DIP Episode 639 - USMLE Free 86 Series 1 (Q1-10, for Step 2/3)

All right, welcome. My name is divine. This is episode 639 of the Divine intervention podcasts. Into these podcasts, I'm gonna start what I call a USMLE Specs series. This is going to be series one. There is about 86 questions that I'm gonna go through and I'm gonna go through 10 in each podcast for the most part, you know, within reason. And you may wonder like where did you get this from divine? Well, this is something if you do like search for USMLE Specs. They have like these very good step two CK step three like questions. That's on their website. There's 86 of them. They're very good. So I will say this podcast is certainly for a person studying for step one. I mean for step two CK or step three. It's almost like doing another free 120 and I'm gonna go through every single question. Why the right answers are right and why the wrong answers are wrong. I'm gonna post a PDF of this document in the with the podcast as well. All right. So let's do question number one. So a 14 year old girl who has received three courses of chemotherapy for Hodgkin's disease is brought to the office by her father because of worsening cough, shortness of breath, a low grade fever and fatigue for the past two days. No one at home is ill. She says she's taking no medications. Her vaccinations are up to date. She attends a private school. Vital signs her temperature of 98.8. Pulse is 100 per minute. Respirations are 35 per minute and blood pressure is 110 over 72.

Oxygen saturation on pulse ox is 87% while breathing room air. Physical examination discloses a few course breath sounds in the lower lobes and retractions. Chest X ratio shows no masses and a mild interstitial pattern. No infiltrates or effusions are noted and heart size is normal. Which of the following is the most appropriate step at this time? Right. Again, before you jump to the answers, just look at this question. What's going on? Right. So this person is on chemo. Persons on chemo. You're probably minimal compromise. Right. And then this person seems to have a lot of pulmonary symptoms. And we're told that you get a chest radiograph and you see interstitial infiltrates. Right. Again, if you're just looking in terms of disease scripts, this looks an awful lot like PCP pneumonia. Right. So we're gonna try to find the answer that tags along with that. So probably go ahead and pick option A here. Right. Option A says that meet the girl to the hospital for high dose TMP smx therapy. Right. That's the smart play here. You know, option B says begin. I so nice a therapy in the girl and test the family for TB. No, right now. This person doesn't have TB TB usually is going to show up with cafeteria infiltrating the lungs on imaging. We don't see that here. And you're going to have symptoms that are like weight loss, you know, night sweats and all those things, you know, those B symptoms. We don't see those prescribed C pro. I don't think that's a very smart idea for a kid.

Right. You don't want to rupture their Achilles. And remember C pro being a fluoroquinolone also does things like prolong the QT interval. Right. And then prescribed oral floconisol. That's something we're going to do for worried about like oral kind of diocese. This person doesn't have oral kind of diocese or is a vajocanid diocese. Right. This person is not presenting with dysphysia. So that'll be wrong. And then option E says scheduled a long biopsy. No, that's ridiculous. That's that's frankly insane. Right. So good teaching point to keep in mind here is the USML Es. They're becoming very big these days on giving on giving PCP pneumonia to non HIV patients. Right. So like for example, people that are immunocompromised because they have like some immunodeficiency disease. Or they're taking some immunocompromised intro like steroids or TNF inhibitors or chemotherapy, things like that. All right. Now question number two says a 14 year old African American girl comes to the office for the first time for sports physical examination. She's asymptomatic. Her medical history is unremarkable. Family history shows that her maternal grandmother had an MI at age 65. Her mother has hypertension that is well controlled with anti-hypertensive medication. Vital signs or temperature of 99, pulse is 86, respiratory or 16 per minute and blood pressure is 1, 12 over 74. She is 165 centimeters tall. So she's 5 foot 5 inches. She's at the 75th percentile. Weight is 45 kilograms.

So 99 pounds 25th percentile. Physical exam shows a great two out of three out of six, a stoic murmur at the left sternal border. The second heart sound S2 is loud with fixed bleeding and is heard best in the second left intercostal space. The family is anxious and requests an answer regarding the patient sports participation. Which of the following is the most appropriate advice to give the patient and her parents? Resoption A says a laherdo participating all sports option B says a laherdo participating non-contact sports only option C says a laherdo participating sports but recommend cardiac cath option D says a laherdo participating sports but recommend a co-cardiography option E says prescrib prophyllactic antibiotics for use prior to each game. All right so what's going on here?

So we see this girl right she seems otherwise normal but she seems to have all these vovular issues right all these murmurs you know seems like she's got an ASD seems like she's potentially got a VSD as well right the ASD the wife explains right and then we're seeing a lot say that heart sound so that's kind of worrisome that hey she developing like pulmonary hypertension here right but she's pretty normal right like literally like 60% of the question is telling us normal normal normal normal normal normal right so don't go for a gang boasters answer here that'll be pretty ridiculous right so for this girl I think I'm gonna go with option D here right a lot of participating sports but recommend echocardiography right like she's got a murmurs you gotta evaluate those and remember it's not every murmur you evaluate with an echo right but this person has concerning features right so remember what are the things we evaluate by echocardiography murmur wise well if you have a murmur that is three at a six-estolic or greater this person checks that box right if you have a that stoic murmur you should also get it evaluated if you have a symptomatic murmur you should get that evaluated if you have a holosis stoic murmur you should get that evaluated so you know this person has a if you have a murmur as to you know the complication like a person developing a stroke or whatever you should get that evaluated echo cardiography as well right so this girl for sure needs an echo right but she's fine she can probably do sports you're not gonna like not be able to do sports because you have like an ASD or VSD right but yeah like you need to evaluate these this murmur because she definitely has an indication for a kind of a strange she has an she has an echocardiographic indication for a murmur right and again you know remember we we do prophylactic antibiotics to put a half like on on

resolved sanotic congenital heart defects right for endocraditis she doesn't need that criteria and ASD or VSD is not sanotic right a VSD sanotic though when you develop ising mingers right and then cardiac cath you do that when you're worried about like coronary artery disease right she doesn't seem to have that and again non-contact sports remember that's something we do with people that have mono right mono so they don't rope sure they're spleen we tell them that hey about four four weeks after you know wait for four weeks before it's that doing non-contact before it's that doing contact sports actually sorry that non-contact sports is a very good uh a destructor there right and they remember people that have morphine as well should also be careful of contact sports so they do explode their yodders right and then yeah she should she should be allowed to participate in all sports but you gotta evaluate that murmur so ease ease right so item number three and four so an 81 year old woman is being prepared for discharge for in a three week stay in the hospital for repair of a fractured hip that she sustained while gardening she now police with difficulties in a walker but she's determined to become independent again and to return to her to her her own home her daughter who is in the room with the patient says I want to take mother home with me because I'm concerned that she could fall and break her hip again mom says she doesn't really want to leave her home leave her own home but she will do what is best the daughter turns to her mother and says firmly isn't that right mom the mother says yes I guess so a verdict I contact with both her daughter and you by looking down toward the floor danger danger danger danger danger what does it sound like elderly abuse right elderly abuse elderly abuse but hey let's look at the actual question question three says which of the fol

lowing is the most appropriate response to the mother excuse me option A says are you sure you want to go home with your daughter option B says how do you feel if you fell again and had another fracture option C says is this really your decision or is it your daughters option D says I would like to talk with you in private now option E says you're lucky you have a daughter who wants to take care of you right we see this question just presents some interesting conundrums right mom wants to go home daughters like hey come live with me right and then the elderly mom is like avoiding eye contact looking towards the ground saying yes I guess so right this looks like elderly abuse and elderly abuse if you have any suspicion you have to have already you got a report it right so obviously I would really really hope you're saying that divine the right answer probably should be option D right because you're removing the grandma the mom from the situation and evaluating like to just check like hey let me just kind of dig into this a little bit more is this lady been abused or or what right and then option E says you are lucky to have a daughter who wants to take care of you yeah it's good to have kids that want to take care of you in your old age but you got to evaluate that elderly abuse then first right C says is this really your decision or is it your daughters um ultimately it's the mom's decision right because she's lucid right so I mean it is her decision like there's clarity on that already option B says um how do you feel if you fell again and had another fracture your guilt stripping your patients right don't build these guilt guilt in your patients answers and then option A says are you sure you want to go home with your daughter well she has communicated a decision right you can see that she's reluctant but is like in the heat of the moment she said what she got to sa

y right but we're worried about it already abuse so we need to do something about that and then question four says which of the following is most likely to prevent another fall and a possible fracture in this patient option E says advise her to walk only when accompanied by an adult option B says ensure that she does not have orthostatic hypertension option C says provide her with assistance for activities of daily living option D says provide her with an electric wheelchair option E says request a visiting nurse to assess the safety of her living environment right so what should you pick here um so again here's the thing right whenever a person has a high risk of a fall right um you always want to evaluate factors in their lives that may lead to them falling right is it like polyfarmacy or do they have like a non-safe home right or do they have like a musculoskeletal disorder where strength training may be helpful or whatever right you got to do a full risk assessment right that's one of the smart things to do you got to do a full risk assessment right it's just kind of like when a this is like a completely unrelated point but it's kind of related you know the USMLE is you see like a disaster that happens like a natural disaster whatever right and then they ask you like what's the most important initial public health response you want to pick the answer that talks about doing a needs assessment right do a needs assessment like hey what's going on first before you start doing all these interventions right so our cell option E is the best answer here is the best answer here right option D provide her with an electric wheelchair is not a good idea because um you know she can start having DV Ds and P Es and all those problems if you can get her moving um I think you should and this lady can ambulate we see in the question she now ambulates with difficulty using a walker so

at least she can ambulate don't just give up on that and make the person non-ambulatory no and then option C says provide her with assistance for activities of daily living this person just struggles with walking not with activities of daily living so that's wrong option B says ensure that she does not have orthostatic hypertension well there's nothing in this question that tells us about orthostasis right so it's like why make that leap of faith don't make leaps of faith on your exam that's not a smart testing strategy and then option A says advice her to walk only when a company ban adult no this lady doesn't need to be a company ban adult right you're placing severe significant limitations on her life don't do that that's going to be wrong on your exams right now question number five says a 27 year old Mexican woman gravita 4 par 2 about a one who is a 25-wish gestation comes to the e ed because of painless vaginal bleeding that she noticed two hours ago after sexual intercourse well that must have been intense after sexual intercourse with her husband sorry just kidding all right the patient has not received routine prenatal care during her pregnancy though she was treated for chlamydia with a zythromycin at 15 wish gestation she gave birth to both of her daughters at home in Mexico via normal vaginal delivery she had once spontaneous abortion at five wish gestation vital signs her temperature of 37 degrees Celsius which is 90.6 degrees Fahrenheit pulse of 100 per minute respirations at 24 per minute blood pressures 110 over 64 sterile specular examination shows 4 milliliters of blood in the vaginal vault the cervix appears closed ultrasoundography of the pelvis is most likely to show which of the following causes of bleeding in this patient right so again this question is talking about painless vaginal bleeding right again don't overthink this thing this is pain

less vaginal bleeding in a person that is pretty close to the end of the second trimester slash early third trimester right so this she is more in the second trimester but she's pretty late in the second trimester right so painless vaginal bleeding right so we know that hey if you're talking about painless vaginal bleeding you're talking about the previous the previous at painless right but the placental abruption the uterine rupture those are painful right so you can probably get rid of option you know because option A says serviceitis option B says placenta creda option C says placenta previous option D says placental abruption option E says pre-term labor right option E makes no sense this is not pre-term labor this lady is not having contractions that's wrong option D says placenta abruption that causes pain full vaginal bleeding that's wrong option C says placenta previous that causes painless vaginal bleeding that's a pretty good answer option B says placenta creda placenta creda is like a labor complication right you're trying to yank out the placenta E it's not coming out that's not what's going on here right that's not what's going on here right and we don't see placenta creda having like an association with oh you just had sexual intercourse right so that's option E serviceitis serviceitis is going to have a longer timeline than just two hours ago right so the right answer is going to be option C right remember placenta previous when you have your placental vessels overlying the cervical os right so if you know you're having sexual intercourse and you know you the person's penis like slams those placental vessels that can cause like some mal bleeding it's typically going to be inconsequential right but the thing is when a woman has placenta previous you know sometimes you recommend like pelvic rest not bed rest pelvic rest basically like calm down on the sex

right for now so that you don't rupture those placenta vessels that overlying the cervical os and cause a profound bleeding all right now question number six says an 80 year old African American woman is brought to the office for the first time by her son because she has signs of mildly decreasing mental function she's having increasing trouble reading writing and watching television she has mild stable angina pectoris and she had an uncomplicated MI eight years ago physical examination discloses no abnormalities except for corrected visual acuity of 20 other 200 oh you which appears to be caused by cataracts right which appears to be caused by cataracts right which appears to be caused by cataracts now mini mental state exam score how many mental state examination score is between 9 out of 30 which of the following is the most correct statement about this patient's condition right so this person seems to be struggling with you know having like some mental issues you know like just you know signs of mildly decreasing mental function but she's 80 right let's give her some grace and a MMS is 2930 seems pretty good to me but man her vision is terrible all right so let's look at the answers option a says had daily activities would likely improve if she had character character extraction with lens implantation okay option b says had diminishment of status is a contraindication for cataract operation character operation is pretty low risk surgery option b makes no sense option c says that history of cardiac disease and advanced age are contraindications for cataract operation no right cataract surgery is low risk surgery this is something I teach you my social sciences and ethics class low risk surgery you don't need to do any pre-op workup you don't even if you had like a terrible medical history you can still do those surgeries right so c is wrong option d says a mental

status should be written with it in one year no what if he keeps declining and worsening right you want to do something about it now and then option e says you need more information to decide whether she will be held by a cataract operation huh seriously you need more information right that's a this is an example of a person that is like driving up the cost of healthcare right this person's correct the visual acuity is 20 out of 200 that's pretty bad right and then this person you know pierced because by cataracts cataracts is something that can be easily diagnosed with a physical exam right this person if she can start seeing more a mental faculties will probably improve right this person literally cannot read cannot write cannot watch TV because of a poor vision fixed a poor vision right so ideally activities will likely improve if you had cataract extraction with lens implantation so I'm going to go with option a for this one right I'm going to go to question number seven uh 70 year old Vietnamese fisherman is brought to the ED by his son who says that his father has had sweats occurring oh an immigrant with sweats huh I wonder why all right let's keep going uh who says that his father has had sweats occurring twice a night soaking his bed clothes and a cough productive of yellow foul tasting fluid yeah and blotting sputum for the past three weeks his appetite has been poor for two months and he has lost 26 pounds or 12 kilograms during that time physical examination shows an emaciated man in acute distress he is coughing frequently and deeply vital signs are a temperature of 37.8 degrees Celsius which is 100 degrees Fahrenheit pulse is 90 per minute and blood pressure is 105 over 60 his respirations are shallow but not labored loud loud wrong chai are heard on the right side of the chest his liver and spleen are poppable and non tender his inguinal notes are made

it but non tender chest x-ray shown sputum smear discloses multiple neutral films but no more floor appropriate diagnostic tests are completed to confirm the diagnosis which of the following is the most appropriate management at this time guys immigrant immigrant immigrant foreign country foreign country foreign country night sweats weight loss coffin foul smelling blah blah blah blah doesn't even matter what the chest x-ray shows what in the world you think this is going to be this looks an awful lot like TV right so we're going to go for option c here anti micro bacterial therapy right option a antibiotic therapy is too broad so i'm not going to pick that answer right anti micro bacterial therapies are less broad answer and it fits the question better option b says anti-fungal therapy well guys tb is a bacteria it's not a fungus there's a reason why it's called my co bacteria it's not called my co fungus right so option b is definitely wrong option d says bronchoscopy you don't say no why not going to do that they've already done diagnostic testing white white white bronchoscopy and the option e says refer to a thoracic surgeon for right opera lobectomy woo man if we did a surgery for people that had tb thoracic surgeons would be the wealthier surgeons around now why not do that that's insane right all right so this is good question number eight a 50 year old man comes to the ed because of a tour history of vomiting coffee ground material he has lost 10 pounds in the past six months dark blood is obtained on pacinanisogastric tube which of the following is the most important factor in determining the spations long-term prognosis prognosis prognosis prognosis prognosis prognosis prognosis prognosis right guys the USM is they love prognosis right and the thing is some of these questions you can prepare for by just learning some of them you cannot prepare for but again

you need to apply wisdom with these questions right you need to apply wisdom with these questions i i teach how to deal with prognosis questions in many of my classes and i also go over prognosis in my classes but option a says amount on rate of blood loss option b says cause of the bleeding option c says history of previous g i bleeding option d says initial hematocrit measurement option e says initial response to a bolus of cil guys look at the question here which of the following is the most important factor in determining the spations long-term prognosis right and the thing is this guy he's 50 he's coughed up blood his lost 10 pounds that's kind of worrisome right like if if a person think about he just think like pressing comes to your office they're 50 years old they just coughed up they just vomited blood right and the person has lost some weight what is like the first thing you should be worried about i hope you're thinking about cancer right and then look at the say which of the following is the most important factor in determining this patient's long-term prognosis well obviously for this person you probably want to go ahead and do like some kind of e gd with biopsy right at least do an e gd just to make sure like hey what the way this person cough up this stuff right like easy he's by a lorry where it's like we can be like whoo we can he the side of relieving is always like a so-so-joe cancer gastric cancer something kind of bad right something kind of bad right because obviously if it's like peptic ulcer disease or heech by lorry that's causing his problem or you know a so-so-joe kind of diocese causing his problem then they were not too worried right those are pretty low key conditions right prognosis is pretty good for those long-term remember the questions that come out long-term but if it's cancer right like as a so-so-joe cancer typically has a terri

ble prognosis gastric cancer usually has a terrible prognosis right so the cause of the bleeding makes the most sense here right because again that's the thing that relates more to the long-term prognosis right again this question is not asking about short-term prognosis so option A doesn't make much sense a mountain rate of blood loss no they're not asking about short-term here they ask him out long-term right in the short-term how much you bleed yeah the term is your prognosis but long term it's probably not gonna be a big issue right it's probably not gonna be a big issue and then option C says history of previous GI bleeding maybe that tells us okay this maybe what your risk of another reblet looks like but it doesn't really tell us about your long-term prognosis initial hematocrit measurement right it tells us again it's a short-term thing hey if your hematocrit is pretty low and you have a GI bleeding you've probably blood a lot to start right probably tells us that this person's GI bleeding was intense right but again doesn't tell us much long-term right and then initial response to a bolus of ceiling again that's a short-term answer that doesn't line up with a question asking about long-term prognosis right now gonna go to question number questions nine and ten they're co-joined questions right so uh 22-year old African-American woman gravita one par one is evaluating the maternity ward of the hospital 24 hours after giving birth to a 4,267 gram that's a 9.7 ounce million fund via uncomplicated vaginal delivery following delivery she on the when repair of a fourth degree perinial laceration she is currently able to walk to the bathroom and void without difficulty but she has not had a bowel movement since delivery medical histories of the wise-on remarkable and her only medications are prenatal vitamins vital signs are a temperature of 99 degrees Fahrenheit pu

lses 60 per minute respirations at 18 per minute and blood pressures 120 over 86 the uterus is possible to the level of the umbilikas the vaginal laceration is not inflamed or swollen sutures are intact and there is drainage from the site there is no drainage from the site sorry locia is normal hemoglobin concentration is 10.8 grams per decilator the patient states that she is concerned about her insurance company requirement that she stay in the hospital no longer than 48 hours postpartum she is worried that she will not be ready to leave tomorrow as she is breastfeeding and needs more help from the nurses she also is concerned about her bowel function and wants to stay until she is sure it will be normal she asks if he would extend her state to 72 hours postpartum if she is not ready to leave tomorrow all right so here's the thing right this question is long but again thankfully it's basically like one stem for two questions right that's probably why the okay making the question this long right and then question nine says which of the following is the most appropriate response to her request option A says I'm sure the insurance company will understand if you need another day so you take whatever time you need before you go home option B says let me decide whether or not it is too soon for you leave the hospital option C says let's see how you feel tomorrow and we can discuss the most appropriate time to leave then option D says you concentrate you concentrate on getting better and leave the insurance company to me here a doctor okay option E says unfortunately I have no control over the insurance company so you had better plan on leaving tomorrow right this is an ethics question right and again what's the right answer here right so option A I'm sure the insurance company will understand you don't know insurance companies in America all right they will understand if

you need another day it takes whatever time you need no that is not a good use of actually that's a terrible answer that's not a good use of healthcare resources right like if we let patients take as much time as they need patients can really take some time or take too little time right no you need to balance all the information available option A is wrong option B says let me decide whether or not it is too soon for you to leave the hospital see share decision making is a concept the USMLE is love right let me decide no you give recommendations but you need to get some consent from the patient so option B is wrong option C says hey let's see how you feel tomorrow right this is just 24 hours after delivery like chill out woman like let's see how you feel tomorrow and then let's discuss right you talk more right the the USMLE is like you're talking with your patients not just kind of like making a decision touch down and move along no so I like option C a lot option D says you concentrate on getting better and leave the insurance company to me I'll take on the insurance companies many governments administrations political parties many people have tried to deal with insurance companies they've not made much progress you the one doctor wants to take on the system have fun with that that's wrong option E says unfortunately I have no control over the insurance company so you had better plan on leaving tomorrow that's very rude right and what if the patient is not feeling well you're like hey get out no you're not gonna do that so option E is wrong all right question 10 which is linked to the same question which of the following would be the most important indication for extending this patient's hospital C beyond 48 hours post-partum option E says abdominal distension and lack of appetite at 48 hours post-partum option B says lack of bowel movement post pattern option C say

s need for nursing assistance with breastfeeding option D says palpation of the uterus above the pubic synthesis for more than 48 hours post-partum option E says persistence of locca for more than 24 hours post-partum right so again this is like a prognosis question in disguise right it's a prognosis question in disguise right so basically like this is asking like hey what will make us keep this lady for more than 48 hours well obviously it'll have to be something that is pretty serious right so option E presents of locca for more than 24 hours that's ridiculous that's wrong right women can have locca for weeks after delivery of a child it's normal right hey that that blood volume you have of your blood volume increasing by like 50% during pregnancy like you gotta get rid of that blood somehow option D says palpation of the uterus above the pubic synthesis for more than 48 hours post-partum that's fine right you know above the pubic synthesis that's actually almost like it's actually a good thing means that wow this woman's uterus is getting smaller and smaller as is should right because it's contracting down to its normal size after delivery right so that's wrong that's a normal finding option C says need for nursing assistance with breastfeeding you can get lactation assistance outpatient again the thing is go for cost effective options on your exams if you can okay go for cost effective options on your exams if you can right like if a patient can be treated outpatient for something don't don't pick the impression answer that doesn't make any sense right because you're driving up the cost of health care right option B says lack of bowel movement post-partum not having a bowel movement is not a problem right epidurals contain opioids right those opioids can cause constipation it's gonna be fine she's gonna be okay right she loud option E is the best answer right abdo

minal distinction and lack of appetite so she's not eating that's strange abdominal distinction that's worrisome right hey maybe the uterus is not contracting down she could have post-partum hemorrhage right or she's developing some kind of abdominal complication right that will be a situation where it's like mmm let's let's keep you for a bit let's keep you for a bit in the in the hospital right so I I'm gonna go with option A for question number 10 and option option C for question number nine all right so I'm gonna go ahead and stop here again this is a 10 questions which kind of my go for this right but again I hope you found this podcast to be helpful basically think of these questions there's a free 86 questions from the mbm is they're very good so I'm gonna walk through one of them and again you see I'm not just talking about content I'm also talking about testing principles right so if you like the way I teach you you'll certainly love my classes like for example in the month of June there's a 500 question class it's multiple choice where so 500 questions multiple choice class it's a 50 hour class I go through a ton of content a ton of test-ticking strategies is held only once a year is the first week of June this year many people have taken that class and they found this to be extremely helpful and it's not just that you get a lot of supplemental material from the class right so again limited spots available for that but that's a class that many people love right like I integrate so many things very comprehensive coverage of the USMLE exams right definitely for people taking step towards level two step three level three or people taking um um or people actually preparing for residency it's actually a phenomenal course to take to pull together many things from medical school to get you very set for residency and internship right they actually people that have t

aken the class for that express purpose and it will also help you with the in training exams that you're going to be dealing with when you start residency right so just something to keep in mind and then um also offer a 20 hour class that's for step two and step three as well and last minute review that's for step two and step three as well that's three hours long and then um I have classes for step one of the widow step three of a test-ticking class of a bio-stats class of a social sciences and ethics class those are for step one to step three um and all these classes start this month right actually start next week the 50 hour classes first weeks in June but all these classes start next week on Monday actually uh on Monday actually right so if you're interested shoot me an email I can give you some more information again I really make a conscious effort to go over a pathophase make integrations teach your content teach your test-ticking principles as you come through these classes again many people have taken my classes and have done extremely well on their exams also for one or one tutoring for all the US Emily and complex exams and med school exams and I have these podcasts on Apple Google and Spotify and then I have another website called divineinterventionlifelessons.com divineinterventionlifelessons.com so many of you know my Christ follower so every week I post like one or two podcasts from a biblical perspective address a life lesson um there's actually an Apple podcast associated with that called the divine intervention life lessons podcast have almost 400 podcasts on there right so thank you for listening to me today again I do hope you find this podcast to be helpful I also help with Eras applications and mock interviews and personal statements and rec letters and things like that so thank you for listening to me I will see you God willing in episode 640 ha

ve a wonderful day God bless you and bye for now thank you

Painless vaginal bleeding.

PCP pneumonia (Pneumocystis jirovecii).

Fixed splitting of S2 (suggesting an ASD or large shunt).

Remove the patient from the situation and talk privately to assess capacity.

Abdominal distension combined with lack of appetite/poor oral intake.

Tuberculosis (TB).

High-dose TMP/SMX.

Placenta previa.

Murmurs > 3/6 systolic, symptomatic murmur, or fixed splitting of S2.

The underlying cause of the bleeding (e.g., cancer vs. peptic ulcer).

Abdominal distension and lack of appetite/poor oral intake.

To improve function by addressing reversible causes (e.g., cataract surgery).

High-dose TMP/SMX.

Placenta previa.

Murmurs > 3/6 systolic, symptomatic murmur, or fixed splitting of S2.

The underlying cause of the bleeding (e.g., cancer vs. peptic ulcer).

Abdominal distension and lack of appetite/poor oral intake.

To improve function by addressing reversible causes (e.g., cataract surgery).