DIP Episode 566 - 2024 USMLE Step 3 Free 137 Discussion Part 12 (Q111-120, super helpful for Step 2!)

Welcome to episode 566 of the Divine Intervention Podcasts. Into this podcast we're going to be continuing our series on the Step 333-137. This is going to be part 12. So we're going to pick up from Question 111. I begin. A 24-year-old woman comes to the office because she had a positive home pregnancy test two days ago. You're in pregnancy test in the office today's positive. Physical examination findings are consistent with a 14-week gestation. Her sonography shows a twin pregnancy with two female fetuses. This is her first pregnancy and she says that she says she's concerned because she has a family history of an eye disease in which family members lose the vision beginning in their 20s. Testing of her vision today discloses no abnormalities. The patient's pedigree is shown above. The patient is identified as IV in up to, you know, for 4th generation number 2. Which of the following is the most appropriate conclusion about inheritance of this disorder? So here's the trick. Whenever you get questions like this, you should go through every single answer. Pedigree questions, they're like, you should go through every answer. All right. First one says it's an orzo-mode dominant disorder. Remember, an orzo-mode dominant disorder, you know, if any one of your parents has the disorder, if you have even just one of the alleles, you're going to get in trouble.

Well, that doesn't really make any sense for this question because if you notice her dad had the problem and none of the kids have it. It's just not really possible when an orzo-mode dominant disorder because at least some of the kids got the allele. So you don't see any of them having the disorder. So that's wrong. All right. If you have an affected parent, at least some of the ox pring will have the disorder, right? At least some of them, if not all of them, if not all of them. Because at least one of them will have the affected allele, right? So some or all of them may have the problem. So that's wrong. Now, option B says is a chromosome of an uploiti. Well, think about it. What are the new employees that we know? You know, we have a trisome 21. That's down syndrome. That doesn't present with vision problems. We have trisome 18. That's Edward syndrome. People have Edward syndrome or trisome 13, but two syndrome. They don't live for very long. They're not going to be living to their 20s. So that's wrong. Right? That doesn't really fit with what we have in this gusem. So that's wrong. Option C says it is indeterminate. Well, let's let's keep that one. Option D says is an excellent dominant condition. Well, for an excellent dominant condition, you know, what are the classic excellent dominant conditions? The test on the exam outboard syndrome. And again, that's not how this question is presenting. You're not seeing any hearing loss or reno problems like nephritic syndrome.

Another one is fragile X syndrome. Again, this question does not give a presentation of fragile X syndrome. But if you have an excellent dominant condition, if you have the affected X chromosome, you will have symptoms. Or the thing is the dad here is affected. Of the dad of this lady. But if you notice, at least, you know, the son must have gotten the Y chromosome from dad, the X chromosome from mom. So he makes sense. The son doesn't have anything if it were excellent dominant. But at least the dad must have given his X chromosome to his daughters to his daughter. That's, you know, four, two and his son who is a four one. Okay, at least to his daughter, not to his son because he must have given his Y chromosome to his son. Well, you know what? His daughter got the X chromosome from him and she doesn't have any symptoms. So he cannot be excellent dominant and the next regular excessive diseases, the easy way you can rule that out is it tends to just affect males, right? You notice that males and females both are affected in this condition. So honestly, I'm not going to pick that for this for this one. I'm not. So the answer here has to be C option C is the only answer that makes any sense. Again, whenever you get these pedigree questions, you have to work through a process of elimination.

Question 12 says an 84 year old man who was resided in a nursing of a care facility for the past five years is being evaluated at the facility because a nurse discovered a sacral also while beating the patient two hours ago. He is not in pain medical history significant for type two diabetes, CHF, COPD and peripheral vascular disease. He takes insulin, furostamide, metupralol, lysinopralabular role, and hypertropium metadusine healers and it is 1 milligrams of aspirin. He is unable to walk and spend the majority of the day in a manual wheelchair, right? So immobility. That's a very classic risk factor here. That is self-propelled slowly with his feet is BMI is 19. If you look at his vitals, they're completely fine, actually. The patient appears frail along their clear toes quotation, breath sounds are decreased. cardiac examination discloses no abnormalities. There is a three by three by 0.2 centimeters stitched to ulcer on the patient's sacrum with yellowish exoidate at the base and no surrounding area. Thema examination of the extremities shows a dima to the cause bilaterally results of recent lap studies are shown. So if we look at his labs, if we look at his labs, everything here is honestly, completely fine. I don't see anything that's really terrible or kind of concerning, you know, I'm not too concerned about this stuff. All right. So which of the following treatment modalities is most likely to have the greatest effect on wound healing in the patient?

Again, this is a classic question about a sacrode-acquipitus ulcer. Right? So if you think about it, these people, they get it because they are bed bound, they are mobilized. So they exert a lot of pressure on their blood vessels. So that causes the skin of their tissues and they get in trouble. Right? So if you can just frequently reposition these people, it's actually very helpful. So I'm definitely going to go to option B for this one. I'm going to go to option B for this one. A hypercaloric diet, you know, these people, if you feed them with protein, there's also going to speed up the healing of the ulcer, but that's no substitute for repositioning them from side to side. And then silver sulfur diets, they know this thing does not appear in, doesn't really appear infected. I'm not really going to worry about it. They really have to use topical antibiotic therapy for this disorder. And then one deep breathment, you only do one deep breathment for the cubitus ulcers generally. If if it looks like very infected, looks necrotic, or it's gone to the level of muscle or bone, which would have not seen this question. All right. Question 113 says at 36 year old woman is referred to the office for evaluation of a fasting serum total cholesterol concentration of 249. She has a family history of early coronary artery disease and her father, died suddenly at each 46 of myocardial infarction. She tells you that she has never had chest pain.

She is not currently sexually active and has no children. The patient works as an advertising executive. She claims that her high stress lifestyle makes it impossible for her to irregular meals or to follow a special diet. And she usually eats fast food. She exercises to the three times a week for about 20 minutes on a treadmill. She has smoked one pack of cigarettes daily for the past 20 years. Her only medication is a set of men of infertension headaches. She is five foot five inches tall and weighs 167 pounds. A BMI is 28 vital signs today are within normal limits. Physical examination discloses no abnormalities except for mild obesity. Institution of which of the following is the most essential step in the prevention of coronary artery disease in this patient. Well, this is an easy PZ risk factor question. This is why I strongly recommend if you're taking any US Emily exam, you should listen to a PZ 37 97 184 and 239. Again, I say a PZ 37 97 184 and 239. To be honest with you, this is one of these questions where we don't even have to go through the answers. What is the biggest risk factor for coronary artery disease? It's smoking does this woman smoke? She does. If she stops smoking, a problem swell, she'll reduce her risk significantly. So the answer here is going to be option C. The other answers just don't make any sense. These risk factors are things that you either know or you don't know. If you don't know, you will get the question wrong.

If you know, you will get the question right. All right, question 114 says 21 year old woman is brought to the 80 by her parents. After she told them she consumed an entire bottle of an on specified pain medication, three hours ago in a suicide attempt. The patient reports shortness or breath and ringing in her ears. So she has to know it as that kind of tells you what you need to know here. Medical history is significant for MDD. Her only routine medication is easy talo problem and she has no allergies. If we look at a vital temperature is 99.5, post is 96 per minute, respirations are 22 per minute and blood pressure is 90 to 60. Oxygen saturation is 92% on the room air. The patient appears tired and thin, but is not in acute distress. She is slow to respond to questions and has difficulty following instructions. Skin is warm and dry. Examination of tympanic membranes discloses no abnormalities. Oskitation of the lungs discloses bilateral busiler crackles. Cardiac examination discloses no abnormalities. Abdomain is soft and non tender. The remainder of the physical examination discloses no abnormalities. Results of a terrible blood gas analysis on room air shown. A PO2 is low, a PCO2 is low. Her pH is 7.32, so she hasn't acidosis. Now, which of the following is the most appropriate next step in management? Again, let's frame this question. We see a person that seems to have had some kind of toxic ingestion in a suicide attempt.

Now, what are some things that are normally in the question? Number one, this person has tenitis. Number two, this person is tympanic. So, a respiratory rate is elevated. So, it makes sense that she has a respiratory alkalosis. A PCO2 is down. But we also see that a pH is low. Of course, the consequences we choose to not give you the bicarbonate in this question. But I can almost promise you that they give you bicarb here. The bicarb is going to be low. This person is going to have a metabolic acidosis. What does this look like? This looks an awful lot like aspirin toxicity. Now, many resources say that you're going to, aspirin is going to raise your respiratory rate. So, you're going to have the respiratory alkalosis first. And then you're going to have the metabolic acidosis later. If that's what you've learned, you've learned wrong. Okay? In fact, I used to think that back in the day, but that's not true. When people have aspirin toxicity, they're going to have tenitis. They're going to have metabolic acidosis because aspirin is a cytosolacetic acid. It's an acid. So, you can cause a metabolic acidosis. And I own got metabolic acidosis. But it also raises your respiratory rate. You're going to have hyperventilation. So, that's going to cause you to have a respiratory alkalosis at the same time. So, this problem is not like one shows up before the other. They will have it at the same time.

They will have the combination of metabolic acidosis and respiratory alkalosis at the same time. And typically, the way you're going to fix this problem is they're going to give sodium bicarb so that you can alkalinate the urine. When you alkalinate the urine, you bind up the aspirin and you speed up its excretion from the body. So, the answer here has to be option C. Remember, lipid emotion is not going to be right. Anacetyl cysteine is for acetylaminophane is not for aspirin. This person does not need a nutricle intubation because they do not appear to have any signs of serious respiratory failure. And so, probably here is not what he should be doing. You need to get this down out of their bodies. All right. Question 115 says, a 38 year old woman comes to the office for an unall-health maintenance examination. She has been healthy and her last cervical cytology three years ago was normal. The patient has been married for the past 15 years and the couple is monogamous. Today, the patient is a febrile, post is 82 per minute and blood pressure is 1.30 over 82. Physical examination shows no abnormalities, cervical cytology and HPV tests did not obtain. If results from the most recent cervical cytology and HPV tests are normal, at which of the following times should this patient have her next cervical cytology? Well, let's think about this for a second here. Again, this is a classic. This question is easy if you just know your screening guidelines.

I believe I have a screening guideline podcast. I think it's either episode 250 or episode 325. You should really listen to those podcasts 250 or 325. And you know, they may be like one or two out data guidelines there. And I think I may have addressed those in episode 446. I think the out data guidelines are like colon cancer, where in colon cancer, you now start screening at 45. And again, you're going to do colonoscopy every 10 years. And then for long cancer, back in the day, I think it was like late, you know, mid 50s or whatever, but now you start at each 50 and you do the unoludial CT every every year, you know. So but other than that, most of the other guidelines, they're pretty accurate. So it's either episode 250 or 325. I'm fairly certain that it's episode 325, but just go ahead and check that out. All right. Now, again, just do a Google search. I have podcasts on these things. Now, so the thing is with HPV, you know, pop smears typically the way you're going to work with this is you're going to do pop smears every three years. You start at 21, you do it all the way to 65. But if you want to space it out to every five years, you can actually start doing that study in at each 30. If you do a pop smear and HPV, quote, testing. And in this question, it appears that they did a pop smear and HPV, quote, testing together. So we can wait for five years. So option C has to be the right answer.

Remember option B in a year is something you do when a person has HIV people to have HIV. The pop smear interval is every year. At the time of men oppose that's a little too late for from that. Only she gets pregnant. That's wrong. Right. Option E says the patient does not need another sort of course, I told you she she does. You're supposed to do pop smears till about age 65. All right. Again, this is just an easy PZ question. If you know your guidelines. All right. Question 116 says a 21 year old man who is a member of the US Air Force comes to the ED because of a 2 D history of shortness or breath on exertion and when lying down. As well as fever, chills and swelling of his legs medical history is on remarkable and it takes no medications. His temperature is 100.5. Paul says 97. Reservations are 20 per minute and blood pressure is 140 over 91. O2 side is 92% on room air. The patient is this big but able to speak in full sentences. Dr. Gloucino's pressure is 14 centimeters of water. As quotation of the lungs discloses bilateral bisiler crackles cardiac exam discloses a regular rhythm with an S3 galobot no murmur. Abdominal examination discloses no abnormalities. There's one plus period in the demo of the lower extremities results of lab studies show a serum BMP that's elevated and a white count that is elevated results of serum chemistry profile and remainder of CBS of complete blood counter within the reference ranges.

ECG shows no abnormalities except for non-specific ST7 changes. Echo cardiographials are dilated left ventric with an injection fraction of 0.4 that's 40% and no pericardial effusion. Which of the following is the most likely long term outcome for this patient? Again, this is a classic easy PC pathology. Right. So we see this person has a URI. You may also see this disorder in people that may have had a URI recently. And then you notice that you're having heart failure symptoms. So URI plus heart failure symptoms on your exams should be your clue into what? You should be your clue into a person having viral myocarditis. And what is the most common cause of viral myocarditis? It's going to be the coxac UB virus. Okay. It causes like a systolic heart failure problem. That's why you see this person having an S3 heart sound. They have encircles in their lungs and it is going to present with a dilated cardiomyopathy. Now, the good thing is most of these people are going to recover. Most of them are going to recover. There's not many treatments. You know, you can maybe give them like classic heart failure therapy. But thankfully, most of these people are going to recover. Although some people can have disease that is so bad that they actually progress to having a heart failure and requiring a transplant. We just kind of sat. So again, prognosis question option is going to be the right answer. Most of these people recover a dastolic dysfunction.

No, these people tend to have systolic dysfunction or dastolic dysfunction. And then PE. Well, they would get a PE because the heart is not contracting well. So they may develop an embolus, right? But again, it's not the most likely long term outcome. If a PE were to happen, it would probably happen fairly soon for this person. Requiring parocarditis, this person doesn't appear to have parocarditis. And then option E says severe systolic heart failure, regarding cardiac transplant again, that can happen in some cases, but that's not the case for most people. All right, question 117 says a 31 year old woman who is in the US Air Force comes to the office because of a 1 D history of fever, sore throat, body aches, muscle weakness and dehydration medical histories remarkable for lupus. She has no known allergies. Coral medications are calcium hydroxychloroquine iron and vitamin D. She has a five year old son who currently has a febrile illness and a rash on his hands and feet. The patient's BMI is 24. Temperature is 101, pulse is 96 per minute, reservations are 20 per minute and blood pressure is 115 over 77. Physical examination shows an erythematos throat with vesicles on both tonsils. There is no observation of the tongue. There is bilateral cervical lymphatic in the lungs are clear. A rapid strep test result is negative, which of the following is the most appropriate treatment for this patient? Okay, let's stream this question.

So this person has fever, sore throat, body aches, muscle weakness, dehydration. And then if you notice on physical exam, you know, she has a fever and she has an erythematos throat with vesicular lesions on the tonsils. So vesicular, okay. And we notice that it looks like her child has a febrile illness and a rash on the hands and feet. Right. If you see this in a child, what do you think this is? This is probably hand-forth mouth disease, right? It's like the child has the hand and foot problem and the mom has the mouth problem. You see these vesicular lesions, they look vesicular. Whenever something looks vesicular, we usually try to slap the name herpes on it. So the mouth lesion is known as herpanjina. This is hand-forth mouth disease is caused by the coxacce a virus. There's no great treatment for it except like just give a fever reducer. So this person should get option D, ibuprofen, right? Option A cycloverse for herpes. This person doesn't have herpes infection. Option B is a moxacillin. We tend to use that for acutotitis media. This is not acutotitis media. Option C, a moxacillin clavolaniac acid is the second line treatment for acutotitis media. This person doesn't have acutotitis media. Prednisone makes no sense for this. So option D is the right answer. This is hand-forth mouth disease caused by the coxacce a virus. All right. A 45-year-old, so 180 and a 45-year-old woman, comes to the office because of a six-month history of progressively slurred speech.

During this time, she has beaten her tongue frequently and has had difficulty swallowing food. She also has felt clumsy performing normal activities. She has not had changes in vision, sensory symptoms of bladder dysfunction. Five years ago, she undowent cervical fusion for degenerative disc disease. She takes to medications. Vital signs are within normal limits. The patient is unable to prove her tongue. There is deep furrowing and bilateral fasciculations of the tongue. She is dysathric. When the patient is asked to say, ah, there is symmetric body in complete elevation of the palate. Mosul-tun is normal throughout. Mosul strength is 4 out of 5 in the redoper extremity and there are fasciculations in the right deltoid and biceps. Mosul strength is 5 out of 5 elsewhere. Deep tendon reflexes are 1 plus in the right biceps and bricure idealis. And 3 plus in the triceps and right lower extremity. EMG and nerve conduction studies show motor denervation in the tongue and right extremities. Which are the following factors in this patient's history, most negatively impact her life expectancy. Well, let's look at this for a second. Again, what does this lady have? We notice that she doesn't have any sensory problems, but you notice that she has a lot of motor problems. She has both upper motor neuron problems and low motor neuron problems. What does that sound like? A pure motor neuron disease. That's ALS. This lady has a myotrophic lateral sclerosis. Very bad disease.

You know, you can treat it with a right loser. But again, it will only work so well. Most people that are diagnosed with this disorder within about 5 years, they're dead. Right. Now, this is literally asking about a prognosis question, like which thing affects her life most badly, basically. Again, I've discussed this principle now with two questions in this review. Whenever they give you questions like this, ask yourself which one is the worst of the bunch? Well, option A says age. It's not the worst of the bunch. Option B says ball bar weakness. Kind of looks bad, right? Because you could aspirate. You may have trouble feeding after a while. You may have to get like a tube. You could have aspiration pneumonia. You may have trouble speaking. That can severely impact the person's quality of life. So I'm going to keep that cervical fusion operation. She had this surgery like five years ago. It looks like she did pretty well since then or until this problem started. Ah, facculations again, facculations. You know, she's having this with a tongue. It's kind of a problem, right? It's kind of a problem. But again, this person like does just a very super specific part of like her swallow, you know, whatever we're seeing like, you know, ball bar weakness is like a more comprehensive term encapsulating like some of a tongue issues, a swallow issues and things like that. So honestly, these just not as great as option B and the engender. No, that doesn't make any sense.

Where some good option B here actually, Boba weakness. It's just the worst of the list and it can really impact her life very, very poorly. Question 119 says a 64 year old woman comes to the clinic because of a two year history of constipation. She initially had bowel movements every other day and past hardstools. During the past four months, she has had three bowel movements weekly. Fibersomplementation during the past three months has not increased the frequency of bowel movements. She has not had abdominal pain, fever, weight loss, or blood in the stool. Okay, so does have any kind of worrisome symptoms. She has hypertension and only medication is like Cino Prele. Colonoscopy five years ago on cervical cytology three years ago should not abnormalities. There's no family history of colon cancer about the soldiers. The patient does not appear to be in distress. She is five foot four inches tall and weighs 145 pounds. BMI is 25. Vial sensor within normal limits. The abdomen is soft, non tender and non-distended. Bowel sounds were normal. Rectal examination shows decreased femur tone. There are no masses. Soft stool is noted in the rectal vault. Test of the stool for a cobalt is negative. Again, no alarm symptoms, which of the fluen is the most appropriate next step in management? All right. So looking at this question, it's kind of hard to tell what this lady has. So I think it may be helpful. It may be helpful to review these answers.

And let's kind of see if we can kind of do a process of elimination here. Option A says additional bisacodial to the medication regimen. I didn't miss a cordial. I don't know if that necessarily going to help this person. You know, bisacodial, this person's issue is chronic constipation. You know, the bisacodial may help with the constipation somewhat, but I don't know if it's something I would think about in this circumstance. I don't think bisacodial is something that will necessarily help this patient. I don't think something that will help this patient. I'm going to get back to that actually in a second here. But let's look at the other answers. In a rectal monometry, in a rectal monometry, well, this person, you know, we're told that, you know, we did a rectal examination and she has decreased a sphincter tone. So honestly, that may be something we could maybe look at, right? That may be something we could maybe look at. Because, you know, yes, this person has constipation. Well, having this decreased fincter tone is kind of worrisome. Right? You shouldn't just kind of blow that off. So she has constipation and she has the decreased fincter tone. I don't know. Maybe her sphincter is kind of not working right or whatever. So maybe in a rectal monometry, make sense. A colonoscopy option C makes no sense. You get colonoscopies every 10 years. She got one five years ago. We don't see any concerning features for colon cancer in this patient. So that's wrong.

Option D says this continuation of lysinopryl. No, you don't have to stop it. lysinopryl does not cause you to have constipation. The option E says recommendation to maintain a daily bowel movement journal for a month. This woman has given us a pretty detailed detailed history of the problems with a bowel. I don't know if that's a good thing to do. So what kind of between option N, option B? You know, again, bysacodial is kind of a laxative. So it would probably help with the constipation. But the thing is you're ignoring this glaring problem of decreased fincter tone. Right. You know, so I would probably go to option B for this question. Actually, I probably go to option B for this question. You know, this person may have, you know, especially a person that is like 64 years old. She's kind of old. You know, maybe she has like some pelvic issue or whatever. And the retoma nonmetry, honestly, is the answer that just makes the most sense to me out of this bunch. Again, divine doesn't know everything. Right. There are some questions you're going to see on your exams. That's going to be like this. If anybody tells you that, Oh, after I teach you or tutor you or whatever, everything you see on the test, you know, that that's ridiculous. Right. There's nobody that knows everything. You only present that news. Everything is God. So I don't know everything. But honestly, on the exam, I will certainly pick option B for this question.

Because the BSA code of that's like doc do collacs. Again, it's going to help with the constipation, but you're kind of ignoring this fincter problem. So honestly, I'm going to be going option option B for this one. All right. Now question 120 says a 72 year old man is brought to the ED by emergency medical services. Approximately 45 minutes after losing consciousness, what I'm attempting to stand from a seated position. What watching television at home? Here again, consciousness spontaneously after five minutes. He has had persistent lightheadedness since this episode, but no other symptoms. He has felt like headed during postural changes in the past, but he has never before lost consciousness. Medical history is remarkable for his kidney cardiomyopathy with 11th grade injection fraction of 40%. Medications are daily metoprolysisopryl, spironolactone, atovar, stata and 11 milligram aspirin, as well as ferozomide every other day. There have been no changes in his medication regimen during the past year. His temperature is 96.4, pulse is 30 per minute. Whoa, that's that's pretty low. Respirations at 24 per minute and blood pressure is 75 over 35. That's just pretty low. Autosight is 90% on room air. The patient is that already can pale. Eocationally, does not respond accurately, appropriately to questions or commands, but is oriented to pressing, please, and time. Skin is cool to the touch.

Oscotation of the lungs discloses bilateral crackles, which of the following is the most appropriate next step in management. Right. So this guy has syncopy cardiogenic syncopy, I would say. Kind of maybe looks like it's from another rhythm. Probably a breathing or a breathing. I mean, look at, she's look at his pulse 30 per minute. If your pulse is 30 per minute, you bet your blood pressure is going to be low, right? Because if your pulse is that low, your heart rate is low. So your cardiac output is going to be low because remember, your cardiac output is your heart rate multiplied by your stroke volume. So it has a breathing or a breathing and it's symptomatic. So you should probably be going for like atropine of some sort or peace. And right many times they love you to use peace in on the exams. It's actually very effective for these breathing. At least to kind of keep them going so they don't die. So option A says a denocene therapy. No, that's for SVT. This person does not have SVT. They're not tachycardic. Option B says continuous infusion of the beauty mean. Again, you're going to do that for cardiogenic shock. If it's because you have like a reduced ejection fraction or whatever, you know, let's say you have cardiogenic shock because, you know, your heart is really not pumping well. But we know what that's why you can not just make these blankets statements on the exams. You need to examine pathophysiology.

This person, the vitamin would help if they were in cardiogenic shock because of like, you know, really bad CHF exacerbation or something like that. But that's not the cause of the person's cardiogenic, you know, cardiogenic syncopy. They have this problem because they have a breathing. So option B will not make sense here. Option C says infusion of epinephrine. Again, it will not make sense here. We need to fix this breathing. Epinephrine, the vitamin, that's not your fixed breathing. It's atropine pacing. That's how you fix breathing. It's defibrillation. We're not going to do that. We remember we're going to do defibrillation. I remember another name for that is on synchronized cardio version. We're going to do that when you have V-fib or you have V-tack with no pulse. Those are the classically tested, defibrillatable rhythms on the USML Es. And then option E says intubation and mechanical ventilation. No, fix the cardiac issue. Option F says transcutaneous basin. I'm definitely going to go with that answer. So I'm going to go ahead and stop here. Again, if you're studying for step one to step three or level one to three, I have many classes in the month of February that are going to be very helpful to you. For step one to step three, I have a test taking class, a bio-stats class, and a social sciences and ethics class. That's from step one to step three. That's taking place like, you know, like the third week in February, roughly.

And then for step two, step three, I have a 20 hour review. And is a 20 hour review, but it almost seems like a 40 hour review with how much we cover. Again, many people have taken these classes and done extremely well on the exams. And again, these classes are updated very frequently, just to make sure we're keeping up with the USML Es. And then I also have a last mini review for step two, step three, that also is going to be taking place in February. Again, I have a podcast where I literally pencil out the dates. And if you want more information, just shoot me an email. And then I have in the first two weeks, so you'll have a 50 hour class for step two, step three. Amazing, amazing class. I have a podcast where I talk about that class in detail. There's still some sports remaining, so you should still be able to sign up. And then I also offer one on one to your end for all the USMLE on complex exams. And then in addition to that, I have this podcast on Apple Google Spotify. And I have a You Tube channel that you can check out where I post the podcast that I make. And then finally, or I guess not really finally, but also help with your applications, you know, mock interviews, personal statements and things of that nature. And then another thing I'm going to see here is I have another website called divine intervention, life lessons, calm, divine intervention, life lessons, calm.

Every week, I post like one or two podcasts, where from a biblical perspective, address a life lesson. There is actually an Apple podcast associated with that. Again, many people listen to this podcast and they find them to be really, really helpful. So thank you for joining me today. I will see you in episode five hundred and sixty seven. Have a wonderful day. God bless you and bye for now. Thank you.

Metabolic acidosis + Respiratory alkalosis.

Frequent, scheduled repositioning (turning).

Upper respiratory infection (URI) history plus acute heart failure symptoms (e.g., S3 gallop, crackles, dilated cardiomyopathy).

Rectal manometry.

Coxsackie A virus (Hand-foot-mouth disease).

Every 5 years.

Metabolic acidosis (due to salicylic acid) and Respiratory alkalosis (due to compensatory hyperventilation).

Alkalinizing the urine.

Recent Upper Respiratory Infection (URI).

Amyotrophic Lateral Sclerosis (ALS).

Decreased anal sphincter tone.

Atropine and transcutaneous pacing.

Metabolic acidosis (due to salicylic acid) and Respiratory alkalosis (due to compensatory hyperventilation).

Alkalinizing the urine.

Recent Upper Respiratory Infection (URI).

Amyotrophic Lateral Sclerosis (ALS).

Decreased anal sphincter tone.

Atropine and transcutaneous pacing.