DIP Episode 207 - The USMLE And Geriatrics Part 1

Okay, welcome. My name is Divine. This is episode 207 of the Divine Intervention Podcast. And in this podcast, I'm going to be talking about the USML in relation to the geriatric population. This podcast is actually going to be in parts, probably like two, maybe three parts. This stuff is actually floridly high, you know, to know for the exam. So because I, if you remember from the USML and the military podcast, I said I'll make a geriatric one. So this is a geriatric one. It's just a geriatric topic. It's a little more, there's a lot of them. So I will just kind of talk about some some key things, right? In this podcast, and then continuing the next one. So basically the geriatric population, again, if you read the USML content outline, it's not like I'm giving you some secret or whatever, although it's almost like a secret because people don't read the USML content outline for whatever bizarre reason. But this stuff is actually very important to know, right? So the thing is if you are dealing with your like the elderly population, right? So the big thing you want to think about is no like certain key topics that the MBA Me tends to focus on, right? And the thing is many of those key topics that the MBA Me focuses on are all contained in something known as the comprehensive geriatric assessment, okay?

Basically, the comprehensive geriatric assessment, it kind of, you know, kind of checks out a few things that's common to the elderly, like checking like they're hearing, checking their vision, checking like if they have your inner inconvenience, checking their cognition, right? Checking like they are for risk, and also just checking their functional capabilities, right? So those are all things we'll talk about because the thing is if you actually do these assessments and have an idea of these things and actually do something about them, it's actually associated with reduced mortality in the elderly population. So there are all things that you need to keep at the back of your mind for exams. Now one classic thing that the MBA Me kind of cares about is like polypharmacy in the elderly. The thing is it is actually very high you to know for purposes of MBA Me exams. They can literally give you questions where we have this elderly person taking like a crap ton of medications, right? And then the right answer may be to like review the person's medications, right? Like or they may say which of the following interventions is most likely to decrease this patient's risk of falls, right? Actually reducing the number of medications really does help. I mean really does help, right? That's bad English. So in general, again, if you have an elderly patient and usually they'll make it a pretty obvious question on exams with this person's taking like a crap ton of meds.

If you want to reduce your risk, one thing you can absolutely do, right? It's actually that's again very high you to know is to reduce the number of medications they take. And really, I mean if you just take fewer medications, you also have like less risk, less risk with with drug interactions, obviously, right? And then one of the thing you want to keep at the back of your mind is just remembering the buzzword beers criteria. So B-W-E-R-S, right? So the beers criteria is used pretty extensively at least by jurisdictions in the US to identify medications that are kind of high risk on the other end of the elderly that you'd want to avoid. And then obviously, another key elderly issue is like elderly abuse, right? So if you see any signs of elderly abuse, you do need to report it. Remember the things that you report mandatory in this country, you report elderly abuse, and you also report child abuse, right? You report elderly abuse, and you also report child abuse. So again, those are all big things to keep in mind. So let's maybe begin to go by topic, just be a little I just wanted to give you like the low-hanging fruit. So let's begin to pick some of these topics apart and discuss as many as I can, probably in about like, you know, like a half hour or something like that, right? So the first one is assessing the presence like functional ability.

I remember again, I said that you want to check functional ability, you want to check hearing, you want to check vision, you want to check for earring, continents, you want to check for risk, right? You want to check all those things, right? So let's talk about functional ability, right? So the thing is if you want to assess a person's functional ability, you basically assess their ED Ls, right? So what do I mean by ED Ls? Well, ED Ls are essentially a person's activities of daily living, okay? That's literally what the word EDL stands for, activities of daily living, right? And the thing is for the MBA, your friends at the MBA may expect you to know that there are two kinds of ED Ls. There's basic ED Ls, and there is instrumental ED Ls, right? So there's basic ED Ls, and there's instrumental ED Ls. So you may say, okay, hmm, divine. What's the difference between these two things? Well, the thing is basic ED Ls are things that you need to be able to live independently, like you're like they can safely leave this elderly person at home and they can live on their own, they won't have any problems, right? But the instrumental, right? Think of like instrument, like using something, like using a tool, an instrumental EDL is something that is necessary for the person to be able to function, like interact with society independently, okay? So make sure you're able to delineate the difference between those two things.

I promise you, this stuff I'm talking about is super high ill to know for the exam, okay? So basic ED Ls, right? Again, there are things you need to be able to live, like you can say, oh, old person, I can leave you at home, you can live on your own, right? Versus an instrumental EDL where it's like, oh, old person, because you may have basic ED Ls, but you may not have functional, I mean, instrumental ED Ls, right? So the instrumental ED Ls, you need to be able to like do things in the community, right? So maybe if I give you some examples, you'll understand exactly what I mean, right? So the thing is, if a person, the basic ED Ls are things like, oh, can you take a shower, right? Can you dress yourself up? Can you use the bathroom, right? Can you feed yourself? Can you pee and poop on your own, right? Those are all basic ED Ls, those are things that, again, you need to be able to live independently, like in a safe manner, right? But instrumental ED Ls are things like, oh, can you take your meds? Can you make your own food, right? Can you clean up your apartment? Can you manage your finances, right? Can you go and get groceries, right? Those are things you don't necessarily know those things, you need to live at home safely, we need them to be able to function independently in society. So those are kind of the big things that your friends at the MBM expect you to know with regards to assessing a person's functional ability, right?

And then the next thing I think I want to talk about, I want to talk about like cognitive function, this one is relatively easy, pretty much for cognitive function in the elderly, the tool you're using is the MMSC, right? The mini mental state exam, right? It's pretty good. And one magic number you want to remember is the magic number 24, okay? So basically, if you do an MMSC on a patient and the MMSC comes up to a number that's less than 24, that person that person very likely has some kind of cognitive dysfunction, doesn't include the number 24, but anything below 24. So basically from 23 downwards, right? That tells you the person likely has some cognitive dysfunction. And one unusual tool you'll mission you on your MBM exam as an answer instead of the MMSC is something that's like relatively newer that a lot of a lot more people are beginning to use. It's known as the mini cog, okay? The mini cog basically it's a super quick test that's actually it's actually a lot shorter than the MMSC, right? And it takes much less time, right? And basically what you do is you tell the patient a series of words, you ask them to draw a clock, and then after they draw the clock, you ask them to recall those three words. Basically if the patient cannot recall any of those words or maybe they can recall some of them, right? But they also draw the clock inaccurately. This person very likely has some kind of significant attention to that word, significant cognitive issues, right?

And the thing is obviously if you identify that an elderly person has cognitive problems, you want to try to roll out reversible causes of the cognitive problems, right? So you want to measure their TSH, you want to check their B12 level, right? You want to check their medications, again, just to make sure they are not experiencing side effects of medications. And you also want to just get a BMP, right? Just check their labs, right? Because many old people shockingly have hyponitramia and that's the thing that makes them some some no-lent and then they begin to get into all these cognitive problems. Now one of the key things you want to keep at the back of your mind for exams, like sensory problems in the elderly, this one I'll probably talk about it some more in the next podcast, but let me just kind of give you I guess a preview of coming attractions. Basically in terms of sensory problems, you are looking at vision and hearing, right? Vision and hearing. Like hearing loss is actually a pretty big problem in the elderly. I mean like almost 50% or more of people over the age of 85 have some kind of hearing loss, right? And the thing is if an elderly person has hearing loss, right? That's actually a risk factor for like depression and for them just not having life that is good, right? So the equality of life kind of goes down the drain, right? So the thing is again they can frame some of these questions as risk factor questions on your exams, right?

So those are things you want to know, right? And I mean if we're looking from the perspective of hearing loss, what is the most common cause of hearing loss in the elderly? Well, I hope you're telling me press by Qsis, right? Press by Qsis is basically a sensory neuro hearing loss and for the most part the people that have pressed by Qsis, they tend to lose like high frequency hearing. At least that's what they typically lose, that's what they typically typically lose first, right? And the thing is again your friends are they may be going to ask you like, oh which of the following is the best screening to detect hearing loss in this patient, right? Basically what you do is you can do one of two things. Actually, it's not one of two things you do both of these things, right? So for example, you just ask the patient, do you have any issues with hearing, right? And then after that there's something that you need to do that's called the whispered voice test. Again, that's something the MBME cares about a lot, right? So the whispered voice tests, basically the thing you do is you go behind the patient, you whisper something and then the patient says like, Doc, I can't hear anything you're saying in or they cannot repeat like, they're like, yeah, Doc, I feel like I have issues with hearing or they cannot repeat the things that you told them accurately. Then your next step in management on an MBME exam will be to re-fread them for audiometry, right?

Refread them for geometry so that their hearing can be analyzed. And then in terms of vision, right? Like, again, like people that have people that are, again, pretty old, they tend to have like problems like molecular degeneration, diabetic neuropathy, I mean, retinopathy, opulangu, glaucoma, presbiopia, presbiopia, it's just when the presence lens cannot accommodate very well, right? So those are all things that can cause visual problems in the orderly. And again, I'll probably talk about that some more in the next podcast. And then old people also can get depressed. So let's talk about depression in the orderly people, right? The thing is, especially if you have an old person that has like coronary artery disease or they have like some chronic kidney disease or like a stroke or something, those things can be associated with pretty, pretty, like if you add depression to any of those problems, then those people are in very serious trouble as the orderly, right? And remember that older people, they have a much higher risk of committing suicide than younger people, right? Then younger people, right? And if you're like, okay, how does you're going for depression in an old person? Do you see the caps? No, okay, you do not use the caps on an in-game example. I mean, obviously, if it's like a mainstream question, yeah, the caps is just fine.

But typically they will make it a question where it's like, obviously, like they're trying to flush out this knowledge from you to see if you really have to really understand down what's going on with the orderly, right? So the thing is, if you want to at least screen, right? If you want to screen, basically, you essentially ask two questions, right? The first question you do is like, oh, you know, in the last two weeks, have you fell down, have you fell depressed, have you felt like hopeless? That's the first question. And then the second question is, oh, over the last, over the last two weeks, have you like lost interest in doing things that you previously enjoyed? Those are two questions you can ask. And when you ask those questions, you can pretty, you can very quickly figure out if the person has a depression or not, right? And again, you still ultimately apply CE caps, but don't forget these two questions that I mentioned here, right? And I mean, in terms of depression, the orderly, pretty much all you do is you do like, you know, you give SSR Is, SSR is my first line. They'll try to trick you on your examine to begin a TCA, right? Do not pick a tricycle and tidy present. Because remember, those TCA's can cause a lot of problems, right? So they have like anti-hamm side effects, so anti-heach ones, so the cost addition, anti-r4 ones, so they can cause like orthostatic hypertension, which can again raise the elderly person's risk of faults.

And then they also cause, so anti-muscular in the effects, right? So anti-cholinergic, remember, those can trigger delirium in the orderly, so you want to try to avoid that if you can, right? Now, one other thing here, I think I'm going to go ahead and talk about is fall risk, right? So the thing is, falls are bad, bad, bad, bad, you know, people, I mean, it causes a lot of morbidity and mortality, right? So really, for the most part, if you have a geologic patient, you know, you want to go ahead and screen them for, like, screen the afford risk, right? You basically ask them, like, do they have like any history of falls within the past year, right? Within the past year, you don't need to ask them for like, oh, for 20 years, no, no, no, within the past year, have you had any problems with fall, have you had a history of falls, have you had any problems with like your gate and your balance, right? So, you know, you just basically screened them that way, right? And then there is something else you also do, right? And again, this thing, I promise you, this thing is flirty, high, you know, all your exams, right? This thing is called the get up and go test, right? The get up and go test. Basically, the thing that happens is you tell the patient to rise from a chair and they shouldn't use the hands to rise from the chair, they just rise from the chair on their own, right? And then they walk 10 feet and then they come around and go back to the chair, right?

And usually, you know, for normal people, it's like 10 minutes, you know, if you're kind of old, like 11 to 20, sorry, not 10 minutes, 10 seconds, if you're kind of old, you know, it's like 11 to 20 seconds, but if it's more than 20 seconds, that is clearly, clearly, clearly abnormal. And usually people that have like an abnormal get up and go test, they also tend to have like issues with like, um, they're usually going to have issues with completing their like activities of, of daily living, right? So again, if a person has a high risk of falls, again, go ahead and look at their vision, right? Again, make sure they don't have cataracts, look at the medications they use, look at their ideals, right? So like the basic ideals, again, that I talked about, see for living at home, instrumental ideals, I talked about see for, you know, like interacting with society, right? Check their cognition, right? Check if they have with those study hypertension, check if they have any deep problems, right? Those are all things you want to keep at the back of your mind with regards to falls in the elderly. And then one thing that your friends at the end, you actually love to test quite frequently is, are there some interventions you could employ to decrease the risk of falls in the elderly? So actually, there are three super high old ones to know. The first one is if they could exercise regularly, that helps for sure.

And then if they could, if they could, on the go physical therapy, that also helps. And then another one that's kind of unusual, right? That's why a lot of people will likely get this wrong going to test is supplementing with vitamin D, vitamin D supplementation has actually been shown to be beneficial in decreasing the risk of falls in an elderly person, right? And then one other big topic, I guess, that's important to know in the elderly. There's actually a few more topics I have to, I want to talk about here, right? So things like urinary and continents, right? So urinary and continents, I mean, there's different types of talked about these things so much in my many different podcasts. But I guess since I'm talking about the geriatric population, and I talk about it here, right? So obviously, you know, there's urgent continents, right? Sometimes it's called overactive bladder and exams, right? So these people, right, during the D time, they can get to the bathroom on time, right? And again, for the most part, it arises because the nutritional muscle is hyper tonic, right? So like, essentially like the nutritional muscles contract involuntarily, right? So you've lost pretty much all control over them, right? And for the most part, again, in the elderly, you typically want to try like bladder training, right? You want to try like bladder training, sometimes you can actually try biofeedback.

But for the most part, I'll say the big one I want to think of on you, exam is bladder training or like timed voiding, right? Where like, oh, every one hour or whatever. You have them go go and pee, right? You have them go and pee. The thing is, you can also give drugs, right? If you remember from my previous podcast, right? Like the anti-cooling energetics, like the anti-muscle knee agents, like oxybutamine and toterraging the arphenicins or events in drospium. So the thing is those drugs, they work well for urgent continents, but you want to try to avoid them in the elderly, right? Because those drugs are anti-cooling energetics, so they can trigger like confusion, they can trigger delirium in the elderly, right? Which is again very hard, very hard to treat. So hopefully that's something you understand. And then stressing continents is just like if the pressing exerts any kind of effort or the increase in drop, the more pressure is for you reason. They then just, you know, begin to kind of like release urine in small spirts. The big thing I'll say is for the most part, right? These things tend to arise like when a person has like nerve injury, let's say they've had like some kind of your logic surgery, right? Or let's say they've had like multiple, let's say they've had like, you know, like multiple, like deliveries, right? So let's say it's a woman that's like G6 or some some ridiculous number or something like that, right?

If you see that stressing continent, you know, you want to consider doing like a TIGL exercise, right? Because those will strengthen those pelvic floor muscles. If for example, that is not, if for example, that is not cutting it, right? Then you can consider doing like the sling procedure, right? It's literally literally like a sling that just suspends the, suspends the urethra, right? And they're overflowing continents, right? Like these people, they'll have a high positive weight as it will, they'll have like super big bladders, right? And basically here, it's almost like the opposite of the problem you have in urgent containers, the trusom muscles are hypotonic, right? They don't sense when they're full, so they don't contract, right? So again, for the most part, you can do like, for these people, you can do like a, you know, you can maybe consider like self-catheterization, you know, like time-void in and things of that nature, but that's all I'm going to say about a or flow of in-continent. So again, hopefully it's something that you understand, right? And I mean, there's another kind of in-continent, it's called like a functional in-continent, basically it's like a person that has like an old person that has like, they can move for whatever reason, like they have like really bad arthritis, they can move or they have like a cognitive problem, right? And typically the thing that will happen is these people like they will give you like everything is normal, right?

Like, oh, they don't have any like increased urge to go to the bathroom, they don't have any blood problems, they don't have any sphincter problems, right? But they cannot get to the toilet in time. If you see that, think about something called again, functional in-continents, right? And again, for these people, you essentially need, they need a caregiver, they need help to avoid regularly, they need timed voicing, again, that's another common one. And also if you can put like a commode by the bedside, that's something that also tends to help, tends to help these, tends to help these folks. So that's a big topic to keep at the back of your mind for tests. And again, try to avoid those anti-colonial energies that will use for urging continents because you can trigger delirium in the elderly, right? And then like if you're doing in terms of like end of life, like care or whatever, right? The thing is you want to hold this discussion, especially when the person is like medically stable, when the person is like cognition is intact, right? Now there are some terms here, I think I'm going to go ahead and define to that you make sure you actually kind of like understand them, right? So what are these terms, right? The first term I think I want to define is something called the the living well, right? So the living well, sometimes people call it like the what's the other name? What's the other name for this stuff?

Yeah, living well, sometimes it's actually called, yeah, it's actually sometimes called the the is actually called the advanced directive. Yeah, it's actually called the advanced directive. So yeah, living well, yeah, it is sometimes called advanced directive. And basically, right, it you essentially talk about things like do you want any measures to prolong your life? Do you need like artificial nutrition? Do you need like to keep remaining on a ventilator, right? If for example, the patient like, you know, becomes incapacitated, they are not able to like say, they are wishes anymore. Living well, advanced directive kind of tells you exactly what to do in these kinds of situations that have highlighted, right? And then on that term, you need to understand and remember for your exam is something called like a healthcare proxy. Sometimes they are called like a DPOA, right? So like a durable power of attorney, right? Basically, the thing that happens is these people make decisions for patients when they're incapacitated, okay? They make decisions for patients when they're when they're incapacitated. Um, oh, and the thing is, let me maybe go ahead and say this thing about these healthcare proxies. So these healthcare proxies is not like they're the endow bill, right? The thing is, when a healthcare power of attorney, look, look at the name, healthcare power of attorney, or healthcare proxy, whatever, right? A durable power of attorney.

All these people do is they make decisions on healthcare. They don't make decisions on any other stuff besides healthcare. And the thing is, when the person's like the old person's like decision making process kind of comes back, then the powers that this healthcare proxy has essentially goes away, right? That's kind of different from a person that has like a full power of attorney, a full power of attorney can make decisions that include healthcare and other stuff, right? Then when the old person's like cognition comes back, like the decision making capability comes back, you don't necessarily need to, you don't necessarily need to like say, okay, this person with a full power of attorney cannot make decisions anymore. That's actually a high old difference to keep at the back of your mind, for example, right? So knowing the difference between a healthcare proxy and a full power of attorney, and then there's this form that's called like the post form. I feel like in, like I remember, like I went to Mexico in Maryland, so I went to Hopkins, from Mexico. There's in Maryland, they had like their most, but just think of like the post form. That's probably that's likely what you'll be, because I mean the MBME exams are not written for the state of Maryland, the origin for the whole country, right? So think about like post form, so POLST, right? Basically POLST means physician orders for life's sustaining treatment, okay?

Basically the thing that happens with these post forms is you usually sign them when a patient is like super, super, super old, right? Or a patient has like a terminal illness, right? Where they have like a stage four long cancer or something like that. Basically, it essentially is almost like a menu where you say, okay, this is what I want to be done. If an emergency, if I need emergency treatment or an emergency scenario where to pop up, right? Let's say like, oh, this person was doing well and then boom, they start crashing like within minutes, right? Like this post form tells you things like, okay, should we do CPR? Should we into Bates? Should we use antibiotics? Should we take you to the ICU? Right? Again, for the most part, the patient fills it out, but when the patient is filling it out, a healthcare provider has to be present. That's a very high-yalth thing to know. A healthcare provider needs to be present, right? And again, probably in the next podcast, I'll see some more things about palliative care. Well, basically, palliative care is something you institute. Or even like, I'll say like, palliative care if a person has like severe illness or whatever, you institute palliative care. But if, for example, a person is going to likely be dead within six months, that's criteria for initiating a hospice care in those people, right? So hospice care, don't forget the timeline six months.

If you suspect that a person will likely be dead, unfortunately within six months, then hospice care is something you need to begin to chat, chat about with those people. And then, basically, right? Like in terms of like driving, occasionally this kind of question tends to pop up on exams, right? But if a person has like mild, if you have an elderly person, a person has like mild dementia, or the person is taking a psychotropic medication like a benzo, or they are taking opioids for chronic back pain, or they're taking like a tricycle, right? Or the person has like really bad cognitive issues, really bad vision problems, they have like a history of like falling, right? They've had like a history of falls, or they have troubles like with like, um, like, they have trouble moving around, or they have like, you know, like a really bad stroke, or they can like, they have like some, you know, like, really bad like a degenerative disease, where they have trouble like rotating their heads from side to side, or they've had like, mutov equal accidents, these people in general should not drive on an MBM exam, okay? So you may have to actually report, usually what you do is you try to like talk to the patient first, but you may also have to report them to the DMV, right? So the department of mutov equals on an MBM exam, right? So again, those are how you think to know for tests.

Now, the last thing I think I'm going to talk about today, then I'm going to call it because this podcast is getting to about 30 minutes, is like this whole issue of pressure ulcers, right? So the thing is you want to know risk factors on MBM exams for developing pressure ulcers, right? So if a person is old, right? If a person has limited mobility, or they have again sensory issues like, they have issues with vision hearing, right? Or they have like a chronic illness, or they have like stool or like urinary incontinence, or they have like really bad like vascular disease, let's say like a person that smokes a ton, right? Or if a person is like malnourished, right? Those are all risk factors for developing like a pressure ulcer. Sometimes you see that referred to as a incubator ulcer, right? And they can have it like on the back of the head and things like that, right? And what are the three things that you need to essentially try to prevent so that people don't get pressure ulcers? One is you don't want people to apply continuous pressures to a part of their bodies. Number two, right? You want to reduce the friction between the patient and whatever surface they align on. And then three, you want to reduce share forces, right? So like the forces of share, S-H-E-A-R on the person's skin, right? And I mean like some things you can do, you can kind of turn the patient from side to side every two hours, you can use like an air-fluid diced bed, right?

That's something that typically helps. But I feel like I'm nothing that actually helps quite a bit here. And actually again, this is super high yield. And this is not just for the step two CK. This is actually something that pops up quite frequently on exams just from a perspective of like knowing like the different stages of pressure ulcers. They love to test these things, these things on medicine shelves as well. But basically, right, you want to know the four stages, right? So stage one is like this person just has like everything on the skin, right? And usually it's like, it's usually like non-blanchable, right? That's like a stage one ulcer. A stage two ulcer basically is like, you know, like you lose like a partial thickness of skin, right? But the most part it tends to involve like the epidermis and the dermis, right? And if they have ulcers, it'll be like, you know, very superficial, it'll look like a blister. It's usually pretty shallow, right? Versus a stage three, a stage three is when you've lost the entire layer of the skin, you've lost the epidermis, you've lost the dermis, right? You're beginning to see like subcutaneous tissue like even you're beginning to have like necrosis of the subcut tissue, right? But the place where the box stops for stage three ulcers is at the fascia, right? You do not see any prop like involvement of like bone or tendon or muscle if you see any of those things involved, that's a stage four ulcer, right?

So as the four ulcer, if you see bone muscle or tendon involved, that's stage four. If you notice that it's pretty deep, you've lost the epidermis and dermis and a sense of cutaneous tissue, that's stage three, right? And then stage two, right? Again, it's just like superficial ulcer, stage one is just a female like redness and it's like non-blanchable redness for the most part. And then one thing I guess I will just say so that this is I guess a little complete is, I remember I was talking about like this, like oh, let's say a person needs like a sorry decision maker, right? Like let's say they don't have like a living will or whatever or pound of attorney, you can basically use like the next of kin, right? And in general the way you, the thing you do is you ask the espouse first, right? Like the husband or wife, right? And then after that, if you don't see, if that's not available, you need to consider like the children, like the adult children. And then if the children are not available, you consider the parents, okay? If the parents are not available, you consider the siblings, right? And then if the siblings are not available, available, you can then begin to think of like other relatives, right? So spouse, right? Children, so spouse first, then children, then parents, then siblings, right? And then like, you know, like other relatives, if you don't think they mean we will like stretch it out that stretch it out that much, right?

And also one other thing I forgot to say is with this pressure ulcer, with the pressure ulcers, you want to give these people as much nutrition as possible, right? And in general, if a person has a stitched three of stitched for ulcer, you need to consider the bremedment, right? On your test, right? You need to consider the bremedment on your test so that again, they don't have sepsis or they don't get like a skin and soft tissue infection, like cidilitis, for example, right? And typically you want to apply dressings to you want to go ahead and apply like, you know, like some occlusive dressings and things like that, right? So yeah, I'll see for the most part, that's all I'm going to say about pressure ulcers. I hope you find this podcast to be helpful. Again, as I do at the end of every podcast I offer, one on one, and a large group tutor, in for step one, two CK, two CES, step three, pre-clinical medical exams, 30-ish-elf exams. If you're a medicine resident, I need tutoring for the internal medicine, training exam or the IBI-I-M board exams, offer tutoring for those. And then I do these booster courses, right? It's 20 hours for a step one, and 15 hours for step two CK and step three, we are going to review the most notes. It's one on one. We review the most notes that are very necessary for you, you taking any of those respective exams.

I've done this with a ton of people, and all the people have done it with a found it to be extremely helpful and extremely high-yout for the exams. And at least God will enough, got in a pretty good track record with people have tutoring for these USMLA exams. And then if you're a college student, I need tutoring for like Gen CAM, O-CAM, Physics, Bio CAM, Histology, Physiology. Again, I offer tutoring for all those things. I tutor for the MCAT. And then finally, I do like this coaching. So if you're like a medicine and applying to a residency, so like an ERAS application, or a college student applying to a medical school, so like an AMCA application, I do one on one like almost like consulting, right? So like rec letters, personal statement, editing, editing applications, more interviews. Again, I've worked with tons of people, and the vast majority of people I've worked with have all much of the first choices. And I have like one year's worth of admissions committee experience at a top two-med school, right? So again, if you need any of those things, feel free to reach out to me, either through the website, or you can send me an email at the Vine Intervention Podcasts with an S at gmail.com. So have a wonderful day. God bless you. I'll see you in the next podcast. Thank you.

Functional status assessment (AD Ls/IAD Ls) and screening for key deficits (hearing, vision, cognition).

A score less than 24.

The Get Up and Go (TUG) test; a time greater than 12 seconds (or >20 seconds, depending on the source/specific protocol mentioned) suggests increased risk.

Anticholinergic agents (e.g., oxybutynin).

Presbycusis; high frequencies are typically lost first.

A Healthcare Proxy only makes decisions regarding healthcare, whereas a full POA can make decisions about all aspects of life (financial, legal, etc.).

Activities required for basic self-care necessary to live independently at home (e.g., showering, dressing).

Complex activities needed to function and interact with society in the community (e.g., managing finances, grocery shopping).

Pelvic floor muscle strengthening exercises (Kegels) and timed voiding/bladder training.

The Mini-Cog test.

Continuous pressure, friction, and shear forces.

When the patient is expected to live or die within six months.

Physician Orders for Life-Sustaining Treatment.

Activities required for basic self-care necessary to live independently at home (e.g., showering, dressing).

Complex activities needed to function and interact with society in the community (e.g., managing finances, grocery shopping).

Pelvic floor muscle strengthening exercises (Kegels) and timed voiding/bladder training.

The Mini-Cog test.

Continuous pressure, friction, and shear forces.

When the patient is expected to live or die within six months.

Physician Orders for Life-Sustaining Treatment.