the one thing I guess I'll go ahead and see is right like at that first prenatal visit, right? That's where you check a mom's RH status, right? So you check the RH status. Obviously, mom is RH positive. Then she's not going to make antibodies against the baby or anything like that. She I mean, you're not going to make antibodies against yourself, right? Probably doesn't make much sense to do that as a mom. But if mom is RH negative, right? Then the next thing you need to do on an MBA me is to check a RH antibody status, right? And you check that RH antibody status by doing an indirect combs test. That's very important. Not direct and indirect combs test. And if that indirect combs test is negative, right? That means, oh, mom has no made antibodies. That is awesome. I remember the indirect combs test looks for antibodies in moms like serum versus the direct combs test that looks for antibodies that are already pre bound to read blood cells from mom. Okay. So remember the direct combs test we use it mostly to detect like autoimmune hemolytic anemia. What indirect combs we use it to check check the antibody status. So if mom's antibody status is negative, then your next step is just to follow the normal guidelines, right? You know, you give RH 28 weeks. And then obviously after the woman gives birth to the child, first you do the Clyde Howapet key test so that you can figure out the, you can figure out the, the dose of RH.

RH, you're supposed to give right basically it's a dose figure in our test essentially right if for example mom has extensive mixing of a blood with babies blood. Then of course you're going to go ahead and give like a big dose of RH. But if there's like very minimal bleeding right then all you have to do is pretty much to give a smaller dose of RH. So you need to give it within the first 72 hours or postpartum, right? So that's the algorithm if mom's RH antibody status is negative, right? So this is again for an RH negative mom. If you do the indirect combs test and it's positive, well, there's the potential that babies in big trouble, right? So your next step on the mbim exam, many times people want to start picking all this invasive crap. Don't do any of those things, right? Essentially on your test, what you want to do is to check the father's RH status, right? You check the father's RH status. If that is RH negative and mom is RH negative, which we know already, then there's no chance that the baby can be RH positive. And then we just continue the normal, basically we don't bother, right? But if that is RH positive, then you need to begin to surveil the baby. Usually the mbim, they don't dip their toes in these kinds of waters. But if they wanted to be particularly mean on a given test, some things you want to keep at the back of your mind is that you can do like a doppler ultrasound of the middle server, a lot of the baby you can do it like while the baby is in utero.

If you notice that there is like increase flow, right? And that gets you worried that the baby has anemia. If the baby has anemia, then to figure out to confirm because that mc flow like with doppler, right, is a figure in our test, like it's almost like a screening test. You need to kind of confirm that the baby is actually anemic, right? So typically for that, you do something called a precutaneous umbilical blood sampling. That's basically like some very risky mechanism of obtaining some blood from the baby and checking the baby is checking the baby's um you know red blood cell status, right? And if the baby is anemic, you can actually give a transfusion at the same time using that precutaneous or a blood sampling again. Please remember if you do a pubs, right, or you do a new synthesis or a woman gets an abortion or she has an ectopic pregnancy or she has a high the telephone. These are all indications. If the one is in trauma, if she's in an accident, these are all indications for getting a room get right. So you got to you know give a room with that procedure again. There's just all high yield things to keep out the back of your mind for exams, right? And then um some things I think I kind of want to talk about. I want to talk about like some high fractures that your friends at the mb me that they just love to throw in on exams right. They love to throw in on exams, right. I'll talk about as many as I can because again, this is a rapid review podcast.

So I'll kind of like shut down after a short while. Right. So basically um because also you need to sleep it's like past 10 here. Well, this is like the free time of hot today. So I figured I might as well make a podcast. I have many podcasts that I want to make that I in my mind, but it's just the time to make them that's the limiting factor here. So basically if we're talking about the upper extremities, right. So let's say we're talking about the arm, right. Remember the arm, the big bone in the arm is the humorous ring. And we know that for the humorous, we have like the surgical neck of the humor. So the way I can teach people to remember this is if you look at the arm, the arm has a curved part that's called like the surgical neck of the humorous. And then there's a part in the middle, right. You know, the neck is kind of like curved. So you know, like the curved part of the humorous that's kind of leading into the arm as a surgical neck. Right. And then in the middle, we have the mid shaft, right. I mean, like the like the it's like the middle of the bone. So mid shaft, right. And then we know that the tail end of the humorous is kind of like those are epic condils, like the lateral and the media, like condils and stuff. Right. So just above those condils. That region is known as the supercondular region of the humorous. Right. So let's maybe talk about the surgical neck first. Right. So remember, if you fracture the surgical.

Okay, let me do something here to maybe help you along. The thing is if you're going in that order surgical neck to mid shaft to supercondular, right. There are different nerves that you can destroy. Essentially, if you fracture any of those any of those parts of the art. So if you fracture the surgical neck of the humorous, it's the accelerator of that will get all screwed up. Right. If you fracture the mid shaft of the humorous, it's the radio nerve that will be all screwed up. If you have a supercondular fracture of the uterus, it's not of the uterus, whoops of the humorous, you'll fracture the mid you'll scrub the median nerve. Do you see that the first letters of those nerves spill out the word arm. So a for axillary, R for radio and M for median. Right. So that's a nice thing to kind of keep at the back of your mind there. So let's kind of talk about this axillary business. Right. Let's talk about the axillary business. So the thing is for the axillary nerve, right. For the axillary nerve again, you can get it when you can injure the nerve when you have like a fracture of the surgical neck of the humorous. But remember that the axillary nerve can also be injured in many of the ways. Right. So say for example, if a person has an anterior dislocation of the shoulder, right. When a person has an anterior dislocation of the shoulder, then they're going to look the axillary nerve, right.

Because remember when a person's shoulder dislocates the most common dislocation pattern is anterior. The only way you will ever get posterior shoulder dislocations on MDM exams is when you have some electricity involved. Like, you know, you probably got electrocuted or you were struck by lightning or you had a seizure, right. A seizure is kind of like a like too much electricity in the brain. Right. Those things are the only things, right. So listen to me carefully. Those are the only things on MDM is now whatever causes a posterior shoulder dislocation. Right. And then another thing that can kind of like local persons axillary nerve is. Is if the person has like, you know, like a breath injury. So let's say you have like an infant of a diabetic mom right on this inference, like 11 pounds, something like that. Right. You know, that's like shoulder distortion. We tend to happen. Right. So you know, in the process of trying to extract that baby from the universe, the thing that will essentially happen. Is that you can tear C5 C6 and C5 C6. It can kind of touches the axillary nerve quite a bit. Right. So basically, right. Those kids can essentially have like axillary nerve injury. But you'll get all the kinds of nerve injury in a like other nerves involved because C5 C6 doesn't just supply just the axillary nerve. You know, it also kind of supplies the nerve data.

It takes care of like your your bicep reflex and you know, it kind of touches the muscular cutaneous nerve some and all that's right. So that child will obviously have a wider step up the formity. Right. And well, what is the axillary nerve important like who cares about the axillary nerve? Well, the thing is the axillary nerve control sensation for your arm. Right. For like your lateral arm around your shoulder. Right. You axillary nerve countries controls the sensation there. Right. And they remember that the axillary nerve actually helps with shoulder abduction like AB, right. A as an apple, be as a boy. It controls shoulder abduction, right. Shoulder abduction. And one thing that your friends at the end of me kind of care that you know about is they actually want you to know about this shoulder abduction business actually. Right. The thing is when you abduct your shoulder, right. You cannot abduct it in degrees, right. So basically like they will give you questions about a person that has like messed up shoulder abduction. And in the kind of expected to know what's going on and it's not every shoulder abduction problem. That is an axillary nerve issue. I'll tell you that right now. Right. So see for example, the tell you on the mbim exam that a patient has trouble initiating abduction. I'll see that again. A patient has trouble initiating abduction, right. Like basically going from the first zero degrees to 15 degrees of abduction.

Hopefully you think about a rotator cuff tier with that, right. Because remember to initiate abduction to go from zero to 15 degrees that falls primarily under the purview of the supraspainitas supraspainitas muscle, which if I'm not mistaken is a very bad suprascapular nerve. Remember the supraspainitas muscle is the is one of the parts of the rotator cuff. Remember the rotator cuff is like that sits no money. You probably remember from step one like supraspainitas infraspainitas teris minor and sub scapularis. The most commonly injured and probably the only one they will test actually on step two CK in terms of the rotator cuff muscles that are messed up is the supraspainitas muscle. So when people have a rotator cuff tier, right. The classic thing they will put on the exam is that M-T4 can test where you, you know, try to adopt the presence arm and try to see if they can like turn a can up down, up down, up down. It's almost like they're turning their hand like like they're turning a key, right. They won't be able to do those things, right. That's basically like a supraspainitas supraspainitas injury, right. So if a person cannot initiate abduction, that's a supraspainitas problem. That's essentially code word on an Mbim Exam for rotator cuff tier, right. And then if for example they tell you that, oh, the person can initiate abduction, but going from like 15 to 90 degrees is a pin in the butt, right.

They want to think about the axillary nerve on that those circumstances. That's basically the deltoid that's giving you trouble at that point. Remember the axillary nerve innervates the deltoid muscle and the teris minor muscle, right. And you probably, I mean, if you live in a home, you know, you probably have like this ADT security, remember the security company, right. So the A for axillary and then the D for deltoid and the T for teris minor, right. So axillary nerve innervates deltoid and teris minor, right. So again, those so if a person has problems going from 15 to 90 degrees, that's going to be axillary nerve, that's going to be axillary nerve damage, right. And again, the deltoid is not helping you out there, right. And then if they tell you that's going from 90 degrees all the way, right. Going from 90 degrees all the way, then you want to be thinking more along the lines of help from our two muscles actually your seredus anterior and your trapezius, right. Maybe like divine. I don't know about what you're seeing here. You're probably what if you're aligned to me like, how does the seredus help with abduction? Well, if you don't believe me, just try to move your abduct your hand, but at the same time try to touch your scapula, right. And you know, when you start moving your hand, you notice your scapula is not moving, right. Until you hit like 90 degrees and then once you hit like 90 degrees as you abduct your hand, you notice that your scapula moves a lot, right.

Remember that your seredus anterior helps with some of those scapula movements, right. But those are lower for the test, right. So if a person can abduct up to like 90 degrees, but you notice that beyond 90 degrees, they can do squat where you want to think about injury to either seredus anterior, right. Or the trapezius muscle, right. Seredus anterior or the trapezius muscle. And one way that they can integrate this on a test is they can give you a question about a patient that just had some kind of mastectomy or like an axillary lymph node dissection for breast cancer. And then they tell you that the person has problems with shoulder abduction, right. So that abduction after the surgery, you want to think about injury to the long thoracic nerve. The long thoracic nerve is commonly injured in the setting of like breast surgery of some sort, right. So obviously that person, if you injured the long thoracic nerve, if you remember the salt, no morning, SALT, remember, SALT is seredus anterior, LT is long thoracic, right. So those people have a winging of the scapula after the breast surgery, right. But in addition to having a winging of the scapula, they also have paralysis of arm abduction past the 90 degree mark, right. Because seredus anterior doesn't work. And then the other muscle, I said that, you know, kind of helps with shoulder abduction is the trapezius muscle. Remember the trapezius muscle is actually integrated by cranial nerve 11, right.

The spinal accessory nerve. Remember cranial nerve 11 does the trapezius muscle and it also does the sternoclidomastoid muscle, right. And remember that your sternoclidomastoid, right. It kind of helps you with turning your head to one side after the other. So if remember, if you have a cranial nerve 11 problem, right, that can cause problems with shoulder abduction because of that trapezius link, but they will also give you other differences like the person will have trouble like turning their heads to the opposite side, right. Because of that sternoclidomastoid weakness and they also have trouble. They will also have trouble. They'll have like shoulder droop on the same side, right. So they'll have shoulder droop on the same side of the lesion. They'll have problems abducting their own past 90 degrees on the same side and they'll have trouble turning their heads, control lateral to the lesion, right. They have trouble turning their heads, control lateral to the lesion. So these are all different. So you see like a medieval finished axillary nerve, although pretty much almost done, although I'm thinking I'm gonna stop around here, but let me say like one or two more high your things, right. Since we're kind of talking about talking about the neck. I mean like axillary nerve here and like we're like in a throughout the word sternoclidomastoid, right. So one thing I think I want to talk about sternoclidomastoid are trotically, right. So they'll basically talk about a child.

They'll tell you that this child, you know, his neck, like he's will be like a new born or like, you know, few weeks old. And his neck is like off to one side, like it's angled towards one side or the material that he's joined, angled towards one side. When you see that you want to think about congenital trotically, right. The pathophysiology, because sometimes the endemic, can you do your dirty like that. The pathophysiology behind these trotically is actually from fibrosis of the sternoclidomastoid muscle. Okay, I'll see that again. It's from fibrosis of the sternoclidomastoid muscle, right. So the way you fix those kids is you do like, you know, like neck exercises and all that stuff to kind of help help out there. So that's the way you kind of deal with that. Yeah, I don't think there's that radio nerve because there's a lot of a lot of like high-yodememic stories. I'd like to tell the radio nerve, but again, I love to keep these rapid reviews on there 30 minutes. And as I do at the end of every podcast, again, I do want to go for one or one tutoring from any exams. Step one, step two CK, step two CS, step three pre-clean cool med school exams, 30-ish-elf exams. I offer like, you know, one or one tutoring, also offer booster courses. It's 20 hours for all the USM and exams, step one, step two CK and step three. Again, I've done this with tons of people and lots of people have been very successful with this, like got in big scoy increases.

And then also do longitudinal tutoring, you know, if you're a med student, I can tutor you for your block exams or your shelf exams. And then at the same time, I tutor you for your upcoming USM and exam. And then if you need a like, you know, like coaching for your process of applying to, you know, let's say you're a med student applying to residency. So like, you're asked to like, college student applying to med school. So like, I'm cast, especially with this COVID season, right? Like if you're interested because again, many people kind of have like screwed up plans because they couldn't do a ways or with the squad poly on step one, any of that, whatever. If you have a tricky application like I've worked with people with many tricky applications, like, oh, I graduated from med school 10 years ago, or I had low scores on step one, or I have no research or I have this, I have this bad experience. I have to explain away or whatever, right? Just reach out to me again, I've worked with lots of people in tricky circumstances and the vast majority of people have worked with have actually matched right. I have like many people that are residents that have kind of worked with and most people I work with have really much of their first choices. And then, you know, if you have a buddy that needs to learn for like, you know, any of the med school, the premier exams of the MCAT, I do, again, I do offer tutoring for all those things.

So please feel free to reach out to me either through the website, divine intervention podcasts with an SADN.com, or you can send me an email at divine intervention podcast with an SADN.gmail.com, right? So please subscribe to the website, subscribe to my You Tube channel, it's called Divine Intervention, USMLA Podcasts and Videos. And then please subscribe to the podcast, it's uploaded on like Apple Podcasts, on Google Play and Spotify. And then, yeah, and again, if you're interested in that one person course, so do I think I will make a formal podcast kind of advertising the course I'm holding a next week Saturday. And I have like a step one, one-deer review course, maybe two days and also a step three one-deer review course in the works, right? Like the group courses, like I did last week, the session last week was a blast, it was a, I got a lot of great feedback from the people that I kind of attended the class. And then my life lesson for today is the importance of being generous, right? The importance of being generous, right? So the thing is, like think about it when a person dies, right? You know, maybe in some weird situation you'll be the person with like a car or gold or whatever, right? But the thing is if you go on earth, the body, like you know, like four or five weeks later, it's probably the skeleton that will be remaining. And after a few months, you won't even see anything.

The person that almost completely disappeared, other than some very like solid like calcium structures, right? So the thing is many of the things you have here on earth, you're not gonna take them anywhere with you, right? So just be generous, right? And again, like there's this saying that givers never allow, right? Givers never allow. And what you say in the Bible says that what you sow your reap, right? So the thing is, you know, like if you have something in your hand that you know can bless someone or you know can solve a person's problem, just kind of release it, right? Because if you're liberal, right, then you will be like you'll be blessed. Basically is what I'm saying, right? So be generous. Don't be too stingy. Don't like there's the person that keeps, keeps, keeps, keeps, keeps, keeps, keeps. Never let's out, right? And then the person goes to poor. There's like a part I think in the book of Proverbs that said that, you know, there's on the whole back more than his meat and the person tends to poverty. I can't remember if it's probably somewhere in the Bible, right? So, you know, just be generous, be generous, help your fellow man. Again, we are all in this race together, right? You know, at some point you, you will live this earth, right? What kind of legacy do you want to leave? Right? You want to be generous? You want to help people out, right? Like how will people remember you after you're gone? Right?

So again, don't you are not here to just go and reach yourself and be happy? No, you are here to invest in the lives of many people. There are some people's destinies that depend on you. Right? So just kind of be mindful, kind of be mindful of that. Even when you get married, right? You're essentially given to your wife, you're being generous, you're like, you're to your wife, you're giving love to your wife, right? To your kids, you're investing in their lives. So have that investing, have that giving, have that generosity mindset. So thank you for listening to this podcast. I will see you in the next podcast. Thank you and God bless you.

To prevent urinary tract infections that increase the risk of preterm labor and delivery.

Direct Coombs test.

The indirect test looks for maternal antibodies in the serum; the direct test checks if antibodies are already attached to the patient's red blood cells.

Long thoracic nerve palsy (due to damage from surgical trauma).

Elevated $\beta$HCG and elevated MCA-AFP/uE3.

Cranial Nerve XI (Spinal Accessory); Congenital torticollis is often due to fibrosis of this muscle.

Axillary nerve (Surgical Neck), Radial nerve (Midshaft), Median nerve (Supracondylar).

Axillary nerve (innervates the deltoid and teres minor).

Supraspinatus muscle (via suprascapular nerve) and potentially the infraspinatus.

These findings are highly suggestive of Down Syndrome (Trisomy 21).

Chorionic Villus Sampling (CVS) (Risk is ~1%, vs. Amnio's much lower rate).

The presence of circulating maternal antibodies that could potentially attack the baby's red blood cells.

Axillary nerve (Surgical Neck), Radial nerve (Midshaft), Median nerve (Supracondylar).

Axillary nerve (innervates the deltoid and teres minor).

Supraspinatus muscle (via suprascapular nerve) and potentially the infraspinatus.

These findings are highly suggestive of Down Syndrome (Trisomy 21).

Chorionic Villus Sampling (CVS) (Risk is ~1%, vs. Amnio's much lower rate).

The presence of circulating maternal antibodies that could potentially attack the baby's red blood cells.