DIP Episode 549 - 2024 USMLE Step 3 Free 137 Discussion Part 2 (Q11-20, super helpful for Step 2!)

All right, welcome everyone. My name is Divine. This is episode 549 of the Divine Intervention Podcast. And into this podcast series we're going to be continuing the 2024 USMELY Step 3, free 137 discussion. This is going to be part two. I'm going to be doing questions 11 to 20. And again, I will encourage you if you're studying for Step 2. This stuff is also super helpful for those that are taking Step 2. All right, so we're just going to jump right into it. So question 11. 37 year old woman comes to the emergency department because of a four hour history of severe rights I did abdominal pain. She describes the pain as sharp and says it reads to the pelvic region. She reads the pain as a nine on a 10 point scale. She has had a associated nausea but has not vomited. She has not had any recent trauma fever. Chills changes in bowel habits or urinary symptoms. She took a proper treatment three hours ago but has had no relief of her current symptoms. Medical history is otherwise unremarkable and she takes northern medications. She does not smoke cigarettes or drink alcoholic beverages. She is not sexually active and her last minutes for a period in it for these ago. The patient is holding a right side and is grimacing in pain. A vital is her. She's the kidney. Her blood pressure is not too bad. Oskultision of the chest disclosis no more breath sounds a no more less one and S2. Abdominal examination.

Disclose this normal bowel sounds tenderness with voluntary guarding on the right side but no palpable masses. Pini is elicited and percussion of the over the right cost of her tibial angle. And then we look at the labs, right? So a utrophil count is 13,000. So what are the pertinent labs? There's a bunch of labs here but again you can see the white count is pretty high. And there's barely any blood in your urine. And then we're told that there's intravenous fluids and analgesic therapies are initiated. Which one following is the most appropriate next step in evaluation, right? So we see this person. This person has had like very severe, you know, right-sided pain. And you know, has cost of her tibial tenderness. Has like a mild local cytosis. We can see some, you know, trace positive blood in her urine. But this woman's labs and vitals are of them otherwise fine. So the thing is if you really think about it, we're kind of worried about this person having like what's the most likely things person is going to have? What's person is likely going to have kidney stones, right? Kidney stones, which kind of makes sense, right? You know, you see the person they have cost of like cost of her tibial angle tenderness. They have like some blood in the urine, you know, some trace positive or call blood in the urine. And this thing started four hours ago. Now, I know some poor maybe seen divine. I should be seeing a lot more blood in the urine if it's nephrolithyases.

But the thing is pretty much every other part of the question is going to give us a clear picture for nephrolithyases. So don't overthink this thing, right? Don't overthink this thing. And you know, four hours is really hard to go from zero to pilot a flight is in like four hours because that's the other thing you'll think about. So for this, I'm going to think of a kidney stone. And if you're trying to evaluate a kidney stone, you want to do a non-contrast CT of the abdomen, right? A non-contrast CT. Many times they call it a helical CT of the abdomen. So option C is going to be the right answer. So it's not copy doesn't make any sense. We do that when we're worried about bladder cancer. X-lap, right? We do that when you have like penetrating injury to the abdomen or you have long-force trauma or your hemodynamic on stable or you have like signs of parotonitis, stuff like that. Yeah, the other answers don't make any really make any sense. All right, we're going to go to question number two, question number 12. So a 75 year old woman is brought to the ED by her husband. 60 minutes after she fainted while standing at the bathroom sink. The husband witnessed a fintin spell and says she lost consciousness for approximately 15 to 30 seconds. All right, he says she was alert upon a weakening but looked pale. The patient did not have any tonic lonic movements and sustained not dramatic injuries during the fall.

She did not have palpitations or other warning signs prior to losing consciousness and has not had slurred speech or abnormalities of movement upon a weakening. Medical history is significant for hypertension and gout. Medications include like synoprilometoprolone, aspirin and allopurinone. She has no drogology. She's doesn't smoke or drink alcohol. She's not in acute distress. Her vitals are pretty fine. Okay, but blood pressure is 162 for 74. That's not very fine. That's actually pretty high. Her standing pulse and blood pressure are 70 per minute and 172 over 75 millimeters of mercury. Her pulse and blood pressure after a standing for two minutes are 68 per minute and 140 to over 58 millimeters of mercury respectively. Okay, so examination of the neck discloses GVD, you know, five centimeters or 30 degrees, no carted breweries, lungs are clear, cartic exams, those are soft systolic ejection manner heard best at the left upper sternal border. No peripheral and demon pulses are 2 plus bilaterally. The allergic examination and ECG disclosed not abnormalities, serm troponing concentration is 0.1. So it's normal. Results of the remaining lab studies are within the reference range. CT scan of the head shows not abnormalities, which are the following is the most appropriate next step in evaluation. Option A says EEG, option B says outpatient ambulatory ECG monitoring, option C says outpatient echocardiography, option D says telemetry observation, option E says a tells test.

Right, so we see this person seems to have had a single bell episode, right? And then she had a rapid return to baseline. So you see stuff like that you're kind of worried about, you know, especially as syncopy. What kind of syncopy is it? Because usually on the exams when you're talking about syncopy, you're going to notice that, okay, you see they're going to be viso vehicle where their face turns white and then they pass out or neurogenic, which is usually seizures of cardiogenic, which is usually from some kind of arrhythmia. Right, so if you frame the question, you see that, wow, sodium syncopy, a rapid return to baselines, probably going to be cardiogenic. And we also see this person has other things that I kind of worry some, right? Like this person has like orthostasis. We see that, you know, between, you know, sitting on standing, there's a decrease in systolic blood pressure by 20 or more. That's the criteria for orthostatic hypertension. And you can see that that stably blood pressure going down by 10 or more, you know, with going from sitting to standing, right? That's going to be orthostasis. Or if your heart rate increases by more than 30 bits per minute, by 30 or more bits per minute from sitting to standing, that's also orthostasis. So this person clearly has orthostatic hypertension. So we're worried about cardiogenic syncopy, right? So we should probably try to see, like, hey, does she have an ongoing arrhythmia?

So let's look for the answer that sounds like EKG. I like option D, because you don't want to send this patient home with all these symptoms. She literally fainted, right? An option B looks very good. But typically you're going to do that ambulatory CG if you don't see anything in the hospital. Let's say you do the telemetry in the hospital, you don't see anything there, like, okay, fine, fine, whatever. Let's go ahead and do the ambulatory CG. So I'm going to go ahead and go with option D. Remember option A, something will do for an eoregenic syncopy, aka seizures, the TL table test option E is going to be for viso-vigal syncopy, okay? And we're not going to be doing a echocardiography to detect electrical abnormalities in the heart, right? That doesn't really make much of any sense. All right. So we're going to go to question number 13. It says, 52-year-old man comes to the ED because of fever and non-peridic lesions that suddenly develop. And his legs are twars ago. He has no had any GI symptoms. Medical history is significant for type 2 diabetes and cirrhosis secondary to hemocromatosis. Medications include insulin and spironolactone, vaccines are up to date. The patient returned home one day ago from a vacation in the south eastern state. He has had no, no contact with anyone who has been ill on arrival. He has a high fever, 101.5. His tachycardic, his tecnic, blood pressure is evolved a 50 that's really low. O2 SAD is 93% on room air. Longs are clear.

Cardiac examination discloses a great 2 out of 6. Sestolic murmur heard best at long the left sternal border. Spider and jumas are present over the torso. The abdomen is distended and the fuselid total per caution. Pau-patient of the abdomen does not disclose tenderness, the liver and spleen are not palpated. The lower extremities are theemidos and one to the touch. The marajic boule are present from the dorsum of the feet to the knees bilaterally. This is not good, this is not good, this is not good. Results of lab studies are shown. Okay, so I can not read of all these labs. What are the things that are pertinase? Cratinase is high, his sodium is low, he has hyponitremium, his bicarb is low, so he has a metabolic acidosis, his glucose is 345, sorry, 354 is pretty high. Has a big time glucose cytoces, mostly neutrophil, so it's probably some bacterial thing. Okay, so again, so he says which of the full microorganisms is the most likely causal agent of this patient's condition? Again, let's frame this question. Option A says enterobacter aerogenase, option B says enterococcus fecalus, option C says micro bacterial marina, option D says vibrioloneficus. Again, let's frame this question, right? Don't do anything this thin, frame it, frame it, frame it, frame it. You're going to keep here, let me see these terms, frame, frame, frame, frame, frame, frame, frame, frame, frame, frame, frame a question.

This is a serotic that this is literally a serotic that has what look like neck fasch. Now you see something like that, that's pretty classic for vibrioloneficus, right? Many times you're going to have bully on the skin. So if you see a serotic that has neck fasch, always think of vibrioloneficus, that's the classic presentation. The only other answer here that is exam worthy is option C, micro bacterial marina, so the answer is D, micro bacterial marina is wrong. You're going to see a pressing that works in an aquarium, and the pressing will have like, they'll have like what looks like sportry courses, but instead of the exposure being like leaves and flowers or gardening or whatever, it's going to be more like aquariums, right? Like fish tanks, stuff like that. All right, so the answer to 13 is D. Okay, let's go to question 14. A 58 year old man comes to the office for full-up of an eight month history of blood pressure readings, ranging from 150 and 180, the numbers of miraculous stallic and 85 to 100 millimeters of mercury that are stallic. Medical histories are the wise owner remarkable. Medications include 20 milligrams of lysinopriol, 100 milligrams of a tenelol, HCTZ and amlodipine. At the patient's last visit six weeks ago, the dose of amlodipine was increased from 5 to 10. The patient does not smoke cigarettes and drinks alcoholic beverages socially. His name is 24. His vitals are completely, well, actually his vitals are not great.

The big one that's really bad is blood pressure 176 over 102. That's not good. Physical examination discloses no abnormalities, results of lab studies are shown. We look at all these labs, honestly. They all look pretty clean to me. So we're not going to spend too much time on those. Okay, now specific additional history should be obtained regarding which of the following, right? So we look at this. Let's let's frame this person. Let's frame this question. Well, let's let me read the answers first. Option E says caffeine use, option B says exercise history, option C says frequency of fast food consumption, option D says refill patterns on medications, refill patterns on medications. Okay, so let's frame this question. This question is talking about poorly controlled high hypertension in a person that is on multiple anti-hypertensives, right? You're like, gee, like dude, like you'll be nice fine. You don't have the trappings of a person that is on a healthy, right? His BMI is 24. This doesn't look like a person that should be hypertensive. Well, look at this dude. Like this guy is on like Sinopriol, Attainolol, AC Ts, and amlodipine literally four things that can lower blood pressure. Although I don't think Attainolol is going to be doing a great job of that. His blood pressure is pretty high, right?

And then we look at his labs because I know our friends at the MBA meetings, they want you to think, oh, primary high-proud of sterunism, primary high-proud of sterunism, but this person does not have hypokillemia, this person does not have metabolic acolysis, right? So we can look at these things like, uh, these things don't really make much of any sense. Um, so when you see something like this, you know, caffeine use, no, that's not going to cause your blood pressure to be this high. Exercise is straight out of the making sense, right? That doesn't make any sense. Option C says, frequency of fast food consumption. He's saying anything about fast food here, and he doesn't even smoke, doesn't drink alcoholic beverages socially. This guy looks like a pretty stand-up guy, right? But let's see, like, is this guy kind of screwing up with his medications, right? That's the only thing that makes any sense here. Again, just kind of analyzing this question deeply. So I'm going to go to option D here. He's refueled patterns on medications, right? So again, again, we notice this guy sticking all these meds, they bumped up his dose, his blood pressure is still not well controlled. There's something wrong here. There's probably a more of a behavioral thing that's going to mess in this guy up in this question. All right. So we're going to go to option D. Okay.

Now question 15 says, um, a 65 year old man comes to the office because of a four month history of increasingly severe joint pain medical history is significant for an anterior, an acute anterior myocardial infarction five years ago, chronic medications that metoprololan in 1 milligrams of aspirin active and passive motion of the oboe and knee joints elicit pain, a diagnosis of osteoarthritis is made. The patient says that a colleague of his recommended celacoxid to treat his pain, the concerns with adding celacoxid to this patient's medication regimen are related to inhibition of which of the following processes, right? So option A says both coxone and cox 2 decrease in prostanoid production. B says coxone decreasing prostacetylin production. Option C says coxone decreasing thromoxin A2 production. Option D says cox 2 decreasing prostacetylin production. Option E says cox 2 decreasing thromoxin A2 production. All right. So here's the thing, right? Like pharmacology is pretty high up to know for your USML Es. Many people kind of think that this stuff is going with step one, but not really unfortunately. So we see this person right here saying that hey, let me stack it to the coxip, right? But many of you say that coxip, it's a cox 2 inhibitor. There is a reason we don't give it to people that have people that are that have cardiac issues, right? Because it can cause problems in people's hearts, right? It can layer cause problems in people's hearts.

It's not necessarily the the best thing for people, right? It's not necessarily the the best thing for people. So that cox 2 inhibition is a problem. Because if you look at it, so it's going to be between options D and E, right? So let's ask ourselves, huh, between options D and E, which one should we pick, right? So if you think about it, it says cox 2 decreasing throstocycling PGA2 production. Well, what does throstocycling do? Throstocycling is a I like to call of think of it as a something that inhibits the aggregation of platelets, right? Something that literally inhibits the aggregation of platelets. I like to think of PGA2 as a platelet gathering inhibitor, right? A platelet gathering inhibitor. And then throstocycling E2 is something that actually causes platelet aggregation, it causes platelet aggregation. So if we then ask ourselves, huh, cox 2 decreasing prostocycling production cox 2 decreasing thromboxin A2 production. Well, again, how do cello coxib work? Cello coxib works specifically to inhibit cox 2 and cox 2 leads to the production of prostocyclins, right? Cox 2 inhibits prostocycling production. And when you inhibit prostocycling that is not necessarily a good thing for a person's heart. That is not necessarily a good thing for a person's heart. That can actually cause problems, right? That can cause problems because it's a platelet gathering inhibitor, right?

So it's something that does you good because if platelets are gathering then you can come thrombine your in your coronary vessels and you can get in trouble and that's no good. That's no good, right? So we don't want to be decreasing the production of something that protects the heart from harm. PGI2 is good. It's a, I like to think of PGI2 as a platelet gathering inhibitor. You don't want to decrease the production of a platelet gathering inhibitor. If not, platelets are going to gather in your heart and you're going to get an MMI and die and you don't want that. So option D is the correct answer. Option E is a very good distractor but it's wrong because thromboxin E2 actually encourages platelet aggregation. It's one of the things that encourages the third step of primary hemostasis which is platelet aggregation. The thing is you want to decrease platelet aggregation. That's a good thing. So that's a beneficial effect. So option D is the right answer. Option E actually almost fell for this but option E is definitely wrong. I'm going to go to option D here. So do you see where understanding comes in when many of these exams? If you're a person that just blindly memorizes stuff, you're going to follow one of these questions because you may know that select cops here. You've memorized it from your on key deck that you need inhibits cox 2. But you need a little more understanding than that.

See like from first principles, you can actually derive many of these things and answer your questions correctly. I'm going to get off my sub box. But remember asprining inhibits cox 1 and 2 irreversibly and then your insides inhibit cox 1 and 2 reversibly. Reversibly. So I'm going to go to page. I'm going to go to question number 16. I kind of printed out the question package. So I'm just going to go in through good old school way. Okay. So question 16 says the QI Department of a hospital has received several incident reports indicating that patients admitted to the hospital have received a different amount of oxygen down was originally pressed or by the admitted physician. That's no good. On admission, the current practice for ordering oxygen therapies that the admitted physician includes oxygen in the written admission orders. An example of admission orders for oxygen is shown below oxygen two liters via nasal cannula with goal of oxygen saturation greater than 90%. Okay. And then he says after patients admitted to the hospital, the amount of oxygen of patient receives is based upon physician and nurse discussion, which is not usually documented in a medical record as an additional order. That's a problem. In addition to reviewing the hospital's protocol for oxygen delivery, instituting which of the following measures would most likely decrease discrepancies in oxygen delivery without creating additional risks. Let me teach you something here, right?

Whenever you get these QI questions, many people are like, oh man, how do you prepare for this stuff? Honestly, one of the simple smart things to do is to ask yourself, what's the problem? What's the problem? Many times you can figure out what the problem is in the question. Just speak and answer choice that directly addresses that problem and we're in good shape. Like look at this. There is what are the two problems I can see in this question. You know, you know, the the issue is that there is even a different amount of oxygen that was originally ordered. That's no good. And then another problem I can see here is that man, okay, the physician and nurse would discuss to change the person's oxygen, but they won't document it in the medical record as an additional order. That's not smart, right? You're not keeping things standardized. So we're kind of looking for an answer that will put everything in the medical record. So that anybody that wants to adjust the patient's oxygen regimen, they can see and say, oh, okay, this was supposed to do. So let's look at the answer choices. Option E says, conducting an in-service program on oxygen use and documentation of orders. That doesn't make any sense. We're trying to like put the orders in the medical record and keep it there. Option B says, creating a standard set of oxygen orders that include initial dose, titration parameters and go-dose. I like that answer. So I'm going to keep it.

Option C says, encouraging the nurses to refrain from adjusting the patient's oxygen dose without a routine order from the physician. No, you want to keep it in the medical record, right? So that everybody is on the same page, right? Because you don't want to keep introducing too many steps, right? Hey, I got to talk to the doctor. If you can just put the orders in and save yourself on the nurse's time, right? And make patient care a little faster. So I'm not going to pick that. Option D says, requiring nurses to interval orders in the electronic medical record and requiring physician signature within 24 hours. What if a patient needs oxygen like like now, right? You don't want to wait 24 hours, right? You don't want patients to die because of your in-descrations. Option E says, requiring nurses to telephone a physician prior to any deviation from your original admission over for oxygen therapy. Again, the thing is, see, whenever you're doing a QI thing, you want to make it has to have as few steps as possible. The more steps you introduce, the more problems you're going to bring in, right? So let's just create a standard set of orders and everything. And then everyone just has it there, like a rating guideline, so that everybody is on the same page. So I'm going to go to option B for this one. All right. Now, question 17 says, a 21 year old ballet dancer comes to the office because she and her husband would like to conceive.

She has not had a menstrual period during the past eight months. She runs it miles daily. Okay. The patient identifies as white. She's five foot five inches tall with 105 pounds, BMI is 18. Her vitals are completely fine, although, yeah, I'm not sure, 90 over 70. Well, it's pretty low, though. Physical exam discloses a thin woman. The remainder of the physical examination shows not the malities. The patient's advice to gain weight and to decrease the amount of strenght of sexist size. She returns for full up three months later. She says she still has not had period, even though she has gained 4.4 pounds, that's two kilograms. Which of the following is the most likely cause of the patient's immunaria, right? So this is a person that is pretty thin, BMI's 18, runs it miles daily, extremely physically active, right? This person is probably not taking enough calories, right? So ballet dancer kind of fits the stereotype. Unfortunately, so, I'm here's the thing, right? When you're not taking enough calories, your body's going to be like, hey, we don't have enough calories for us. We're not going to try to create another human being. So you're going to shut down your HPG axis, right? So your gene average is going to be low. Your FSC is going to be low. Your LH is going to be low. Your gonads, since they're not being stimulated, they don't make estrogen, they don't make testosterone, right? So you're going to have like a kind of hypogonadotropic, hypogonadism.

So, you know, basically like functional hypothelomic immunaria, right? So the only answer that makes any sense here is B, right? So we're going to go to option B here. One of them, we're going to close it out this since disease, right? Primary adrenaline is efficiency. Remember, they're going to have hyponatremia, metabolic acid doses, hyperchilemia. We don't see that here. Partial hypopitrytoryzim, that doesn't make any sense, right? Doesn't relate to anything into the question. PCOS, no, PCOS, you're not going to have a BMI of 18 and a half PCOS. And she doesn't have signs of hyperindrogenism. And for my short, very unfairly, nah, we have a reason. Whenever you have a good reason for something in a question, stop considering crazy things that maybe true, may sound plausible, but don't agree with the question. All right, let's go to question number 18. It says, a 19 year old woman who is at 32 weeks gestation comes to the clinic for a prenatal visit. She says, I try to quit smoking as soon as I knew I was pregnant. But she admits that she has only been able to decrease her smoking to 5 to 10 cigarettes daily. A partner has continued to smoke during the pregnancy. The patient has a history of cocaine use, but a urine drug screening studies have been negative during this pregnancy. The patient is unemployed and dropped out of schooling the 11th grade. She has been receiving supplemental nutritional foods during this pregnancy.

She says she plans to bottle feed this baby because her friends have told her, breastfeeding hurts you and besides, formula mix babies grow faster. No, which of the following factors in the in this patient's history places are in front of greater greatest risk for said, starting from death syndrome. Asha A says, the employment status of some B says, history of cocaine use, C says lack of breastfeeding, this is maternal smoking. Right. So again, I'm going to tell you this risk factors matter. Listen to episode 37, 97, 184, 239 study of her risk factors. Right. But see, what are the risk factors for saides, lean, you know, co-sleeping, right? Is the risk factor for saides smoking in the home or a child that lives on their belly instead of on their back, right? You know, all these things. Now, smoking is the big one here. Right. So we're going to go to option D here. We're going to go to go to option D here. Remember cocaine is a straight out mole with like a placental option. Lack of breastfeeding. When we're in the breastfeeding, a child on a new bottle feeding. The child is going to have a higher risk of allergies, asthma, acute otitis, median, and things like that. All right. Let's go to question number 19. Now, patient information. So this person is 66. She's female. She's coming to the office. Okay. So the patient presents because of a three-day history of increasingly severe pain, winds, swallowing, solids, and liquids.

Use of over the counter-anticit as no resultating relief. There's no associated nausea, vomitting or loss of appetite. Medical history is remarkable for hypertension. That control type two diabetes, migrate an osteoporosis, cream medications, and lentronits, colophagol, propronolol, somatribten, and calcium, citrate with vitamin D supplements. She has smoked one half-pack of cigarettes daily for 10 years and drinks one to two alcoholic beverages monthly. She does not use other substances, BMI's 24. Her vitals are totally fine. This exam shows no abnormalities and doscopies most likely to show a solution of which of the following structures. Right. Swallowing, solids, and liquids. Right. When you have swallowing problems, think of the simple thing. Don't overthink your exam questions. This is an esophagus question. And we see that this person mysteriously is taking a bisfoss finit. Right. Remember things like bisfoss finits can kind of crush your esophagus, right? Pilling due to insurgitis, bisfoss finits, potassium, tablets, tetracycline, can kind of mess up your esophagus. Right. So I'm going to go to option B here. The other answers make absolutely no sense. There are questions on your exams where you don't spend time reviewing the other answers. This is one of those questions. All right. Let's do our final question for this podcast question. 20 says an 11 year old boy is brought to the office by his parents for a well-child examination and routine vaccines.

His medical history is unremarkable and he receives no medications. Vaccinations were up to date. At his most recent examination, one year ago, he is not sexually active in the families of Lita with a religion that teaches abstinence. The parents express reluctance. Sorry, I steepled my paper kind of a weird way. So I'm going to turn this around weirdly. Okay. Parents express reluctance about administering the HPV vaccine today because of the potential adverse effects. As we know, the vaccine, the acid virus really needs this vaccine today. Given that he will not become sexually active until he is much older and married, patients vital signs are within normal limits. Physical exam is fine. Which of the following is the most appropriate response to the parents? Okay, so here's the thing. Again, whenever you see these QIO social science questions ask yourself this. What's the problem? What's the concern? Take the answer that directly addresses the problem, directly addresses the concern. I'm telling you, if you follow the mantra, you're going to be in good shape with these questions. Resolution A says, acknowledge that they are risked as relevant vaccines, but emphasize that those as relevant with the HPV vaccine are small because it is an inactivated vaccine. Hmm. Man, this question they integrate in stuff. The HPV vaccine is certainly not live-at-end weighted, but I'm pretty sure it's not inactivated either.

HPV vaccine is almost like a vaccine with it, basically like simulate a bunch of peptides from the from HPV put it together to elicity immunogenicity. It's actually not an inactivated vaccine. So, option A actually sounds like a good statement, but it's actually pretty wrong. It's actually a false statement. It's a false statement, right? Whenever there is something that is just factually wrong, it will never be right on your exams, right? So the HPV vaccine, it is not a live-at-end weighted, it's not a live-at-end weighted, it's not an inactivated vaccine. Okay, option B says, advise the parents to vaccinate their sonnual contribute to the elimination of the of HPV from the general population. That is, potentially false because that does not address the problem. What are the two problems? They're worried about adverse effects. That's one. And then they're thinking that, hey, you know, this person is going to abstain till they marry, so it's not a big deal. But the thing is, yes, it has adverse effects, but it's pretty low. Most vaccines have pretty minimal adverse effects. And then number two, let's keep going, right? Option C says, explain that even if they are sonnual with some until married to half sex, it will still be exposed to HPV by its future partner. Okay, let's keep that answer. I like that answer.

Option B says, provide the patients with literature about the vaccine and advise that demy, defer the decision because the vaccine may be administered until the age of 26 years. No, okay, that sounds like a good statement, but you're not addressing the problem. There are two problems here, adverse reactions and hey, he's going to be fine. He's going to abstain till he gets married. But what if the person gets married to his wife in the future has HPV? And then he's going to contract the HPV, right? Even if he's in one relationship with that person. So I think option C is the one that's kind of like the best answer here. So explain that even if they are sonnual with some until marriage, right? He's still going to be exposed to HPV by his future partner. So I think by his future wife, I think I like that option. Option A is definitely wrong because it sounds good. You know, you're acknowledging the risks. So that first half of the question is kind of nice. You've been very relational to your patients, but it's kind of wrong too because you know what? It's not an inactivated vaccine, right? So that's actually wrong. That's why option A is wrong. So I'm going to go ahead and stop here. If you're taking step two or step three or step one, I have a bunch of classes coming up at the end of this month, studying on the 22nd. I have a step one class in December, but I have a lot of step two, step three classes this month from the 22nd to like the 31st of October.

So if you're interested in any of them and also a bunch of step one related classes from the 22nd to the, to I think the 25th, I made a podcast on that. Just check that out. If you're interested in more information, shoot me an email. And again, the the the class is not a still class. The thing is, the USML is as many of you know, they make changes pretty much every every year. They they update their question pool, right? So these classes, I try to make sure that they are updated because again, the USML is in the have one focus in 2020 and then they have a different focus in 2022 or different focus in 2024, right? So again, I try to make sure that I stay ahead of the curve with the USML. So that's one benefit of my classes. The material is like very obsessively updated, just to make sure that you're pretty well prepared for your exams. All right. So thank you for joining me today. You can subscribe to the podcast on Apple, Google or Spotify. Have a You Tube channel. You can check out just type divine intervention USML podcasts and videos. Have another website called divine intervention life lessons.com where every week I try to post about a podcast or tour from a biblical perspective address a life lesson. And you know, I also help with your applications, more interviews, offer one on one tutoring. So if you're interested in any of these things, just shoot me an email through the website.

Or you can send me an email at divine intervention podcasts with an S at the end, divine intervention podcasts. So S at the end at gmail.com. So thank you for listening to me today. Have a wonderful rest of your day. God bless you. Good night. And bye for now. Thank you.

Non-contrast CT of the abdomen (or helical CT).

Nephrolithiasis, pyelonephritis, or renal abscess.

Cardiogenic causes of syncope (e.g., arrhythmias).

The presence of "neck fascia" or characteristic serotic plaques, often following travel to contaminated water sources.

Excessive exercise/low caloric intake (functional hypothalamic amenorrhea).

The vaccine is necessary because exposure can occur from future sexual partners.

Cardiogenic syncope (arrhythmia-related).

Systolic BP drop $\ge$ 20 mm Hg, Diastolic BP drop $\ge$ 10 mm Hg, or Heart Rate increase $\ge$ 30 bpm upon standing.

COX-2 inhibition (specifically preventing the decrease in $\text{PGI}_2$).

Chronic use of PP Is, bismuth compounds, or potassium/calcium tablets.

Functional hypothalamic amenorrhea (Hypogonadotropic hypogonadism).

Rhabdomyolysis can be associated with high doses of statins or myotoxic agents.

Cardiogenic syncope (arrhythmia-related).

Systolic BP drop $\ge$ 20 mm Hg, Diastolic BP drop $\ge$ 10 mm Hg, or Heart Rate increase $\ge$ 30 bpm upon standing.

COX-2 inhibition (specifically preventing the decrease in $\text{PGI}_2$).

Chronic use of PP Is, bismuth compounds, or potassium/calcium tablets.

Functional hypothalamic amenorrhea (Hypogonadotropic hypogonadism).

Rhabdomyolysis can be associated with high doses of statins or myotoxic agents.