DIP Episode 567 - 2024 USMLE Step 3 Free 137 Discussion Part 13 (Q121-130, super helpful for Step 2!)

Welcome, my name is Divine, this is episode 567 of the Divine Intervention Podcasts. So this podcast will be going to be continued on a step 333-137 series. Again, you're studying for step 2. Chances are by Thamiru Dix, step 3, a new one would have come out, so just listen to this too. Alright, question 121. So this is path 13. 25 year old man comes to the clinic to request vaccination against HPV. Medical history is unremarkable, he takes no meds. He's sexually active with one male partner and uses condoms consistently. He's a member of the US Marine Corps, BMI's 21. Vital signs are within no more limits. Physical examination shows no abnormalities, which are the following is the most appropriate next step in management. Well, we know that the HPV vaccine you can get is starting at age 9 and you can go the way to 45. Basically, if you're between ages 9 to 14, you get 2 doses. If you're over 14, you pretty much have to get 3 doses. So I don't see any contraindications in this question, so this guy can certainly get the vaccine. I'm going to go with option A. Option B says obtain HPV serologic testing doesn't make any sense. Performance in all pap smear. No, pap smear is usually don't just in women and then motivational interviewing. No, don't do that. Just just give him the vaccine. Alright. So question 122 says 55 year old woman with long standing hypertension comes to the office.

Because of a 5 month history of fatigue, that worsens when she walks upstairs or exerts herself. At least 3 times weekly, she has shortness or breath, requiring the use of 3 pillows to sleep at night. She has not had chest pain. She has been an established patient for 10 years. During this time, hypertension has been well controlled with HCTZ. However, 2 months ago, she developed increased regurg. That was evaluated by a 2 months ago, she developed increased blood pressure and lysinopryl was added to her medication regimen. No history also is significant for mitral valve regurg. That was evaluated by a cardiologist 3 years ago. At which time, the patient was asymptomatic, BMI is 28. Her temp is fine, pulse is fine, resps, fine blood pressure is 150 or 85. Longs are clear. Cardiac examination discloses a diminished S1, audible S3, high pitch grade, far to 6, stolic murmur, radiating to the left axilla. Examination of the extremities shows 1 plus pd in a dima to the middle of the tbia bilaterally, which one is the most up and right next step in management. This person seems to start having heart failure symptoms. We know that this person has mitral regurg. Remember, mitral regurg can cause heart failure. It can cause the stolic dysfunction that leads the cardiomyopathy.

Because over time, as you keep having that regurgitation back into the lefty trim, it's almost like the lefty trim is then getting feeling from the pulmonary veins, but it's also getting feeling back from the left ventricle. The preload for the lefty trim goes up over time. The preload for the left ventricle goes up over time. That's going to cause chronic volume overload and that's going to cause a stolic dysfunction. This person has mitral regurg. She's beginning to become symptomatic. She has this audible S3. That tells you she's beginning to have stolic dysfunction. You should go ahead and fix this mitral valve problem. Those didn't become worse. Generally, if a person has mitral valve issues and they have become symptomatic, just replace the valve. She's 55. She's a good surgical candidate. Sometimes, if a person is asymptomatic, but you see that their EF is dropping. If it's under 60%, you should also go ahead and replace that valve. Let's look at the answers here. Option E says that. I'm low-deep pain. That doesn't make any sense. That doesn't make any sense. We're not going to do that. If I look at her for valve replacement, that seems like what we should do. Let's look at the other answers. I'm going to increase the doses of anti-pretentives. Blood pressure doesn't seem to be well controlled, but again, this question is focused so much on the shortness or breath difficulty sleeping. She's having heart failure symptoms.

Option D says, recommend a low sodium diet that includes low fat deer. Come on. No. Option E says, recommend starting a low-impact aerobic exercise regimen for 30 minutes. Just fix the mitral valve problem, please. All right. So the answer is B for that one. All right. Option 23, 68-year-old man is admitted to the hospital because of a two-month-history gradually worsening dyspnea. And swelling of the lower extremities. Medical history also is remarkable for OSA. It takes no meds, BMI is 40. His vitals are actually fine, but he's also salicy, 99% on the room air. Oscutation of the lungs discloses decreased breath sounds on the right. Chas per caution discloses don'tness and decreased femurus. Right? So obviously there's fluid in his lungs somehow on the fusion of some sort. Okay. So there's bilateral pylodema, chest x-ray shows a plural of fusion. Okay. Makes sense. Autrosanography, guided thuracentesis is done on disclosed serotoninous fluid. Results of lab studies are shown. Right? So we see the serum studies and the plural fluid studies. So we have the serum LDH, serum protein, plural fluid pH, LDH and protein. And then we have two cultures on cytology of the plural fluid and negative. Which of the fluids is the most appropriate next step in management? Right? So let's look at this. Whenever you're dealing with a plural of fusion and they give you serum studies and plural fluid studies, they're pretty much telling you, hey dude, calculate lights, do lights criteria.

Right? Because you want to figure out if it's transudative or an exudative fusion. So let's do that. Right? So I remember lights criteria. First one is a plural fluid to serum. So plural fluid protein to serum protein. The ratio, you know, for us to see it's transudative, it should be less than 0.5. So let's see. Or the plural fluid protein is 3.9. Serum protein is 5.3. If you take that ratio, it's more than half, right? Half of 5.3, from doing my math right, is 2.65? Yeah, 2.65. Right? So 3.9 is certainly more than 2.65. So this cannot be a transudative fusion. Remember, light criteria, plural fluid protein to serum protein, ratio less than 0.5, plural fluid LDH to serum LDH, ratio less than 0.6. And then the third criteria is a plural fluid LDH being less than 2.3 of the upper limit of normal of serum LDH. Basically, if you violate any of those criteria, you're no longer transudative or exudative. So we can just see easily that this is clearly an exudative fusion. Even the plural fluid LDH to serum LDH, the ratio is like 0.9 or more. I'm just doing mental math here. So this is an exudative fusion, right? And again, in this person that is 60 years old, kind of thinking, because exudative effusions, you're thinking of cancer and stuff like that, right? So let's see what the answer choices here say. So if Johnny says broncoscopy. I don't know if I'm going to be doing broncoscopy, something I used to get a biopsy specimen.

But again, you need to figure out what's going on first. And all you've done is a chest x-ray, right? Option B says CT is kind of the chest. Again, if you want to follow it for person for a long cancer, Option B seems like a pretty good option. But let's look at the other answers for now. And then option C says echocardiogram. No, he has long problems, not heart problems. Option D says fluorosomide. Again, that pitalidema is just a nice, wonderful distractor. Option E says moxyflox is in. No, right? This guy doesn't appear to have any infection. So no, I'm not going to do any of that, right? This guy, whenever he's like an old person, he having a plural effusion and it's exudative, you really want to try to rule out a long cancer, right? So this person should get a CT. You know, I know many resources talk about this, beloved old chest x-ray, but there's nobody that will touch a person that is suspected of long cancer if you've not done a CT. So I'm going to do a CT for this guy. I'm going to go to Option B for this one. All right. I'm going to go to question 124. So 46 year old woman comes to the office. For teen health maintenance exam, and I know some will be like, oh, divine PE can cause exudative effusion, but like this guy symptoms have been going on for two months. You really think that's a PE that doesn't really make any sense, right? Okay. So let's not do that. Okay. So 124. 46 year old woman comes to the office for a teen health maintenance exam.

Reports know symptoms. Medical history is remarkable for polycystic kidney disease, hypertension type 2 diabetes and hypothyroidism. The kidney disease was diagnosed five years ago. CT scan at the time showed in large kidneys with extensive cysts bilaterally. Medications are a result of a statin like Cino-pril gliburid and liver thyroxin, BMI32, her vitals are actually fine. Oto-satisfying. Cardiobominal examination discloses not the malities. Mosul strength is 5 out of 5 in all extremities and deep tendon reflexes are 2 plus throdeol extremities. There's also fasting labs that are shown. So let's see what's abnormal here. Total cholesterol. Let's see. Cranin is pretty bad. 2.1. You know, 2.1 is pretty high. But if we look at all the labs, I don't see anything that's extremely worse. You know, so then says we try to follow and find these most strongly indicates a poor prognosis in this patient. Again, this is, I've been trying to kind of mentally keep count of this mantra with the USML Es. But again, whenever they are giving you a prognosis question, just find the worst on the list, right? Find the worst on the list. Like for example, just look at all her labs. Like, which one is the worst? You know, option F says urine sodium. My urine sodium is normal. So it can be the worst on the list. Option E says serum LDL. LDL, again, 110 is not a very high number. So it's not the worst on the list. Plasma copeptin, how copeptin is completely normal. It's not the worst on the list.

Number of kidneys says, okay, let's keep that kidney function. And my creatinine is 2.1, right? So it's like, wow, it's kind of bad, right? It's kind of bad. So let's keep that one to BMI of 32. I'm going to put a walk around BMI of 32 is not a big deal, right? So and the thing is a number of six. I don't know if that's going to be as worrisome as the kidney function because the thing is remember, EDPKD, it's a, it's a more dominant disorder. And you know, typically these people go into renal failure, like nstitriinal disease, like in their 60s or thereabouts, right? But we're seeing this person beginning to have like signs of like bona fide renal failure and she's just 46, right? That's kind of bad. It kind of tells you that this person may not do very well long term. But actually we need a renal transplant a little earlier than normal. And honestly, again, of this list, just the creatinine is just a thing that's like super worrisome. So I'm going to go to a shambhi actually for this one. I'm going to go with a shambhi for this one. All right. Now question 125 says, again, this is the fourth time, right? Fourth time. This principle is really helpful. Whenever you get a pregnancy question, what's the worst of the list? That's like one of the big things you should think about. All right. Question 125 says that 48 year old woman is referred to the office because of a finger stick blood glucose concentration measured at a health fair four days ago.

You know, it was so referred to the office because a finger stick blood glucose concentration measured at a health fair four days ago was 200 medical histories are remarkable and she takes no medications. BMI is 30. Temperature is 90.6, pauses 84, resps are 16 per minute blood pressure is fine. She's not in a good distress. Examination shows normalities. There's also fasting blood lab studies obtained in preparation for today's visit are shown. So glucose is 146. A1c is 8.3%. You're in microbumeons less than 30 milligrams in 24 hours. So the patient is cancelled regarding lifestyle modifications in addition to metforming which of the following is the most appropriate pharmacotherapy. All right. So make sense, right? Like this person's fasting blood glucose is over 125. So she definitely has diabetes and then we'll see another test. A1c is 8.3%. So it's over 6.5%. So she definitely has diabetes. Although she does not have microbumeons. I remember for you to say that pressing has microbumeons. Your, your obviously into creatinine ratio must be more than 29 milligrams per gram. But your microbumeons like super, super low. So no, she doesn't have microbumeons. So she's not studying like renal damage. All right. So let's look at the answers. So they already study metforming. They're actually in a diabetes. So what else? So option E says it 1 milligram aspirin. There's no need for that right now. Ojambi says corthali doing. She doesn't have high blood pressure.

So we're not going to do that. That's a, that's a thazide diuretic, right? And then option C says like synopril. Well, you give like synopril. If the person is hypertensive, or they have like signs of microbumeonuria, this person does not have it. So that's off. Option D says matupro-law. This person doesn't have like heart failure and you know, whatever. So that's wrong. Option E says no additional pharmacotherapy is indicated. Yeah. One, going to go that one, right? That's the thing that makes the most sense. She just has diabetes. That's all she's got. All right. So the answer is going to be option E. Now question 126 says a 65 year old man who has been your patient for five years comes to the office because he is notice slowly progressive deformity of his left lower leg. He says my leg seems to be a lot more bold than I remember. Doesn't look, he didn't look this way last year. On for the questioning here reports that he has had aching pain in his left leg and hip for the past month. And that he has been taking ibuprofen daily for pain relief without much effect. He identifies as Swedish American. Again, when the USM is give you like demograph, like ethnic demographics or whatever, it's probably important, right? So it's present in European. Now physical examination is normal with the exception of a valgus deformity of the left lower leg. With pain on the position of the TBO shaft, X-rays of the lower leg show cortical thickening.

And intramedularis clearosis in the TBA, which are the fullings the most appropriate pharmacotherapy. All right, so what do you think is going on here? Again, let's put it all together. Let's frame this question for this. An old guy is having bone pain, he's European. And we see that he's having cortical thickening intramedularis clearosis. This is pretty classic for Pages disease of the bone, right? Pages disease of the bone. Remember typically these people, the most common presentation is they may be completely symptomatic, but their alkyphos will be elevated. So how do we treat Pages disease? Typically you're going to give a bisphosphonate. So let's just look for the bisphosphonate answer. So I'm going to go with option A, right? Alendronate is a bisphosphonate. There's no other answer here that makes sense. Calcy toning is option B, calcy toning is option C. Calcy toning, I would think of it as you can give calcy toning when a person has like a cure hypercalcymia, after you've done fluids. Remember when a person has symptoms, I'd like hypercalcymia to give them fluids first. And then you can give calcy toning. It can help you get your blood calcyml levels down fairly quickly, but that's not what's going on here. My thromisein is something you could use for like cancers back in the day. It's pretty, you should pretty much not select it as an answer on the US Emily. It's pretty much no one uses the stuff anymore. And then the proxene, the proxene, that's an end set.

That's not how you treat Pages disease of the bone. You're going to use a bisphosphonate, right? You're going to use a bisphosphonate. Remember the other, so you don't use Pages disease, right? They can get high up with heart failure because their bones become hypervascular. So the heart has to work harder, supply no those excessive blood vessels in the bones. Remember they have hats, may not fit. They may have hearing problems. They may have like radical apathys of the spine. Just tough to keep in mind, right? Okay. And if they had you pick a diagnostic test, you can do a bone scan. You can do a bone syntography for this stuff. All right. Now question 127 says, a 46 year old man with a 70 year history of spondylulistesis, a resulting chronic low back pain. Comes to the office for refill of his sustained release oxycodone. Okay. He reports persistent back pain for the past two months and requests an increase in the dose of oxycodone. Hmm. Okay. He has had to previous unsuccessful back surgeries. The patient's friend will drove him to the office and from the nurse. But he thinks the patient has been selling his oxycodone on the street. Oh, no. The patient's medical history is otherwise unremarkable and he takes no other medications. Vital signs are within normal limits. Physical examination. Discloses for predictable pain over the low back but no of your small small spasms.

There's a well healed surgical scurver, the lumber spine, street leg rates, testing is negative bilaterally. The remainder of the physical examination including neurologic examination discloses no abnormalities. Which of the following is the most appropriate next step? Hmm. Okay. So let's frame this question right. So this is a person that say, hey, I want to op my dose. And his friend said, I think this dude is selling the stuff on the street. Um, okay. So, but hey, maybe the patient is in real pain and maybe the friend is lying. I don't know who knows, right? But we need to figure out like, we need to figure out the truth of what's going on here before we start giving new medications, right? Like you're not just ignore this information that has come to light from this friend. So let's just investigate it. So we're gonna look for an answer that investigates it before we then say, okay, okay, if the, if the friend is true then hey, probably won't be doing that. We will not do the dose increase. When the friend is lying, then yeah, we can do the dose increase. But hey, let's figure out what's going on first. So, if he says discontinuity codeon, come on. You're not investigating any theft. No. Option B says notify the police. Again, we're just going off of the word of the friend and then just tell the cops immediately. Uh, no, right? Again, do your job as a doctor, figure out if this is true or not. Option C says all our random urine tests for oxycodone.

Yeah, we inject the urine. Oxy certainly shows up in the urine. So it's like if it's there, then hey, okay, maybe this person's taking his meds. If it's not there, then hey, maybe he's not taking his meds and maybe he is selling them the street for profit. So we'll see, but I like option C. Let's keep that for now. Option D says refer the patient to a method of clinic. We don't have to do that. That's what we do that when a person is diagnosed with opioid use disorder. This person has nothing that goes to opioid use disorder. Option E says switch oxycodone to a different pain medication. That doesn't figure out what's going on. The oxycodone's helped him before. Why do you want to switch to another medication? No. So I think for this, we're going to do option C, right? Because it's an investigative answer. We figure out, hey, dude, I use, if this is in his urine, at least it means he's taking it. But if his lung is using urine and it's complaining of all the pain that it means that, dude, you're already not taking the stuff. You're already in this in some way or shape or form. So we're going to go to option C for this one. It's actually not as hard a question as it looks on initial inspection. All right. On the official 128 says a 40 year old woman gravitated two par two comes to the office because of a one month history of weakness and intermithia and diarrhea.

She also reports frequent populations and says she has felt shaky and warm during the last two weeks, the past two weeks. She has lost 20 pounds during the past two months. And was initially excited about the weight loss medical histories remarkable for two C sections at ages 20 and 22. She takes no meds family histories remarkable for glaucoma agnosti and maternal grandfather age 65. She does not smoke drink alcoholic beverages. So use other substances. She is five foot eight inches tall, weighs 120 pounds, BMI Z team. She appears anxious and he's sweating mildly. Temp is 99.4, pulse is 115 per minute. Herpes versions are fine. Blood pressure is 140 for 90. Physical examination discloses bilateral lid, lagen exo-thomas. I would hope at this point in this question, you know what's going on. There is mildly diffused enlargement of the thyroid with no discrete papal bone nodules. Cardiac examination discloses irregular rhythm. There's a fine resting tremor of both hands and hyper-reflexion all extremities. Results of lab studies show a serum TSH of 0.2 without tripping, which of the following is most likely to develop in this patient. So this person is clearly hyper thyroid. If I had to put some money on this, sounds a lot like grooves disease. Remember grooves disease is the most one cause of hyperthyroidism in the US, right?

And typically if you have graves, we're gonna do, if you do a rye of scan, a radioactive iodine-optic scan, you're gonna see a diffused increase in uptake. And you know, you can start off the therapy with these anti thyroid drugs. Those are thyroid peroxylase inhibitors like PT or methamazole first. We'll use that as a bridge ultimately to I-131 radioablation. That's how you definitively money-crease disease. But again, he's saying that, hey, if you don't treat this, what's gonna happen? Option A says CKD. I don't know if that's right. I'm not gonna pick that. I don't know if hyperthyroidism has any big as we don't know, like kidney disease. Option B says CHF. I'm gonna keep that because remember, one of the jobs of thyroid hormone is that he puts more beta-1 receptors on the surfaces of your cardiac maiocytes. If you put more beta-1 receptors, your heart becomes more responsive to cardiac holamine. So your heart rate is gonna go up. Your cardiac output is gonna go up, right? So it's almost like your heart is always working hard, hard, hard, hard, hard. Again, it's like giving your heart a chronic, big, intense workout every single day. Well, over time, that heart is gonna get tired and say, you know what, I'm done, I'm done, right? So the person can literally probably go into high output heart failure. Don't forget, many people don't think of it this way, but high output heart failure is something that can absolutely happen to people that have hyperthyroidism.

This is one of the reasons why we take hyperthyroidism kind of seriously. You can get high output heart failure. It's a kind of systolic dysfunction, actually. So let's keep option B, I like option B a lot, actually. Option C says fibromyalgia, come on. I don't know of any real association between hyperthyroidism and fibromyalgia, right? Like, and most likely to develop, that's crazy. Option D says glaucoma, no. Right? Again, this X-opthamus is not good. We should fix this tired problem and they'll probably fix the X-opthamus, but. Option E says MS. Again, hyperthyroidism doesn't have like a crazy great relationship with MS. I'm gonna go to option B. Option B is the answer that makes the most of your sense in this question. All right, we're gonna go to question 129 at 32 year old woman, gravity two part two, who is three months postpartum and breastfeeding is admitted to the hospital. Because of a warm tender, erythematos lump in her right breast, that has increased in size during the past week, despite applied heat and cephalectomy therapy. She has repeatedly pumped milk from that breath by the symptoms of not improved. The patient's pregnancy was complicated. By preterm labor, for wish was hospitalized for one week prior to giving birth via vaginal delivery at 32 weeks. Medical histories of the wife's unremarkable, she takes a prenatal vitamin and is allergic to so far containing medications. On admission, the patient appears flushed. Her temperature is 101.1.

That's kind of high actually. She's stachycardic, blood pressure and respiration are fine. Physical examination discloses a warm 10 by 10 centimeter erythematos tender mass. In the upper outer corner of the right breast, the mass is not fluctuating, so maybe it's not an abscess. Several enlarged tender lymph nodes are probably in the right axilla. So tender lymph at an upper thyroid. So these are bona fide infection. Autosanography guided as perition of the mass is scheduled. Which of the fluen is the most appropriate for medical therapy at this time? So this person clearly has mastitis and you don't like usual therapy. Because usually when people have mastitis, we wanna cover them against MSSA, methicillin sensitive staphorias. But if you've tried MSSA therapy and it's not working, concern we begin to worry about is, does this person have merse and this person definitely has a risk factor for merse. She also hospitalized for a week. What location in this world do you know where it's like, gee, there's a ton of merse in these places. I don't know, like hospitals, right? Merse is a very common hospital acquired infection. So this person has like risk factors and look at her temperature is pretty high. She's very tacky-cardic as well. This person has many risk factors for like resistant organisms. So we should probably cover against merse. I like covering merse here. So option E says IV and pistling so back then that does not cover merse. Option B says IV sephazolin.

That does not cover merse. And you've given something that is kind of sephazolin. If given sephalects is one of these early generations of low sporens, it's not really going to help with like a very serious infection. Option C says IV piptazol. Piptazol is first to the monos, right? It covers gram negatives pretty well as well. It does not cover merse. And then option D says IV vancomycin. Yeah, I like that a lot. So let's maybe do option D. Option E says oral dichloxacillin. Dichloxacillin is for covering MSSA, methecylin sensitive staphorias. It doesn't do squat for merse. So we're not going to do option E. We're going to do option D. And this person being this sick probably should get IV antibiotic therapy, right? Just make sense. All right. Question 130 says that 34 year old man is referred to the office by his new employer because of a positive ppt skin test. Medical history is remarkable for three episodes of skabies during the past year. He previously harvested asparagus at a local farm but says he recently acquired a position at a local nursing home. Part of the required examination was to have the ppt skin test. Okay. His test result was positive with 15 millimeters of interracial. Chest X ratio is not normalities. He's 32 year old wife and six children who range in age from 12 years to 16 months living in the same house. The patient is started and I sony is it therapy. Which of the following is the most appropriate next step? All right.

So this person has lethal TB, right? They have a positive TB skin test and they have a negative chest X ratio. So this lethal TB, gonna do isonize it plus B6 for nine months. All right. Although there's other regimens these days that are preferring, right? Like especially like these are reforepentin based regimens that are like four months, fewer side effects because you're not taking the drug for as long and things like that. So, you know, and then don't forget, if you ever take it nice, you should take B6, right? Because remember, I sonize it in habits that the activation of vitamin B6, right? So there's like an enzyme known as paradoxin five prime I think phosphokinase that activates paradoxin, which is vitamin B6. That enzyme is inhibited by isonize it, right? So you should be taking B6 with this stuff. Let's look at the answers I guess. Let me not get ahead of myself. Well, this lethal TB, we started treating, right? So it says, it says administer PPD skin test to the whole family. Oh, it's kind of a weird answer. Option B says, optin interferongamarylisase. Why would you do that? Like the PPD skin test already shows what we're worried about, the aslii-thin TB. What you want to do on interferongamarylisase, that makes no sense, right? Crossed out of. Option C says, optin's other sputum cultures and gastric washings for the whole family. No, come on. Why would you do that? Is anybody in the family symptomatic? No, why are you doing that, right?

That doesn't make any sense. Option D says, schedule another chest X-ray in three months. Why would you do that? The chest X-ray is negative. You're studying, you've studied therapy. What do you think is magically gonna change? There is no indication for getting another chest X-ray in this question. So I'm not gonna pick that option. E says, start the patient's trusion or not. So now he's it. Have we diagnosed these kids with TB? No. Okay, what's the answer that makes the most sense of this bunch? Honestly, I guess I don't know any great reason to take option A, put option A just makes sense. Like, be through E make like zero sense for this question. Again, with this podcast, I try to be realistic, right? You're gonna see questions like this, like where's like what? But I guess option A makes sense. I mean, this guy for him to have 50 millimeters of endurance. That means she, this guy's had a lot of TB exposure in his life. So, yeah, so option A, hey, let's check out the whole family. You know, why don't we do risk reduction? So yeah, option, honestly, option A is not a great answer, but he's the best answer of the bunch. And that's all they care about on the exams. Pick the best answer of the bunch. All right, so I guess we'll stop here. Uh, there's seven more questions. We're gonna do it in path for, path 14, I guess. And that'll be the last part of the series. I'm so ready to be done with this stuff.

Um, so that I can move on to like other topics that I, you know, wanna discuss. So if you like the way I teach, if you like the way I explain path of physiology, you like the way I make integrations, you've been interested in many of the classes I offer. So I have a bunch of classes in month of February. I have a test taking class, a bio stats class, that's four hours long, and a social sciences, QI, hospital medicine review that's five hours long. These three classes are first step one, two, step three. But first step two and step three specifically. I have a 20 hour review, literally this month as well, and the last minute review, a three hour review. Again, many people have taken these classes and found them to be tremendously helpful for their exams. Again, I've had people as recently as like, just a few weeks ago, take this class and do extremely well on their tests. I'm so if you're interested, shoot me an email, and also have a 50 hour step two, step three review, that's taking place in the month of June. Limit that spot for that one, so if you're interested, just shoot me an email, I can show you how to sign up. All right, and I made podcasts where I talked about those classes specifically. And then I have these podcasts on Apple, Google, and Spotify. So check those out, have a You Tube channel, you can check out. I'll throw one on one to learn from all the US Emily exams.

I also help with errors, applications, mock interviews, personal statements, and things of that nature. And then finally, I have another website called divineinterventionlifelessons.com. Divineinterventionlifelessons.com. Every week I post like one or two podcasts where from a biblical perspective, address a life lesson. And there's actually an Apple podcast, that's a shit with that. So check that out, again, many people actually listen to that podcast. There's more than 300 podcasts on there, or about 300. Again, many people have found it to be helpful. So thank you for listening to me today. I'll see you in episode 500 and 68, I guess. So have a wonderful February. God bless you and bye for now. Thank you.

Prevention of HPV-related cancers and genital warts, as recommended by guidelines covering ages 9 through 45.

An audible S3 gallop, indicating systolic dysfunction/cardiomyopathy.

The ratio of Plural Fluid Protein to Serum Protein must be < 0.5.

A rising serum creatinine level, indicating progression toward renal failure.

Bisphosphonates (e.g., Alendronate).

MRSA (Methicillin-resistant Staphylococcus aureus).

High output heart failure (CHF), due to sustained excessive cardiac workload.

1) Plural Fluid Protein/Serum Protein > 0.5; 2) Plural Fluid LDH/Serum LDH > 0.6; and 3) Plural Fluid LDH > 2/3 of the upper limit of normal serum LDH.

Performing family screening (PPD or IGRA) to identify other potentially exposed members.

Cortical thickening and intramedullary sclerosis in the tibia/fibula.

IV Vancomycin (or other agent covering MRSA).

Because rising creatinine indicates actual progression toward end-stage renal disease and the need for transplantation.

High output heart failure (CHF), due to sustained excessive cardiac workload.

1) Plural Fluid Protein/Serum Protein > 0.5; 2) Plural Fluid LDH/Serum LDH > 0.6; and 3) Plural Fluid LDH > 2/3 of the upper limit of normal serum LDH.

Performing family screening (PPD or IGRA) to identify other potentially exposed members.

Cortical thickening and intramedullary sclerosis in the tibia/fibula.

IV Vancomycin (or other agent covering MRSA).

Because rising creatinine indicates actual progression toward end-stage renal disease and the need for transplantation.