DIP Episode 535 - 2024 USMLE Step 2CK Free 120 Discussion Part 12 (Q91-100)

Welcome. This is episode 535 of the Divine Intervention Podcasts. Into this podcast we're going to be continuing the series on the 2024 Step 2 CK Step 3. I mean the 2024 Step 2 CK Free 120, this is going to be part 12. If you've missed the other 11 parts in the series again I think it's a pretty good learning experience. We've done the first 90 questions so to them I'm going to go from questions 91 to 100. And if you're kind of wondering, what are the specific episodes for these topics? I'll encourage you just literally on the website. Click on Exam Topics list. You'll see a Google spreadsheet that it leads you to. Go there. Under the Step 2 CK Step 3 tab, the Google spreadsheet, if you scroll, scroll, scroll, you'll see the different headings where I put podcasts for the different disciplines. Like Obie Guy, Nure, blah, blah, blah, blah, blah. There's lyrics section, Tidal, Free 120 or whatever. And I put this specific episode numbers. So let's hear about questions 91 to 100. So question 91 says, a 12 month old girl is brought to the office by her father because of a 3-day history of fever and mildly decreased appetite and activity. She has not had cough, vomiting or diarrhea. She receives no medications, vaccinations are up to date. She's at the 35th percentile for a height, 50th percentile for weight, and 60th percentile for head circumference. Temperature is 39.2 degrees Celsius, that's 102.6 degrees Fahrenheit. Other vital signs are within normal limits.

Examination shows no other abnormalities. A catheter urine sample is obtained and your analysis shows 20 to 30 white blood cells per high power field and is positive for nitrates. Oro TMPSMX therapies began the next day during cultural girls greater than 100,000 colonies per milliliters of acerysher coli that is susceptible to trimethopermisophamethoxysol. We should affluent is the most appropriate next step in management. Option A says superflexus in prophylaxis, B says clean the mysum prophylaxis, C says C Turography, D says ultrasoundography of the kidneys and bladder, and E says voidings histoorethrography. But what is this question showing us? This is a pretty simple question. Basically little kids should not get UT Is, simple as that. They should not get UT Is. Even women, they shouldn't get UT Is, but boys especially so they shouldn't get UT Is. Whenever you see a UTI in a child, you're always worried on the USML Is about some kind of anatomical defect that will be causing them to have these UT Is. So usually you're going to interrogate that by studying with a with a renal ultrasound just to see because it may show you what's going on. If the renal ultrasound is negative or whatever, then you can go for the VCUG, the voidings histoorethrography. So option D makes the most sense here as the thing we're going to start with. Option D makes the most sense. If you notice the abdomen is anatomical problem, you figure it out.

Then you can put them on like daily, antibody prophylaxis, but until then we should kind of chill on that. And it doesn't make sense to give C proto a kid, right? You probably don't want to rupture their Achilles, don't seem like a good idea. You don't want to prolong their QT interval. Uncleinda Maizen is a drug for staff warriors and anaerobes. He's not really going to be covering many of the gram negatives that cause a person to have a UT Is. Alright, let's go question 92. So 32-year-old man comes to the office because of a two-week history of persistent and non-productive cough or kerininsured busts. During the past week he has had bilateral chest pain with severe coughing. He has vomited several times after coughing vigorously. He has not had shortness or breath of fever. Three weeks ago he had a runny nose, sneezing and malmalase that results spontaneously after one week. Toward the end of that period he notices the onset of cough, which is since worsened. He has no history of serosyoninsa and his only medication is over the counter-coff drops. He drinks 24 to 36 ounces of bare weekly. He does not smoke cigarettes or use other substances. He's sexually active with one male partner, the use condoms consistently. He has five foot eight inches tall, does 173 centimeters and weighs 86 kilograms, that's 190 pounds. BMI is 29 kilograms per meter squared. Temperature is 98.6 degrees Fahrenheit. Pause is 70 per minute.

Transparency is 12 per minute and blood pressure is 120 over 80. Pause oxygen room air shows an ultra-sad of 98 percent. During the examination the patient coughs several times. There is no sinus tenderness to bowel patient and no cervical infotainability. The oral firing disappears normal, long-sert clear dose quotation. Cardiac examination discloses not the malities. We should have released the most appropriate pharmacotherapy. Before I even look at these answers this is a pretty classic presentation. We literally see a person that they have what I like to call cough plus, right? They're coughing, coughing, coughing. And the cough choice seems to be especially severe. You see this person they have cough and they have like bilateral chest pain with their cough. They vomit several times after they cough vigorously. And we notice that before this person's symptoms started they had these URI symptoms where he knows sneezing amalgamalese. What does this look like? This sounds unorthodox like pertosis to me. So if this person has pertosis then the treatment has to be a microlead. Remember you don't just treat the patient, you have to treat their close partner. So option B makes the most sense is it through my身. You know I'll be it around now. I'm not going to do that. Again, live oflox is in no. That's not first life or treating pertosis. My first is only the PPI. That's not really going to be helping you watching pertosis and pregnancy is a stereotype.

We're going to be using that for pertosis. Okay. Question 93 is one of these HPI questions. Again, I'm not going to drill so deep on this. I feel like I've done a bunch of these. These questions actually tend to be probably like some of the easiest questions you can encounter on the US immunities. This is better with a fear that's associated with them. But this lady is 18 years old and she's in the emergency department and her reason for a visit is she's coughing up green and yellow mucus. Now let's kind of go through this HPI. So she's pretty has a history of CF cystic fibrosis to the three exacerbations really for the past five years. Three VHCOV productive of copious amounts of yellow and green speutum has subjective fever, shaking shells, progressive sharpness or breath symptoms occurred first only with exertion but now occurred arrest sharp left side of chest pain. As she attributes to extended paroxysms of coughing, symptoms are similar to previous exacerbations. Again, past medical history of cystic fibrosis complicated by bronchiectasis and pancreatic insufficiency. We look at her labs. The pancreatic lipase that's pretty much pancreatic ends and replacement therapy takes Dorni's alpha that's to break off the medical secretions. I have a cough. There is a treatment for CF. I'll be doing it as needed for pulmonary symptoms. Three percent in health saline for pulmonary symptoms. Okay.

No allergies, family history, brother also has CF, psychosocial history, dosing, doing in nasty things, high school student. We look at her vitals. Honestly, the only thing that kind of sticks out of me up close is 112 per million in regular. So she's tagicardis, she's the kipnic, she's a lot hypertensive, how to sat on a room here, 92 percent, it's kind of low. Appearance, she's a mild respiratory distress, she's an accessory muscle, right, pulmonary diffuse bilateral crackles, you know, whatever. Okay. When we look at her labs, her white count is up. That's the big thing. Every other lab is fine, but 16,400 per millimeter cubed. So she has a local cytosis, but which has x-ray, bilateral, bislor consolidations, we increase interstitial markings. So this presale is pneumonia, simple as that, right? This presale is pneumonia. So it says an addition to beginning birth spectrum antibiotic therapy, which of the four things is the most appropriate next step in evaluation? Well, when you got pneumonia, it probably makes sense, especially if we're present at a CF that has like lots of pneumonia and all that stuff, you probably want to know what you're dealing with, right? So you're going to stop with birth spectrum antibiotic therapy, but again, for antibiotics, the word shape reasons, it probably makes sense to not just give birth spectrum antibiotics, but you want to figure out what's going on. So that you can be more targeting your therapy.

So if we look at the answer choices here, CT angiography of the chest, no, she has pneumonia, we don't need to do that. CT angiography of the chest is for P Es, opion B says, sermiminoglobulin concentrations, you do that when you suspect any amino deficiency disease, but this presale has CF, we know what's causing this problem, we don't have to do that. Opion C says, parameter with lung-wony measurement, now that's for like asthma and all those things. Opion D says, pedom culture, I like that answer a lot. So I'm going to go with D. Opion E says, transparent kill, long biopsy, I don't worry about cancer here. So remember, people that have CF less than 20 most common cause of pneumonia is staff-orius, over 20 should be the monos, right? But again, that's the most common, it doesn't mean that that's the only cause. So you got to figure out what's going on here. So we're going to do a sputial culture. All right, so we've got a question 94. Okay, a 16 year old boy comes to the emergency department because of moderate left knee pain and abrasions, sustained two hours ago in a skateboarding collision. He has a histrovocational injuries, sustained well-skid boarding, including an injury to the same knee six months ago. He says his knee had felt fine until today's injury. And he has been fit and active. The patient has an EXT1 mutation, which is also presenting his father. The patient takes no medications, vital signs are within normal limits.

Examination shows superficial abrasions over the anterior lateral aspect of the left knee. No effusional instability is noted in the knee, but there's tenderness to palpation. The patient walks with a limp, but is able to bear on the leg extra of the left knee shows two 1 by 2 centimeter bone polyps extending one immediately and one lottery from the proximal tibia at the level of the closing fices. This is on change from an x-ray of the same knee, obtained during his previous ED visit six months ago. Which of the following is the most appropriate recommendation for activity and additional workups? So option E says biopsy of the polyps and recommendation to bear with us tolerated. Option B says biopsy of the polyps and recommendation for no weight bearing. Option C says MR of the knee and recommendation to bear with us tolerated. Option D says MR of the knee and recommendation for no weight bearing. Option E says recommendation to bear with us tolerated. No further work up needed. Option F says recommendation for no weight bearing. No further work up needed. All right, so we look at this question. So this person felt why the wear skid boarding, which is a common thing, and the person can bruise your knee and OG. This knee hurts a little bit, but this person can bear with on the knee. Their vitals are fine. There's nothing too crazy going on here.

Again, I know the temptation is just not reading too much into this question, but this person is like the question is just telling us that this dude is fine. Just let it go. He fell down on the skateboard, right? With all being kids at some point in our lives, we fell down and we got back up. We put a bandit and continued playing. So chill out. Okay, I'm going to go to option E here. Recommendation to bear with us tolerated. No further work up indicated. So I like option E a lot. I'm going to read much into this. I mean, this person has this EXT1 mutation. It's something that's as good as some genetic disease called a multiple hereditary exostosis. And basically those people, it's a normal dominant disease. It tends to be associated with people having a lot of osteocondromas. Those are like pedunculated masses you'll find on the surfaces of bone. Again, most times this has been 9. Although sometimes those osteocondromas can progress to be coming out of the condors or comets. So you got to watch out for those. But basically like we're told here that this person has these polyps and it's on change from an x-ray on the same knee. So that means this is not something that's like, oh, change, I'm becoming a legion or whatever. So don't don't don't don't read too much into this question. I'm not going to read too much into this question. This kid seems to be fine. So just tell them just be wise. Go back and play. I like option E a lot. So I'm going to pick option E.

Okay, question 95 says a 70 year old woman comes to the office because of three episodes of retoblady during the past four days. During each episode she has she had the certain urge to have a bowel movement and then past her bright red blood. She's not had any chest abdominal or retopane populations. Dizziness, lightheadedness or blackstores. How most recent could have lost to be years ago. She should not have normalities. She has osteoarthritis treated with daily ibuprofen. She takes no medications. She's 5 foot 6 inches tall. She's 152 pounds. BMI is 25. Her vitals are fine. She doesn't have orthostatic hypotension. I'm going to skip that part on examination because membranes are moist. They have too many soft, non-tender and non-distended. There's no rebound tenderness or guardian. Balsans are normal. Retail exemptions no stone in the vault. They are no masses which are the fullings the most likely diagnosis. So this is an old person, person over 50. Having a painless bloody bowel movement. You see this like a classic pattern. The person feels like they want to poop or then they poop out blood. It's just pretty classic for diverticulosis. So, when you go diverticulosis here, it's going to be option C. Ocolonic polyp, you know, can cause bleeding. But again, you see this pattern, right? Pay attention to the patterns. That's why if you notice in many of my podcasts, I don't just like give you the facts.

No, like I like to give the story because the story many times is what's going to drive you to the right answer on your exams. I'm not going to pick in old feature. We tend to find that in people that have like a histro of chronic constipation or a man having sex with men. This is not a blood no-losser. That's going to be more of an upper GI bleed, not a lower GI bleed. Gastritis, very awesome distracter here because of this whole thing about, oh, she digs the liable profit. But again, you can see that this is a clear lower GI bleed. Gastritis causes more of an upper GI bleed kind of a situation. And again, it's not just going to be the most classic thing for the veneer that has been presented to us. And then if that's an alternative colitis, you're not going to wait till each 70 to start off having an alternative colitis. No, we're going to have found it in a younger male. Okay, so that doesn't make any sense. All right, we're going to go to question 96. So a 14 year old boy is brought to the office because of a six month history of changes in behavior. Two days ago, the patient and his friends were detained by police. For trespassing on abandoned property and injured amount occupied house. No alcohol, other substances were involved. The police officer who brought the patient home reported that there was evidence indicating this had not been the first time the boy's entered the property.

The mother says the son was polite and close with his parents until six months ago when he began socializing with a different group of boys in his class. She says the patient is constantly exchanging text messages with his new friends. The group has inside jokes and nicknames for one another. Every weekend, the patient goes out with his friends and argues with his parents about his curfew. At home, he is irritable and shares few details about his ulcer activities with his parents. He has no history of serocelness and receives no medications. Examination shows no normalities during toxicology screening is negative. We show the following is the most likely explanation for this patient's behavior. Option E says adjustment disorder, this is EDHD, C says conduct disorder, this is oppositional defying disorder. He says normal development. Okay, so this boy sounds like he started hanging out with the wrong crew and started doing bad things. Sounds like the thing that unfortunately a lot of teenagers fall into, a lot of youth fall into. So I'm going to go with option E, this is normal development. This is not adjustment disorder. Just mean disorder is going to see a person that has depression like symptoms, anxiety like symptoms, and they face the stressor a few days ago. They're not going to meet the real diagnostic criteria, however, for depression or anxiety. This is not EDHD.

This is not a child that cannot focus in school or talking out of his turn or things like that in two different settings. No, that's not what's going on here. And then conduct disorder, right? You're going to see a lot of criminal behavior. I know someone will be like, ooh, divine. Is this not criminal behavior? This person is trespassing on a bond on property. But again, look at the context. That's the thing that kills people on these exams. They're so rigid, they're so stuck on. Oh, this is the criteria. I'm going to stick to this criteria. If you violate this criteria, I'm going to slap this diagnosis on you. Well, that's not the way to take you a semi-exams because if you practice medicine like that, like an actual physician, you would do so many things for patients that you don't need. You've got to understand the context, the spirit behind a situation. This kid just started hanging out with the wrong crew, started having bad behavior. That's all that's going on here. We don't have to do anything beyond that, right? So this is also not a positional defiant disorder because this child was polite previously, but we see that man. He's started hanging on the wrong friends and boom, everything went berserk. This is normal development. I'm going to go to the option E for that. The parents should probably do their jobs. Okay. Question 97 says a six-year-old boy is brought to the E.D.

by his mother because of the acute onset of one hour ago of severe, right-sided, number of pain and three episodes of MSS. The pain is sharp and causes him to double over and cry. Medical and family history is unremarkable. The patient takes new medications. He's very tacky-cardic. I'm not going to be reading all these vital signs. He's tacky-cardic, he's the kidney. His blood pressure is okay. He appears to be in severe pain. Abdominal examination discloses red or prochordren tenderness to palpation. The remainder of the examination discloses normalities. IV morphine is administered and results in improving the patient's pain. Results of dipstick analysis are shown. So look at the analysis and the urine spasuric gravity is pretty high. It's pretty high. And then we also notice that there's four-plus blood, one-plus lucosylesterase, five-to-tenorate, white cells per high-power field, but 50 to 100 red blood cells per high-power field. Renal ultrasonography shows severe, I'd say, hydrodynamic process with moderate hydrourator to the bladder, which would have influenced the most appropriate next step in evaluation. So what is this? Sodium onset, flung pain, you look at the urine, a ton of blood in it, sounds unfulfilled like a kidney stone. When you have a kidney stone, especially when it's this severe, you're seeing hydrodynamic process. Generally, for kidney stones, you want to do a CT of the abdomen, a non-contrast CT of the abdomen.

You don't want to use contrast, if it's going to obscure the stone. You want to do a non-concity of the abdomen. So a little good option B here. Most of the other answers are pretty ridiculous. The only other answer that maybe looks good at all is voiding c-story throgram. But you do that with UT Is. Again, that's the context. A little child that shouldn't have UT Is, having UT Is. You're going to do that to interact with an atomic problem. So I'm going to go to option B here. All right, question 98. 20-year-old male comes to the office. And many of the other tests, radio-neucleid cystography, retrograde pyrography, Mach 3 renal scan with ferozomide. Again, those things are really ever correct on any USML exam, right? When you're picking those answers, you better have some very sound reasons for doing that. Those answers that I probably will almost under no circumstance be on the USM Ls are usually pretty wrong. That's like consulting the ethics committee in a sense. All right, so question 98 says a 20-year-old man comes to the office at the end of the summer because of a two-month history of generalizma, leses, fatigue, intramethan, cough, productive, whitish, sputum, and decreased appetite. During this time, he has lost approximately 10 pounds. The patient previously was on the collect track team, but now feels winded when he tries to go running. He has a history of childhood asthma.

He currently takes new medications, doesn't smoke, doesn't drink, doesn't use all those substances. His African-American, of course, they're going to push Dr. Koeidosis as an answer. Yep, they did that. All right, because they know that again, if you don't look at context and you're just like, oh, if you're going to America, I'm sure they have Dr. Koeidosis waiting for you, but hey, let's read the rest of the question. Oh, he has been working as an alumnum male for the summer. Okay, fitting logs into a saw. His five foot ten inches tall, 170 pounds, BMI is fine, 24. His vitals, honestly, are pretty okay. The few crackers are heard bilaterally. The remainder of the examination shows novelmalities, chest x-ray shows are a tickulu nodula pattern that is more prevalent in the upper long field. Results of pulmonary function tests show a mixed obstructive and restrictive pattern, which is a full-length of the most likely diagnosis. You see this person, all these problems started since they started working at a sawmill, at a lumber mill, so they exposed to all these inhaled things. Whenever you're exposed to inhaled things and it's kind of torching your lungs and you're seeing this restrictive picture, you always want to think about hypersensitivity in a monitis. You can be exposed to bird droppings. There are many variants of these bird fanciers long, blah, blah, blah, blah.

And many times, especially when it's been going on for weeks, like it has a chronic period associated with it, it's going to affect the upper lobes of the lung. It's going to affect the upper lobes of the lung. It's going to affect what the upper lobes of the lung, that's the more permanent distribution. So I'm going to pick option C here. As per Gilosis, those in McKinney sense, we don't see as any as per Gilos results. We don't see any inhibition in your xenophils in this question. So we're going to do that. As my recurrence, no, we can see that his problems literally started after he studied in this lumber mill job. He should probably, probably quit. Option D says, so are quite doses. You're going to pick that if you just read this question and ignore everything else, but the African American part. That's not a smart, we'll take exams. And silly courses, right? You're going to be working with sand and all those things. That's not what's going on here. All right. Almost done. Almost done. Question 99. A 32-year old woman is admitted to the hospital. Because of a two-year history of intractable seizures, her boyfriend who has accompanied her describes the seizures as episodes of bilateral limb shaking and moving her head from side to side, during which the patient closes her eyes and cries. The episode lasts 15 to 20 minutes and she's intrametically responsive during this time.

Charles O'Fenny towing, Carbamazepine, Gabbapentin, OX-Cabazepine, and Diva Prox have not provided relief of her symptoms. Her current medications and Zonissa mind and Pregabaline, the patient has a history of childhood sexual and physical abuse. That's a hint. Vital signs are within normal limits. Neurologic exam shows no focal findings. The patient undergoes long-term video EEG monitoring, which shows that her seizures are not associated with any EEG changes, which will have linked the most upper-bredinx-step-in management. So, option A says CBT, option B says hypnotic therapy, option C says increasing the dosage of Pregabaline, option D says psychoanalytic therapy, option A says surgical recession of the epileptogenic focus. So see this person, they have seizures, seizures, seizures, but this person has a psych history, right? Sexual and physical abuse, especially as a history of abuse in the past. And we see if it's person's seizures kind of weird. This person, you know, they're aware intrametically during the seizures and they don't seem to have much of any post-ictophase. And then we see the EEG shows that seizures are not associated with any EEG changes, right? These are psychogenic seizures. These are psychogenic seizures. So these are psychiatric problems. The person's going to get CBT for that. The person's going to get CBT for that. I'm going to pick option A. hypnosis is almost never correct from the USM at least.

We don't need to increase the dose of Pregabaline, these are not real seizures. Psychanalytic therapy is like some stuff that you try to bring a presence on conscious thoughts to the conscious realm. That's something that's almost always going to be wrong on your exams as well. Option E, no, we don't need to surgical say this, it's a psychiatric problem. Okay, this is our last question, our last question. So a two-year-old girl is brought to the, and he put her chest right here. Okay, fine. A two-year-old girl is brought to the clinic by her parents for an initial examination. Medical record shows that she has a cleft palate and VS Ds that have not been repaired. During the past 18 months, she has had two episodes of pneumonia and at least 10 episodes of all tightest media. Should have an antibiotic therapy. You see these many infections, you have an immunodeficiency disease, right? The patient's parents recently adopted her from China. She's at the 10th percentile for height, 5th percentile for weight. Yeah, this is definitely an immunodeficiency disease. Virocytes are within normal limits. It's a nation shows middle ear fusions by LaRulia and a cleft palate. Long-served cleftal scotation agreed throughout a six-olusistolic memory is heard on cardiac exam. So that's the VSD. There's no hepatoclinomagaly. Chestics are shown. Complete blood counties, most likely should show which of the following local side findings in the patient. Right?

So we see a person have ear recurring infections and they have cleft lip cleft palate. They have these craniofficial abnormalities. What do you think that person has? That's the George Syndrome. That is literally the George Syndrome. Right? And again, notice, I didn't even talk about the chest x-ray but fine, let's talk about it. Right? So look at this chest x-ray. Well, this is the George. Look at the top of the chest x-ray. Do you see any big glob of white representing the cell sign of the thymus? No. And it may not be a perfect cell sign, especially for this two-year-old, but you're probably still going to be able to visualize the thymus. It's not there. It's literally not there. This is the George. So what's the path of his behind the George? Well, your third eye, your fourth, foreign jaw pouches, they don't develop. So you guess what? You have no thymus, so you have no t-cells. Right? And you have no parathyrids, so you don't make BTH. Right? Because you have no t-cells, you're going to struggle with lots of infections. I mean, people will think that, oh, it's only viruses and fungi are going to be struggling with. No. The thing is, you need your t-cells to also kind of work with your B cells, kind of stimulate them. It's mainly those helper t-cells. So you're going to have some bacterial stuff going on in your life as well. So again, if you don't have t-cells, your lymphocyte count should probably be down. So I'm going to go to option C here.

I'm going to go to option C here. Option A, use synafilia. Again, there's not many, many deficiency diseases that track with that. Lymphocytosis, not really metropenia, not really metrophilia, not really. Right? This is like a pretty clear case of the George syndrome. So I'm going to go ahead and stop here. Again, I hope you found this podcast to be helpful. I have a bunch of classes for step two, step three coming up, step one, two, step three actually coming up soon. Then the next two weeks, I have a testing and strategies class. I have a bio-stats class. I have a social sciences and ethics class. Those are all for step one, two, step three. I have a separate podcast where I discuss these classes. And then I have a last-minute review, three hours long for step two, step three. Also coming up this month, I have a 20 hour class for step two, step three, coming up this month. And the next month, I have a 50 hour class. It's only going to be held once this year because it's such a class that requires a lot of commitment. But there's a lot of, it's going to be a class that, if you attend it, it's going to be very, very well worth a while. The people that attended last year have gotten so many awesome testimonials from them. And then in July, the first week in July, I'm having a 25 hour step one class. So if you're interested in any of these classes, the whole over Zoom, and if you like the way I teach, that's how those classes are. It's not me teaching lectures.

No, it's me using questions and scenarios to teach you content, explain pathophase, make integrations, to really prepare you for an exam. The way you're supposed to be prepared for an exam. I also offer one on one tutoring for all the US Emily and complex exams. And then I have this podcast on Apple, Google and Spotify, Apple You Tube channel, you can check out. And then I have another website called Divine Intervention Lifelessens.com. Every week, I post about two podcasts. We're from a biblical perspective, I address a life lesson. And also help with the errors, applications and personal statements and, you know, the likes. So if you're interested in any of those things, just shoot me an email. I can give you some more information. You can email me directly through the website. So thank you for listening to me today. I will see you in episode 536. God bless you. Have a wonderful day. Bye for now.

Renal ultrasound (to look for anatomical defects).

Voiding cystourethrography (VCUG).

Preceding URI symptoms $\rightarrow$ severe cough $\rightarrow$ post-tussive vomiting/chest pain.

Non-contrast CT of the abdomen (to visualize the stone).

Chronic cough, dyspnea, weight loss, and exposure to dust/lumber mill work.

Cognitive Behavioral Therapy (CBT).

Cleft palate, cardiac defects (VS Ds), and recurrent infections/immunodeficiency.

Elderly patient; painless, bright red rectal bleeding.

1. Renal Ultrasound $\rightarrow$ 2. VCUG (if US negative).

Staphylococcus aureus.

DiGeorge Syndrome (T-cell deficiency $\rightarrow$ Lymphopenia).

Non-contrast CT of the abdomen.

Seizures are not associated with abnormal EEG changes, and the patient remains intermittently responsive during episodes.

Pneumoconiosis or Hypersensitivity Pneumonitis (exposure-related lung disease).

Elderly patient; painless, bright red rectal bleeding.

1. Renal Ultrasound $\rightarrow$ 2. VCUG (if US negative).

Staphylococcus aureus.

DiGeorge Syndrome (T-cell deficiency $\rightarrow$ Lymphopenia).

Non-contrast CT of the abdomen.

Seizures are not associated with abnormal EEG changes, and the patient remains intermittently responsive during episodes.

Pneumoconiosis or Hypersensitivity Pneumonitis (exposure-related lung disease).