DIP Episode 379 - A Series of HY “Elderly Vignettes” for Step 1-3

Okay, welcome. My name is Divine. This is episode 379 of the Divine Intervention Podcast. And to this podcast, I'm going to be continuing the rapid review series for the USMEL Step 2 C and Step 3 exams. This will be Series 72. Now if you're taking your Step 2 C or Step 3, completely level 2 or 3 exams, anytime within the next one month, I'll encourage you to sign up for the courses I have next week. I have an MBA me testing and strategy scores on Monday the 21st of March. It's going to be from 2 to 4 30 pm Pacific Standard Time. Again, many people have taken these courses. They've done extremely well for exams. And then, and I have, you know, a podcast and announcement podcast I made where I discussed it in detail. And then I have a 24 hour review course. It's going to be taking place from the 22nd of March to the 25th of March. If you're interested in signing up, just shoot me an email through the website and I'll give you some more information on these courses. And then if you're taking your exams in the summer, I have a school that's running. It's a 75 hour school. First, Step 2, Step 3, completely level 2 or 3. That one has a 40-person cap on it. If you're interested in signing up, just shoot me an email through the website and again, I'll be happy to give you some more information. Okay, so what if they give you a question about a person that is 79 years old? And they tell you that he has, you know, Pylon of Fridays. And he has to be pleased on Gentile Myse.

And then the NV Me then poses a question and says, compared to a 29 year old, which of the following has to be adjusted. Well, I really hope that you keep in mind that the person that is older should get a lower dose of Gentile Myse. So what's the reasoning behind that? Today, I'm going to discuss just, I kind of am going to have a focus today on just like weird stuff that people just don't really prepare for. You're very hard to see many resources. But in the just shop as these like out of the blue questions on the, on the USMT. So why in the world are we going to be reducing the dose in this older person? Well, we're going to be reducing the dose in this older person because as you get older, your GFR goes down, right? Your GFR is supposed to reduce as you get older, right? So because your GFR is going down, your creatinine clearance is actually also going down as you get older, right? So since you're not able to clear drugs as amazingly as you wear when you were younger, it typically makes sense to reduce the dose of many of these rainily cleared medications. And fact, this question can just be an indirect way of your friends at the MBM is testing drugs that are cleared rainily, right? So don't forget, right? Like all drugs that have like never toxic effects, right? Drugs that have never toxic effects, right? So think of like you're metformin, right? Think of your lithium.

These are drugs that you need to, you know, think twice before it's that giving mega doses to people that are that are old, right? Just something to keep in mind. So your GFR goes down, your creatinine clearance goes down as you age as you get older, right? And again, just, you know, knowing the other things that happen as your age, you know, it's probably important for your exams, not probably. It is important for your exam, right? Like as people get older, right? Their blood pressure is just rise in general, right? Because if you think about it, as you get older, you know, your older is not as elastic as it should be, right? When it's not a last is when it's not as elastic as it should be, it's not able to like expand in and you know, it's not be basically able to wiggle in response to increase amounts of blood flowing through it, right? So in general, people that are older, they actually tend to have elevated blood pressures, right? People that are older tend to have elevated blood pressures. Just one of those, again, strange, but high old things you want to keep at the back of your mind, for example, right? And really, if you're wondering, hmm, what happens in the lungs of a person that is old, to be honest with you, just kind of think of it as like just remember the changes that happen in people that have like, infezima and you being good shape, right? Obviously, they're not going to be as bad, right?

They're not going to even be half as bad as the infezimato patients, right? But they certainly have those problems, right? So remember, as you get older, right? Your lungs are not going to be as elastic. Let me just tell you this, most of your organs just and not as elastic when you get older, right? I mean, an easy way to think about it is just think of a person that is like, I don't know, like a gymnast or something really young, right? Just put this mental image in your mind. You see how flexible these people are? It's almost like any part of your body that can turn, right? But again, it's really hard for you to see people, you know, competing in the Olympics in their 80s doing gymnastics, right? Just not flexible. Things are just not, again, I'm not trying to crap on anyone here, so please don't take this the wrong way. I'm just trying to give you very vivid mental imagery so that you can remember this for your exams, right? You don't see like 80 year olds, you know, competing for, you know, gymnastics, just not flexible, right? So the thing is the lungs, they're not they're not they're not as elastic, right? So they don't snap back as well, right? They are very good at expanding, but they don't snap back as well, right? Almost like an disruptive lung disease picture as you get as you get older, right? So things like your FIV1 is going to go down, right? Your FIV1 is going to go down when you get when you get older, right? And your FRC, right?

Your lung capacity is going to go up, right? It's going to go up. It's going to go up. And as people get older, they appeal it to A02, right? It also kind of goes down. Because again, just the gas exchange is just more as efficient as it is before, right? And then again, if they give you like really like, let me just actually just go ahead and discuss some old people with me, because these are things I don't know, I feel like I've seen a lot of people just getting many of these questions wrong and you don't have to get any of these things wrong, right? So let's maybe focus on old people's problems, right? How's that? How's that? So, you know, what if they give you a question about like a person that is like 75 years old, you know, and he has this knee pain that is making it hard for him to go in the mornings, he's had this problem for the last few months. Even if that's all the detail they give you in the question, what should we be thinking about? I hope you're saying old divine sounds like this person probably has osteoarthritis, right? This person has osteoarthritis. This person has osteoarthritis. And remember, osteoarthritis is probably like the most common joint disease in the elderly, right? It's probably the most common joint disease in the elderly, right?

Or, you know, they give you a question about a person that is old and detailed that, oh wow, on their skin, you notice some echinosis and some proper, and you notice that they're, you know, they have like decreased skin turgor, like what's going on there? Again, the thing that has happened is that they've lost a lot of their skin elasticity, right? A lot of fibers that contribute to skin elasticity, they break down as a pressing edges, right? They break down as a pressing edges. So the thing that's going to happen is that their vessels, the blood vessels in the skin become very unstable, right? And they become unstable, they're going to like rupture easily, right? So they're going to get BTI, they're going to get proper, they're going to get all those problems easy, they're going to get decreased skin turgor, right? Again, if you're a medical student, let's see your, you know, your young or something, and you feel your skin, you know, you see your skin feels very tight, very tough, right? But as the pressing gets older, everything just kind of gets wrinkly. Again, that's just the thing that happens as a pressing gets, as a pressing gets older, right? Or you see a woman in her sixties on your exam, and they tell you that, man, this woman, she's coming in because she complains that, you know, sexual intercourse with her husband is getting more painful. Well, what's causing that? It's going to be the low estrogen, right? Because think about it.

Again, I'm just trying to make integrations across things as I go out, no, no, no, right? If you think about it as you get older, your ovaries become, you know, nonexistent, basically, right? They don't work very well. They don't work very well, right? You're not, your granulosa cells are not there anymore, you're really making an estrogen, right? So your vulvar and vaginal epithelium, they're not going to be well maintained. And they're not well maintained, they're going to be atrophied. If they're atrophied, they're having been trading intercourse. It's really going to hurt, right? It's really going to hurt, right? So sometimes they can even give you some of these endocrine questions, right? Where you see the asking you, they're giving you all these arrows and you're wondering, hmm, what should the arrows look like in an old female? Well, your estrogen should be low. If your estrogen is low, then there's no negative feedback, right? So all the things that compare to that, your gonadotropins are going to be high, right? So like, for example, your gene average is going to be high, although that's kind of unreliable, because remember, it kind of has like weird secretion patterns, right? Well, your FSH and LH are going to be high as well. But I'll say for producer of exams, gene average is high, FSH LH is high, right? So sometimes, instead of even doing that, it can just put an answer that says hyper gonadotropic hypogonadism, right?

That's something they can put hyper gonadotropic, right? The gonadotropins are high, but the estrogen is low, right? So just something to keep in mind, right? Now, we've looked at things from the female side. Well, on the male side of things, what happens when you get older? The thing that happens when you get older is that you're going to have, you know, it's going to be a male that, you know, has like lower abdominal pain, happens a few times a month, you know, it's completely novurinary dribbling. You notice that this guy's creatinine is creeping up a bit, right? And then they ask you for the most likely mechanism behind these problems, right? And I would really hope you're saying, oh, you know, this person has like hyperpleasure of the of the prostate, right? Priscilla's BPH. Again, BPH, right? The prostate gets really big. And as he gets really big, he's going to squish your prostatic urethra. If you squish your prostatic urethra, it's going to be really hard for your bladder to drain, right? So you're going to start having urinary steases. That urinary steases is going to produce positive to having infections, right? And it's also going to cause like urinary tension. And you're essentially having like an obstructive urethra. Right? You're having like your obstructive urethra. When you have obstructive urethens, you're going to have a lot of problems with your kidney is draining well. So that can begin to cause like chronic renal failure.

Your creatinine can start going up, right? And for this BPH, what are we going to do? Well, for BPH, remember, the first thing you do, if they have like a kidney renal retention, they're very symptomatic, lower abdominal pain. They are just going to go ahead and perform like a catheterization right there and then dread off all that P. They're going to feel great really fast, right? But you can give them an alpha one blocker. That's always helpful, right? So things like Prasocene, Noxazocene, Tamsulocene, those things, the block alpha one receptors. So they're going to open up that urethro's fincter so that the bladder can drain, can drain better, right? Those are things that can help them in the short term. Although remember, those drugs, you want to think twice about giving them to people that are taking another powerful visual dialyde, right? Because you don't want problems with orthostatic hypotension, right? So if the Prasocene and CHF or the Avangin and the Atikin nitrates may not be the best idea to put them on now, an alpha one blocker, right? Or let's say for example, you know, they have like erectile dysfunction and they're like on cell-denafil. Again, combining that with an alpha one blocker is not a great idea at all, right? Or let's say for example, they have hypertension and for whatever bizarre reason they're on hydrozene. Again, that's a very powerful visual dialyde, not a good idea in those people.

And I guess another group you can also keep in mind are people that are low-dipine, right? I'm low-dipine is a pretty powerful visual dialyde, right? You don't want to be giving it to people that are taking another powerful visual dialyde, like an alpha one blocker. Again, that can raise their risk of orthostatic hypertension. And to be honest with you, the NBM is sometimes they like to bring in a psychic relationship here, right? So it can be a person that again is going to be placed on a, it's going to be placed on an alpha one blocker. But they are taking some psych med, they are two psych meds in general that you want to, you know, really think long and hard before putting them on board in a person that is taking an alpha one blocker, right? So for example, right, tricyclic antidepressants, you've probably heard me see this in multiple podcasts, but these tricyclic antidepressants have these anti-harm side effects, right? What in the world does anti-harm mean? I promise we're going to get back to BPH. But again, the H stands for anti-H1, right? So the cost solution, because they have anti-histamine energy effects, that is stands for anti alpha one, right? So they can cause orthostatic hypertension, cause the presence to be dizzy and all those problems, right? And then the M stands for anti-muscarinic, right? So they can cause an anticolynergic toxic drop, right?

So we can get this with tricyclic antidepressants, but don't forget, we can also get these anti-harm side effects in people that are taking these low-potency first-generation anti-psychotics, right? So it drops like chloropromazine, right? Remember, chloropromazine is spelled as CHLOR, P-R-O, M-E-Z-I-N-E, M-E-Z-I-N-E, right? So chloropromazine, right? So these are all things you should not comment with an alpha one blocker. Promazine is just one of those things they love to test on exams all the time, right? So let's go back to BPH, right? So you're given alpha one blocker, but if you want to help them like long term, you know, what are you going to do? Well, the thing you're going to do is you're going to put them on on a five-offery doctorate inhibitor, right? So it drops like finasteride, you testeride, cause remember, five-offery doctorate is an enzyme that converts testosterone to DHT, right? And DHT is responsible for the growth of the prostate, right? That's like an embryologic factoid, right? So if, for example, you know, you give a five-offery doctorate inhibitor, you're going to decrease DHT synthesis. Over time, that's going to shrink the prostate by about 50%, it just takes a few months. So that's not something you're going to be hoping and praying for acute solutions to their problems, right? It's something you want to think more about when you're dealing with, you know, long-term treatment.

And again, if all these measures fail, I don't forget that you can do surgery, right? You can do something called TURP, right? Trans-Urithro, right? Resection of the prostate, right? Trans-Urithro, a section of the prostate, right? And again, I guess from the female perspective, what I talked about with this vaginal atrophy, right? Don't forget, you can give them like estrogen creams, estrogen lubricants. Those things work pretty well in these circumstances, right? And then another thing I should also say, I guess if we look at it from the male perspective, right? As a person gets older, the levels of testosterone actually go down, right? So remember, women also have testosterone. I don't know why people think that, ooh, testosterone is a gift for only men. No, come on, women also have testosterone. But remember, in women, testosterone controls their libido, their sex drive, right? So woman's sex drive actually over time, as she gets older, you know, again, as her ovaries kind of shrivel up, you know, they go down. The testosterone, your sex drive goes down, libido goes down, right? Or if you see a woman that has a T-HPSO, right? A total abdominal hysterectomy, and bilateral salpingo-oferrectomy, I'll say that again, a total abdominal hysterectomy, so it next to uterus, bilateral salpingo-oferrectomy, so you remove the ovaries and the fallopian tubes, right? The woman's libido is going to calm down, because you're literally taking away a source of testosterone, right?

Remember, a woman has cells that produce testosterone in her ovaries, right? But also for men, you know, as they get older, as they get really, really old, that the testosterone actually goes down as well, right? That testosterone actually goes down as well, right? So many times, you can notice, like, atrophy of the testicles in an older guy on exams, right? Although, I'll say probably one of the most common causes of atrophy of the testicles on in-beaming exams, it's going to be a guy that's using like, these synthetic anthrogens to try to bulk up, right? So you see these people, they look very muscular, they look very tall, big, buffy, right? But they have like very small testicles, right? That's usually, again, that's usually like the cause of testicle atrophy on on exams, right? So, again, these are just all things to kind of keep your mind, and you know, if you also look at an old person, right? And they tell you that, wow, they're having trouble like reading signs at night, and they can see very well, right? You want to think about cataracts, right? Again, it's an opacification of the lens. This is actually one of those things on in-beaming exams, where all you need to do is just do a lens replacement, and the person will be fine, right? Cataracts classically happens in old people, right? And it's one of these surgeries where you don't need to do any pre-op testing in general, right?

Cataract surgery is characterized on in-beaming exams, as you know, pretty low risk surgery. So, you need to do any like crazy stuff on exams. All you need to do for these people is just have them have the surgery, and that's it, right? So, doing all this cardiac testing, and many times they will, you know, also just give your hint in the question that, you know what, this person is not like super unhealthy, but for the most part, things like cataract surgery, you're not going to be moving, moving mountains for the surgery. Just go ahead and do the surgery. It's pretty low risk surgery, right? And they'll be fine after all you said and done, right? Well, you see a person, and they tell you that, you know, it's an old guy, and you know, he has to crank up the TV a little bit more. In fact, to be honest with you, even if I said that this is rapid review series 72, I'm not going to call your rapid review series 72, so it doesn't get lost in the rapid review series. I'm just going to call this podcast high-yield elderly people vignettes for the exams. I'll mix series 72, because I feel like I've been focusing almost exclusively on old people. So I'm going to just kind of stick with that. It kind of looks like a topic that keeps expanding. The more I talk about it, the more I get other ideas as to, wow, this looks pretty, pretty high-yield. So we're just going to keep going forward with the old people.

So, right, they tell you that, you know, there's this old guy and he loves watching golf, right? It's meaning, you know, people do, you know, loves watching golf, loves watching basketball. But you notice that he has to crank up the television to allow the as possible setting these these, right? What's going on? So this guy has pers bicuses, right? Remember, it's like high-frequency hearing loss, right? High-frequency hearing loss is something that's pretty common in people that are old, right? Because over time, right? A lot of those hair cells in the inner ear, right? They begin to degenerate, right? So because they're not working as well as they should, right? You begin to lose hearing at high frequencies, right? Although, remember, if you listen to pretty loud music over time, you're also going to start losing a lot of your hearing. It's just something to kind of keep in money, right? So I know medical students love this, put it in my, put it in headphones, crank it up to the top. That's not, you do that for a couple months, couple years. You're going to be paying a price after all you said and done. And then, remember that as people get older, right? Again, they're not going to be smelling as well. They're not going to be smelling things well. The T-sensation is not going to be as robust, right? Again, because again, many of the taste buds, right? They begin to, like, the activity kind of reduces as they get older, right? The activity reduces as they get older, right?

They have all factory neurons, again, they don't work as well, right? Those cells that sense smell, they don't work as well, right? So your smell, sensation, your T-sensation, it actually begins to go down as you age, right? It begins to go down as you age. And then, remember, right? As the pressing gets older, right? They start getting, they start having a high risk of all these skin cancers, right? Because again, if you think about it, your skin becomes more paper thin as you get older. So ultraviolet rays are just able to penetrate, penetrate, penetrate amazingly well through your skin. Well, if these ultraviolet rays can penetrate really well through your skin, they can start getting many of these skin cancer problems, right? Like, actinic aerotosis, you can get in an old person, it's usually going to be an old person that's very outdoorsy on exams, right? They're going to have like, actinic aerotosis, although remember, most people would have actinic aerotosis, they get better, right? That's the most likely outcome. Classic exam question there. But, you know, actinic aerotosis can certainly be comes from a cell cancer of the skin, right? And being a scrimal cell cancer, I really hope you're saying, oh, divine, you know, when we cut out these cancers and look at it histologically, we're going to see keratin pearls, right? keratin pearls. When we're keratin pearls are characteristic of scrimal cell cancers on one exam, right?

And then if you also think about it, you know, they can get bizzle cell cancer. Again, remember UV light exposure is like the big, big, big, big risk factor here, right? Bizzle cell cancer. Remember, bizzle cell cancer, actually the most common skin cancer, right? This one can get melanomas, right? Just things to kind of keep in mind. And one thing I guess I'll just throw in here, right? Remember, whenever you see an African-American with melanoma on NBM Es, many times it's usually going to be the type that you find in like weird places, right? Like under the nails or something, right? That's the one that's called acral lentiginus, right? To be honest with you, there is a ton of melanomas. But really, for the most part, there are two big ones that our friends at the NBM Es love to focus on. They love to focus on acral lentiginus, right? Acral lentiginus in black people. But then they love to focus on lentigum maligna in normal people, right? Like in Caucasians, right? Let me not say normal people, but people that are non-black, right? lentigum maligna, right? So that's just something I want to keep at the back of your mind. Those are like types of melanomas you want to be able to regurgitate on on your exam, right? When people to regurgitate those on your exam, right? And again, if you want to look at the immune system, right? Many of these people that are elderly, they have a lot of problems with generateane cell-mediated immunity, right?

So they become more and more susceptible to these hunky, punky, like really strong infections, right? They can't really deal with it because the number of your CD positive T cells actually kind of goes down as you age, right? So again, they're cellular, your cellular immunity being able to deal with viruses, being able to deal with malignancies because remember your T cells have an anti-cancer effect, right? I hope you know that, right? Your T cells, they have an, I mean like they're maybe all these T cell therapies these days, right? But they have an anti-cancer effect and also the mess-up viral infected cells because if you think about it, what would that get like shingles? It's really going to be like elderly people, right? Or malignancies just go up more as you get older. Why? Because again, your T cells, your semi-duty immunity, it's just not as great as it used to be, right? So that can increase the presence risk of getting our malignancies, right? And again, remember for a woman as well, you know, again, your estrogen is really low as you get older. So since your estrogen is really low, right? You're going to get like breast atrophy, right? You're going to get a lot of atrophy of the breast, right? So that's why as a pressing gets older, you know, the abracer no longer, you know, like a young woman's breasts, let's, let's live it at that, right? Like a young woman's breast, that just doesn't really, doesn't really happen, right?

And again, another reason I guess you can think of as to why a person that is older has a melanoma, I mean has all these malignancies is that the longer pressing leaves, right? This is a very logical explanation. The longer a person leaves the more time they've had for genetic mutations to accumulate, right? And once those genetic mutations have accumulated enough, right? Then the person can start having all these problems with malignancies and all those things. Usually for you to start getting all these crazy malignancies at a younger age, you really need to have some kind of cancer syndrome going, right? You know, like a linch syndrome or a leaf from an eye syndrome or a braca and all those, you know, bad generic problems, right? And again, if they give you a question about like, I don't know, like a 69-year-old female, she tells you that she has like this pain in her lower back, but you notice her calcium is fine, all her labs are fine, she doesn't have anemia, right? Pretty well-be-thing about like an osteoporotic fracture. Remember, osteoporosis is pretty common in people that are old, right? Osteoporosis is really, really common in people that are old, right? And most times when they get fractures, the most common sight of them getting these fractures in the vertebra, right? They get all these vertebra fractures and they kind of get in trouble, right? So as you get older, that's where you start getting osteoporosis and all these attendanta fractures, right?

And also, don't forget that as a pressing gets, as a pressing gets older, right? Their brains get smaller, right? They begin to have all these cerebral atrophy, right? You know, their brains just get smaller, smaller, smaller, right? So if your brain gets small, right? And I mean, it's not like your skull gets smaller, your skull is still same size, but your brain kind of gets smaller, right? If you think about it, let's say like a young adult human being, you know, their brain is like normal sized, right? So it doesn't like, it doesn't bang around the walls of the skull too much, right? Because it kind of matches the size of the skull, right? But as you get older, and you bring it smaller, and it just doesn't really match up the size of the skull anymore. The thing that's going to happen is it can start banking against the walls of the skull. And those veins that connect like your brain to certain parts of your meninges, they begin to, you know, twiddle around, twiddle around, twiddle around, right? And if those bridging veins, you know, get popped, you're going to get the person is going to get a subdural hematoma, right? It's going to get a subdural hematoma, right? So that can cause like a hemorrhagic stroke, right? So just something to keep in mind, usually it's going to be like an old person that is a big alcoholic, right? Because what does alcohol do to the brain?

Alcohol kind of shrivel, especially if you're a chronic alcoholic, it's going to shrivel up your brain, right? That's going to raise your risk of subdural hematomas. And you know, don't forget it, right? Again, all these dementia is also happening as people get older, right? Like the most common dementia, obviously, it's going to be Alzheimer's dementia, right? You're going to see these bidamiloid plaques. You're going to see all these neurofibrillary tangles in the brain. Remember, those bidamiloid plaques are like bid depleted sheets, right? If you look at them under electron microscopy. So some of those weird things you see on the exam, bid depleted sheets. And the last time I learned this was in first year of medical school and you're like, whoa, what happened on this USMLE? We better keep it in mind. Only mentioning it's in a step two, CK step three podcast, if it was not relevant, right? So again, you can get dementia, or if you see dementia with all these neurodeficits, it's almost like one year, one trouble, or every six months, one trouble. Like these symptoms of these neurodeficies that just seem to crop up like every year. And you want to think about like a vascular dementia, right? Vascular dementia, remember, that's the second most common cause of dementia. And you know, don't forget, don't forget, right? That vascular dementia, sometimes on exams, they can call it a multi-infarked dementia, right? Again, the NBM is these these, right?

This is something I emphasize in my review courses and in my test against strategy scores. They love to give these derivative questions, these these, right? Where you know the concept, you know exactly what they're testing. But the answer you're looking for is just not there, right? So they can pull more time, factor dementia on exams. You just want to kind of keep that in mind. So I think these are kind of like the big things. And again, as people get older, they also start getting like type two diabetes. So I think I'm going to go ahead and stop here. Again, as I do at the end of every podcast, but really, this podcast, I'll actually quite surprise, but this stuff I actually discussed today, I promise you is like extremely high yield. You're going to get a few questions on this stuff on your exam. I mean, for me to rename the podcast and say, you know, you should really know the stuff. I promise you the stuff, very important. So I don't want to want to learn for the USML exams. Step one, step two, CK step three, pre-clinical medical exams, third year internship, shelf exams. I also offer tutoring for the internal medicine board exams and the internal medicine training exams. And then, I also help with your applications. I mean, today has been a pretty grateful. A lot of people that I worked with this past cycle have matched. So I'm really, really grateful for that. And again, for those that did not match, I empathize with your situation. Just do your very best in the soap.

I remember that opportunities pop up in many off-cycle spots. But if you need help and you're working against your next cycle with personal statements, recommendation letters, editing the application itself, reach out to me. I've worked with tons of people at this point in a wide range of specialties. People that have unique problems, like they fail the USML exam, they have no research, blah, blah, blah. I've worked with many of these people to really tune up the applications and they've done well as a result. And then, I have these review courses I offer. Can I offer a step two, CK step three review course, 24 hour course and MBA me test taking strategy scores. And then I have the 75 hour school that's going to be taking place in the first two weeks of the month of May. And then, I have these podcasts and all the major podcast apps, right? Apple podcasts, Google podcasts, Spotify. And then, I also have a You Tube channel called Divine Intervention USML podcast and videos. That's where I post the videos that I make. And then, I also have a new website called Divine Intervention Life Lessons.com. It's a website where I use Bible based teaching. So many of you listen to this podcast now, I'm a Christian. I use Bible based teaching and I've, you know, also the podcasts are like 10, 15 or so minutes long.

And I post like two or three every week where I just address like a problem that is very common in humanity, using a biblical perspective to address how those problems should be solved. You know, personal, relationship, things of that nature. I even have a podcast that goes with that is called the Divine Intervention Life Lessons podcast. It's actually an Apple podcast. So thank you for listening to this podcast. The one thing I'm just going to say as almost like a mini-life lesson today is to look forward. To look forward. The thing is, many people, their problems are their past. And I guess maybe I'll look at it from two perspectives. Some people, the hang on so hard to the mistakes of the past. They keep defining who they are now. Remember again, the person you were in the past doesn't necessarily mean you're going to be that person forever. Right? There are people that turn their lives around. Right? In fact, if you do Google search, you know, look on Reddit. Just do a search for like, you know, greatest turnaround stories. You're going to see like these massive threads. Of people that just took certain key steps, right? But these key steps, they took where like looking forward steps. They took certain key steps and their lives have just gotten better. Right? So the thing is, you may have lived a terrible terrible life so far. You may have been feeling many exams. People may have written you off. They may have said, man, this person is a failure.

You can never, there's nothing good that can ever come out of this person's life. But I mean, encouraging you. Just ask yourself, why am I going wrong? Meet changes. And start looking forward and forget the past. Right? Start looking forward and forget the past. That's one thing I'll just really encourage you to do. Right? Again, don't let your past define you. Don't let your past rule you. Right? You can always make a brand new, wonderful, amazing end for yourself. Again, that's one of the blessings I have as a tutor. I've worked with people, I've seen people have these great turnaround stories. I see people go from getting in the 190s on step one to getting in the 240s to 50s on step two CK. Right? Their lives have just been completely turned around because they started taking forward fishing steps. They didn't keep valuing in self-PD because you see many people these days they like to throw these PD parties. Right? These PD parties, you're going to feel good for a few hours because people are consoling you. But the problem is going to be there. Right? Nothing is going to change until you start taking steps. And then another perspective with this past is stop dwelling on your past successes too much. There are some people that after the heat-serting levels of success in life, they just almost like stop trying. Right? Like, I'll give you an example. Right? Like for an MS4. Let's say you crush step one, you crush step two. Let me tell you this.

When you get into residency, no one really cares about your scores anymore. Like life has changed. Like you need to start being a good resident. You need to be like, you know, like actually like good at patient care. You need to be good at your training exams. You need to pass your board exams and all those things. Right? So just kind of keep that in mind. Don't let that. Okay. I got in the 27 days on step one and step two CK, which again, nothing to sneeze at, right? It's a great, great series of scores. But like just tell yourself that, okay, residency, I'm actually going to work hard and apply myself so I can do well, right? Because again, at the end of the day, your scores don't matter if you're if you're a bad physician. If you don't take good care of your patients. So I think I'm going to go ahead and stop here. But remember, you can make a brand new end, right? I love, you know, how that possible Paul in the Bible says that, you know, I let go of those things that are behind me. And I press on, I press on, I look forward. One thing I do, I forget, right? Let me tell you this for forgetfulness is an intentional process. There are certain things you have to choose in your mind that you will never remember. Like give yourself a measure for those things. Give yourself a measure for your past. As that looking ahead towards the future, right? You may not be able to change the past, but you can look ahead to the future and make a good decisions, right?

And I really pray that everything goes well with you. So for those that, you know, match today, congratulations, you know, I'm hoping that on Friday, you get that very also awesome news of you matching into your dream program. So until next time, thank you and God bless you. Bye for now.

Osteoarthritis.

Because age leads to decreased GFR and creatinine clearance, impairing drug elimination.

Chronic alcohol abuse/Alcoholism (due to cerebral atrophy stretching bridging veins).

High FSH and LH, but low estrogen.

Acral lentiginous melanoma.

Alzheimer's (Amyloid plaques/Neurofibrillary tangles) and Vascular dementia (Multi-infarcted).

Low estrogen leading to vaginal and vulvar atrophy.

Tamsulosin, Alfuzosin (or similar agents like Silodosin).

Lentigo maligna is often seen in non-Black/Caucasian patients; Acral lentiginous is common in Black patients.

Vascular dementia.

Breakdown of collagen/elastin fibers (loss of skin elasticity).

5-alpha reductase; Inhibitors include Finasteride or Dutasteride.

Low estrogen leading to vaginal and vulvar atrophy.

Tamsulosin, Alfuzosin (or similar agents like Silodosin).

Lentigo maligna is often seen in non-Black/Caucasian patients; Acral lentiginous is common in Black patients.

Vascular dementia.

Breakdown of collagen/elastin fibers (loss of skin elasticity).

5-alpha reductase; Inhibitors include Finasteride or Dutasteride.