DIP Episode 332 - The Clutch Pleural Abnormalities/Effusions Podcast

Okay, welcome. My name is Divine. This is episode 332 of the Divine Intervention Podcasts. And in this podcast I'm going to be talking about plural abnormalities and the USMELY exams. plural abnormalities and the USMELY exams. This podcast is just one of these podcasts where the topic sounds very benign. But this is probably going to be one of my easy like top 15 highest year podcasts that I've ever made. This topic, the MBM actually finds some nice ways to test this information. So this is something I definitely recommend keeping in mind if I were you. This is something that you should absolutely expect to see a question or two. Actually many times you'll be more than two questions on an exam. What's step one, step two, see case step three. So it's just something you want to keep at the back of your mind for tests. So this podcast, before I go into it, as I said, I'll be in a very podcast if you're starting for the USMELY step two, see case step three exams. I know there's many people taking these exams over the next few weeks here. You know, ahead of the ERAS application deadline. I do offer an MBM Testicking Strategies course. Does taking place next week Thursday, it's from 2 to 430 p.m. Pacific Standard Time. And we'll basically use a bunch of questions because for me, I like to be a very practical person. So use a bunch of questions to talk about how to answer MBM questions. We'll talk about how to read MBM questions.

The key pieces of information to pay attention to in MBM questions. The way to avoid traps that the MBM classically says for people. We'll also talk about how to answer ethics questions. We'll talk about how to answer questions even if you're not completely sure of the material presented. We'll talk about lots of very practical high fidelity techniques for improving your scores on MBM exams. Again, I've had many people take these courses. Like literally, there's a recent example of someone that took the MBM Testicking Strategies course. And a few days later, they took a practice test and they bumped over by like almost 30 points. So these Testicking Strategies, they really help because the thing is the MBM is they're very consistent in the way they set up questions. So if you have a deep understanding of how they set up questions, you'll find that a much easier time like answering those questions correctly. And then I have a comprehensive review course taking place on Friday and Saturday next week. So that's the 13th and 14th of August. And in that course, we'll cover Peds, Surgery, Internal Medicine, OBEGIN, Psych Neuro, Biostat, Ethics, Communications, Professionalism, Multisystem, Processes, and Disorders. Again, I've had many people take these courses and do extremely well on their exams. So if you're interested, just shoot me an email through the website and I'll give you some more information on the courses I held over Zoom. But again, they've been very well received.

The very vast majority of people that have taken these courses have done really well. So this plural abnormalities podcast, I think the first thing to kind of go into is I'm basically going to be again just to keep myself organized. I'm going to be answering different questions as I go through this. So the first thing is what is a plural of fusion? Well, remember, we know what a plural of fusion is. Right? A plural of fusion basically is whenever you have a fluid collection between the visceral and parietal plurus. Because we know that the lungs has a pouch, right? Each lung has a pouch. It's encased by visceral plurus. And then on the outside of that, we have the parietal plurus. So if fluid collects there, that's going to be a plural of fusion. Right? So that's one key thing you want to know about a plural of fusion. Now the second thing I would like to talk about with plural of fusions are what are the classic physical exam findings in a person that has a plural of fusion? Well, obviously there's going to be fluid, right? Between the different plural layers. So we know that sound transmission is going to be limited, right? So you're going to have decreased breath sounds when a person has a plural of fusion. Right? And then that person's lungs will obviously be dull to percussion on exam. Right? So if you think about it, if you take an empty bottle and bang on the bottle, you get more noise from it than a bottle that's full. Right?

And then you're also going to have a decrease in your tactile frimidus. Right? You have a plural of fusion. So that's just something general to keep in mind. Right? So decreased tactile frimidus, don't ask for a caution and decrease breath sounds. So that's the second thing. Now the third thing is how do you diagnose a plural of fusion? Well, many times you diagnose it with imaging. Right? So many times if you get a chest x-ray, I mean, obviously the gold standard is a chest ct, right? But you really shouldn't be getting a chest ct for a plural of fusion on an embankment exam. Right? You should get a chest x-ray, right? Most times the chest x-ray will show you like the bluntness of the cost of frinic angles. Although if you want to even improve the sensitivity of that chest x-ray some more, one thing you can do is you can do it the cubitus chest x-ray, right? Because that will make the fluid layer and actually helps you detect plural of fusion that have much smaller volumes. And most times you have a small plural of fusion, you're not going to get much in the way of symptoms. Once you get about 300 milliliters roughly of plural fluid, that's where you begin to become symptomatic. Now the fourth thing I'm going to because I want to try to keep this podcast as short as possible because there are many different ways of present can really go with this is what are the two kinds of plural of fusion. Right? What are the two kinds of plural of fusion?

Well, and I'm going to discuss mechanisms, right? Again, many of these things, they're just things if you understand them, they don't need to sit down willingly memorizing tons and tons and tons of information. Right? So the first kind of a plural of fusion is that trans-videav fusion. Okay? First kind of plural of fusion is trans-videav fusion. And a trans-videav fusion, the key thing I will say is this usually arises from processes that are outside of the lungs. If you keep that in mind, that will really help you triage the different causes of a plural of fusion. Right? So the trans-videav plural of fusion arises from problems that are outside the lung. Right? First of all, it's an ex-videav fusion. It only happens from problems that are local, that are native to the lung. Right? Well, let me say some more things about the trans-videav fusion when people have trans-videav fusion. Usually arises again, like I said, from problems outside the lungs and those problems can come in two categories. One is problems in the body, like systemic problems that increase your hydrostatic pressures. Two, you can also get them from systemic problems that decrease your on-cotic pressures. Right? So basically things that modulates the starling forces in the body, systemically, can cause a trans-videav plural of fusion. So what are those things? Well, think about it, for example, if a person has congestive heart failure. Right? That's a problem outside of the lungs.

The thing that happens is the hydrostatic pressures in your pulmonary couplers will be increased and that's going to cause extroversition of fluid. Right? So obviously in those circumstances, the person is going to have a plural of fusion. You're going to have a trans-videav plural of fusion. Right? Another classic one, right? If we're looking from on-cotic pressure perspectives, if a person has like nephrodite syndrome, well, you're needing a lot of protein you're hearing. Right? Remember, proteins like albumin are responsible for holding on to the pressures, right? They contribute to the on-cotic pressures of your bloodstream. Right? So if you're getting rid of all that protein, then there's nothing to hold onto floating in your vascular tree. It's going to be, uh, that's going to cause more fluid extroversition. And that's ultimately going to lead to the person having a trans-videav effusion. Right? Well, think about it. What's the organ that produces albumin in your body? That's going to be a liver. Right? If a liver doesn't work, if you have cirrhosis, right? Again, protein in your body is going to go down. That's going to decrease your on-cotic pressure. That's going to cause a trans-videav effusion. Or if a person has like quashiochor, right? These kids are not consuming protein, right? If they don't consume protein, again, that's going to decrease the amount of protein in your body. That's going to lower your on-cotic pressure. Right?

If a person has, um, many triers disease, right? Whenever you have these protein losing gastropathy, it's like many triers disease or chronic cannabis syndrome, in those circumstances, right? Again, you're getting rid of protein this time for the most part in your, in your, in your poop, in your stool. So in those circumstances, again, that's going to decrease the on-cotic pressure of your bloodstream. And that can cause a trans-videav effusion, right? So those are all the things that in general, classically, on-name-beaming exams can cause a trans-videav effusion. And I want you to keep in mind that because these things are, these trans-videav effusions are almost like ultra-filtrates. Most times, they are clear, right? So if you're seeing a lot of cells in a plural effusion, you should probably not be considering that the individual has a trans-videav effusion. And also, if you notice that the glucose of that plural effusion is less than 60, then you really should not be considering a trans-videav effusion. Most trans-videav effusions on-name-beaming exams will have glucose is created and 60 milligrams per less than liter. So that's the first major kind of effusion. That's a trans-videav effusion. Now, the next major kind of effusion is an exudative effusion, right? So for an exudative effusion, right, it's going to contain lots of cells, usually. It's going to contain many times a low glucose. The glucose usually is going to be less than 60 in an exudative effusion.

A paramomonic effusion, so an effusion that arises in the setting of pneumonia, is going to be an exudative effusion, right? Most times, the things that cause exudative effusions are going to be like just straight-up infection, right? Bacterial infection, a fungal infection, a viral infection, TB, right? And also cancer, cancer allows to cause exudative effusions, right? So when people have malignant plural effusions, those are going to be examples of exudative effusions. Now, pulmonary embolite are examples of exudative effusions. Whenever a person has a PE and they have a plural effusion, that plural effusion is going to be exudative, right? P Es do not cause trans-videav effusions. I'll say that again because that's a common misnomer. In fact, I've said that like years ago back in the day, that OP Es can cause both trans-videav effusions. The answer to that is no, right? So more recent studies have actually shown that P Es cause exudative effusions. Because the thing is, when you have a PE, you have all this inflammation happening, right? So you're releasing all these cytokines and things of that nature. Those cytokines, they're going to increase your vasculoprimiability, and that's going to cause like solids and stuff to leak into your plural space, right? The thing that happens with P Es is an exudative effusion, right? So exudative effusions are going to be the thing called pulmonary embolite, cancers, right? So malignancies are going to be the thing called infection.

They're going to be the thing called plurmonic effusions. They're the thing called TB. Those things all cause exudative effusions. But it would be really nice if there was some really nice way of differentiating a transudative effusion for my exudative effusion based on the information that you're given. Because many times when a person gets a plural effusion on the ultrasound guidance, you're going to do a thoracent thesis, right? When you do the thoracent thesis, you get fluid and you send it off for analysis, right? So the thing that really helps in these circumstances is something called light criteria, right? Light criteria. That's the job of light criteria is to help you differentiate between a transudative and an exudative effusion, right? So how exactly does that work? Well, the way that works is, first thing's first, right? You're going to get information from the person's serum, right? And then you're also going to get information from the person's plural effusion, right? And then you compare those things. The first thing is that the ratio from the plurif... So the plurif repurting to the serum protein, the ratio should be less than 0.5, right? Basically, all these criteria that I'm going to state, if you meet all three, then you are transudative effusion. If you violate, even if it's just one, then you are an exudative effusion, right?

So from the transudative effusion perspective, the ratio of the plurif-free protein to the serum protein should be less than 0.5, right? An easy way to triage this is, if you notice that a person's plurif-free protein is more than like four milligrams per... Sorry, let me put it this way. If a person's plurif-free protein is more than like three, then that usually tells you that a person has an exudative effusion, right? Because a normal serum protein usually is between like six and eight, roughly, although the NBM is... they actually give you that value and exams, right? So the ratio between the plurif-free protein to the serum protein should be less than 0.5, to be a transudative effusion. The second light's criteria is that the ratio of the plurif-free LDH to the serum LDH should be less than 0.6, right? Again, for you to be said to be a transudative effusion. And then the third criteria is that the plurif-free... The plurif-free LDH should be less than two thirds, the upper limit of normal of the serum LDH, right? So let me throw out a number here. So let's say that, again, I'm just making up numbers here. Let's say that, oh, the serum LDH is 90, well two thirds of 90 is 60. The plurif-free LDH has to be numerically less than 60, for you to see that the person has a transudative effusion again. You need to meet all three of light's criteria to see that the person has a transudative plurif-free LDH.

So again, just to rehash again, the plurif-free protein to serum protein ratio should be less than 0.5. Second criteria is the plurif-free LDH to the serum LDH. That ratio should be less than 0.6. And then three, the plurif-free LDH should be less than two thirds, the upper limit of normal of the serum LDH. You need to meet all three criteria to be called a transudative effusion. If you violate, even if it's just one of those criteria, you're dealing with an exudative effusion. So those are the two major types of effusions and how to tell them apart from the mechanisms that I want to discuss. Now, the fifth question I want to answer is, what are pyromonic effusions? So the key thing I think I want to talk about, say is that pyromonic effusions, look at the name, pyromonic. So it's pyallel to a pneumonia. So a pyromonic effusion is an effusion that arises in the setting of pneumonia. If you see a person having an pneumonia, they have a pyrolyphusion, that's a pyromonic effusion. And by definition, a pyromonic effusion is a kind of exudative effusion. I'll say that again. A pyromonic effusion is a kind of exudative effusion. So that's the fifth question I want to answer. Now, because the thing is most times, when people have pneumonia, they release all these inflammatory factors because of the immune system cells that are there. So essentially, the thing that happens is that you increase in vasculoprimability. You increase in vasculoprimability.

So again, solids and stuff are going to leak out. So you're going to get an exudative effusion from that perspective. Now, the sixth question I want to answer is, what are the types of pyromonic effusions? The thing is, there are three types. And unfortunately, many resources mishandle the proper classification of this. Believe it or not, it was on cue banks mishandle the proper classification of pyromonic effusions. So you have three types of pyromonic effusions. I'm going to list it from the least batch to the most batch. The least batch is an uncomplicated pyromonic effusion. The middle ground one is the complicated pyromonic effusion. And then the one that is really, really bad is an empire. So let me tell you clearly on NV Me exams, how you differentiate between these three pathologies. Obviously, you're going to get thoracentesis. And then you're going to be looking at certain markers. You're going to be looking at the pH. You're going to be looking at the glucose. And then you're going to be looking at the presence of the absence of bugs. Okay? So let me explain how this works. For an uncomplicated pyromonic effusion, you're going to look, and the numbers you are remembering for pH are 7.2. The number you're remembering for glucose is 60. So for an uncomplicated pyromonic effusion, the pH of that plural fluid is going to be less than 7.2. So I'll say it again for an uncomplicated pyromonic effusion. The pH is going to be greater than 7.2.

The glucose is going to be greater than 60. And the gramsthening, you're not going to see any bugs. I'll say that again for an uncomplicated pyromonic effusion, the pH is going to be greater than 7.2. The glucose is going to be greater than 60. And you're not going to see any bugs on gramsthening. That's an uncomplicated pyromonic effusion. And the way you treat an uncomplicated pyromonic effusion is essentially with antibiotics. That's it. You don't need to do fluorescent thesis for an uncomplicated pyromonic effusion. Now the next one on the latter is a complicated pyromonic effusion. It's actually very easy to remember what you'll find in a complicated pyromonic effusion. For a complicated pyromonic effusion, the pH basically just reversed the signs of the pH and the glucose that we said for an uncomplicated pyromonic effusion. So for complicated pyromonic effusion, the pH is going to be less than 7.2. The glucose is going to be less than 60. And most times, you're not going to find any bugs on gramsthening. I'll say that again. Most times, you're not going to find any bugs on gramsthening for complicated pyromonic effusion. And how do you treat an uncomplicated pyromonic effusion? You're going to basically give those people antibiotics. But in addition to that, you need to do some kind of thoracent thesis. So again, for complicated pyromonic effusion, the pH is going to be less than 7.2. The glucose is going to be less than 60.

And usually, nothing always, but usually you're not going to find any bugs on a gramsthening. That's very important. In fact, I will tell you this. I will say if I were taking an ambient exam, I would go with not seeing any bugs. I will say that again. I would go with not seeing any bugs on a gramsthening. I would go with not seeing any bugs on a gramsthening for complicated pyromonic effusions. Now, for an empirema, basically an empirema is essentially the same thing as a complicated pyromonic effusion. But you're going to see bugs for sure on a gramsthening. So for an empirema, the pH is going to be less than 7.2. The glucose is going to be less than 60. And you're going to see bugs on a gramsthening. In fact, let me just pass this out again. Give you a definitive information. For an uncomplicated pyromonic effusion, the pH is going to be greater than 7.2. Glucose is going to be greater than 60. You're going to find any bugs on a gramsthening. And you treat that with just anti-biotics. For complicated pyromonic effusions, the pH is going to be less than 7.2. The glucose is going to be less than 60. And you're not going to find bugs on a gramsthening. And you treat complicated pyromonic effusions with anti-biotics and thyracentesis. Now, for an empirema, the pH is going to be less than 7.2. The glucose is going to be less than 60. And on a gramsthening, you're going to find bugs. And you're usually going to treat that with anti-biotics plus thyracentesis.

And sometimes for empiremas, you may also have to do decodication. Because sometimes the fluid is very like, calculated and things like that. So that's how I'm going to parse those three kinds of paranomonic effusions for you again. These things I promise you, they're actually very high up to no for, for example. So now the seventh question I want to answer is, what are some special kinds of plural effusions? You may see on an in-beam exam. Well, these are basically things where they will give you certain associations. And then based on those associations, you're like, oh, it must be this exact problem. So the first one is, if they give you a question about a person having a plural effusion, and they tell you that it's false smelling. If you see that, the first thing I want you to think about is that the present has an anaerobic plural effusion. So false smelling, because remember, anaerobic is a lot of fermentation. Fermentation smells, right? So if it's false smelling, it's going to be an anaerobic. Another classic one you may see on an exam is the metelier that a person, you know, was in a motor vehicle accident, or they just had a surgical procedure done, or they were in some kind of trauma. And then you notice that they have a plural effusion. And when you do a thyracentesis, you find like yellowish fluid, and you see a lot of triglycerides, right? Like the triglyceride content is like more than 110.

If you see that, I really want you to think about a chylothorax, right? Chylothorax, chylothoraces usually contain chylomicrons, right? That's where the triglycerides are coming from. Most times, you get that from transsectin, the thoracic dot. Okay, I'll say that again, most times, you get a chylothorax from transsectin, the thoracic dot. Now, what if you see a person having a plural effusion in its reddish, and you see a lot of red blood cells? If you see that on an endemic exam, I want you to think of this person potentially having a chymothorax. And he more thoraces actually treated most times with thoracentesis, right? Thoracentesis, thoracentesis, right? But one other thing that can cause hemorrhagic plural effusions, classically, on endemic exams, is a misothelium. Misothelium is love, love, love, love, love, to cause hemorrhagic plural effusions. And then, another thing I want to say about plural effusions, again, just special case situations, are if a person has a lung cancer, and you notice that they have malignant cells in the plural fluid, right? So many times, they'll tell you that you see a lot of like mytotic figures, you see cells with very large mucleolides, stuff like that. When you see stuff like that, when a person has malignant cells in the plural fluid, that's an example, that's a malignant plural effusion, right?

When people have malignant cells in plural fluid, and it's lung cancer, you can pretty much point that those people have stitched for lung cancer. I'll say that again, when a person has malignant cells in the plural fluid, and they have a lung module, same, those people have stitched for lung cancer. Okay, now, what if they give you a question about a person, they have a plural fluid, and in that plural fluid, you see a lot of cells, and most of, like, you see a lot of white blood cells, and you see a lot of those cells being lymphocytes, and they tell you that, oh, they are denocene diaminist content. Of that plural fluid is really high. If you see stuff like that, I want you to think of a person having tuberculosis as associated plural effusion. Okay, so high levels of adenosine diaminist, high levels of white blood cells with a predominance of lymphocytes, that's going to be a TB plural effusion, right? Again, the fact that that plural effusion does not give you anything, as it fastening, does not mean that it's not a tuberculosis plural effusion, right? And again, most times, when people have malignant plural effusions, most times, it's usually going to be due to, like, lung cancer, breast cancer, those are, like, the two most common malignant causes of plural effusions, right?

But again, those malignant plural effusions, most times, the patient is going to be less than 7.2, and glucose is going to be less than 60, just because of all the inflammation that is going on there, right? And then, if they give you a question about a person having an exomas, and a person has a sideys, and then they have a plural effusion, I want you to think of something called Mike's syndrome. Mike's syndrome is spelled NEIGS, right? Mike's syndrome. If you see stuff like that, if you see that triad of a sideys, and at the next so much, so the patient has an ovarian malignancy that has been 9, and you notice that you have a plural effusion, I absolutely want you to think about Mike's syndrome on a test. Now, one big thing I want to say is, if they give you a question about a person that has had, like, some kind of, like, viral, or respiratory infection, and then, you notice that, not long after, they start having, like, very high fever, really bad headaches, right? And then, they tell you that they have, like, very severe pain, like in their lower chest, right? If I, most times, these people, when they breathe, if they breathe even just a little, right? They take in a deep breath, or they exhale, it just hurts a ton. Whenever you see stuff like that, right? Usually, these people have to take, like, pauses, right? Because they are breathing just really hurts a lot. If you see that, I want you to think about Purudinia, right? P-L-E-U-R-O-D-Y-N-I-A, Purudinia, right?

Another name you may see for Purudinia on an MBMI exam, is something called Born Home Disease. Born Home Disease. Born Home is spelled B, I want to be surprised if that's a Swedish term. But it's B-O-R-N-H-O-L-M. I'll say that again. B-O-R-N-H-O-H-O-L-M, okay? Born Home Disease, right? And for the most part, the way you're going to treat it, is you're just going to go ahead and give NSAI Ds, right? Give NSAI Ds. Sometimes you can put, like, heat packs on the part of the body that's hurting. But for the most part, that's pretty much all you need to do for these people, right? That's pretty much all you need to do for these people. And if you're trying to give you, like, a bog that's causing this person's Purudinia, think of Cox-A-Kee-B. Remember, Cox-A-Kee-B causes two things on an MBMI exam. First, it causes viral microcharditis. And then second, Cox-A-Kee-B loves to cause... Cox-A-Kee-B many times loves to cause, again, this is a Purudinia, right? But one thing that looks a lot like Purudinia, and it's actually treated exactly the same way as Purudinia, is something called pleuracy, right? Pleuracy. Pleuracy, again, many times, it's going to be a person that has, again, they've had, like, a viral respiratory infection, viruses, actually, the most common cause. And again, they will have this low-ancinating pain in their chest. And whenever they move their ribcage, let's say they take a deep breath or they exhale, it hurts a ton, right?

And sometimes you may hear, like, a raw sound, or you may hear, like, a lancin-it-in sound, when they take deep breaths. If you see that, don't you think of Purudsy. Purudsy, again, is treated exactly the same way as Purudinia with NSAI Ds, right? And another thing that also kind of looks like that, to be honest with you, I feel like these diseases all on a spectrum, right? It's something called pleuritis, right? Pleuritis, again, many times, it can arise after an respiratory infection, like a viral URI. But it can also arise in people that have, like, um... It can also arise in people that have, like, lupus, right? People that have these autoimmune diseases, right? Like lupus, chogrens, rheumatoid arthritis, right? And basically, those people, again, they have inflammation of... especially in lupus, right? Those people tend to have inflammation of serosal surfaces, like the pleurosurface. So those people, again, you will hear through in the atticin-debret, right? And again, most times, do we treat those people as with NSAI Ds, right? And then the last plural of normality I'm going to talk about is misotheliuma, right? So remember, misotheliuma will cause, like, pearl thickening on an embankment exam that, basically, may have worked in a shipyard, right? And, again, most times, misotheliuma is, right, they have really bad prognosis. And don't forget, they have associated with some homobodies on embankment exams, right?

Remember, those things are called laminated, or sometimes you may see them referred to as laminated calcifications, right? And then, as bestosis, many times, you'll see peroplex, right? You'll see calcifications in the peroplasms, if you see stuff like that, until you think of as bestosis, okay? So I think that's what I'm going to say from a plural of normalities perspective. Again, as I do at the end of every podcast, I guess maybe one thing I should say is that I do have... Because many people have emailed me that they love my life lessons, the life lessons I give at the end of these... some of these podcasts I make. And again, I'll continue to do that. But, I actually started like a former website called Divine Intervention, lifelessons.com. Again, many of you listening to this podcast, you know, I'm a Christian, and there's just a lot of, like, good Bible-based teaching on there. The podcasts are all less than 10 minutes long. And basically, in those podcasts, I, you know, talk about like a life lesson, something that's applicable to not just people in medicine, but pretty much people from every walk of life, right? So they are less than 10 minutes, I plan to make a couple every week. And so far, I've made 10. I'm going to be making an 11th one actually today. And you just listen to it very short principle.

Now, just like principles I discussed that can help you, like, you know, succeeding in life, while just literally avoiding troubles in life, or just deal with things that are related to like mental health in life. So if you're interested, it's called Divine Intervention, lifelessons.com. And then I also have the podcasts on Apple Podcasts. If you look on Apple Podcasts, and you look for Divine Intervention, life lessons, you will find those podcasts. And then I do also offer one on one tutoring for the USML exams. Step one, step two, CK, step three, pre-clean cool medical exams, 30-ish off exams. And I mean, obviously, the time I have is limited, right? To allocate to those, right? So most times you have to book with me ahead of time if you want to be able to see me one on one. And then I do offer these review courses for step two, CK and step three. And MB Me Testic and Strategy scores that again, tons of people have taken and they found to be extremely helpful. I mean, I've had people attend my review courses and guest courses around the 280s on the USML exams. And then I know that we are going through this era cycle. So if you need help with personal statements, recommendation letters, your era's application, again, I do this at a flat rate. So shoot me an email and I'll give you some more information on that.

Again, I've worked with tons of people that have had very tricky applications, people that have red flags on the applications, people that have failed USML exams, people that don't have as much research as they should. I've worked with people or people that have even graduated from medical 10 years ago, right? If any of these tricky things apply to your era's application, again, shoot me an email. I have a very good track record with people, especially people applying to like many different kinds of residences. So I've worked with people going into dermatology, neurosurgery, plastic surgery, E&T, internal medicine, family medicine, OB-guine, Gen-Surg, urology. I've worked with people going into many different disciplines. So if you interested in email, these things just shoot me an email and I'll give you some more information. So, and also, you know, I have a website, obviously, right, divininginterventionpodcast.com. If you go there and subscribe, you'll get an email notification whenever I make a new podcast. And I also have these podcasts on Apple podcasts, on Google podcasts, and on Spotify. At least the most recent 150, it's a Word Press role. So if you want everything from like episode one, all the way to 332, which is this one I'm making, then I'll strongly encourage you to consider going on the website. You can find all of them there. Okay? So, and also, I have a You Tube channel called Divine Intervention, USMD Podcasts, and videos.

That's where I put all the podcasts that are all the video materials that I make. So, but if you want the slides associated with those videos, go on the website and search on do those, under those are respective episodes. So thank you for listening to me. I really hope you found this podcast to be helpful. I'll see you next time. God bless you. Thank you.

A fluid collection between the visceral and parietal pleura.

Decreased breath sounds, dullness to percussion, and decreased tactile fremitus.

Trans-videav effusion (Transudate).

PFP/SP ratio < 0.5; PFLDH/SLDH ratio < 0.6; and PFLDH < 2/3 of ULN serum LDH.

pH > 7.2, Glucose > 60 mg/dL, and no bacteria on Gram stain.

Complicated pyromonic effusion (or Empyema).

Yellowish fluid with triglyceride content > 110 mg/dL, often from transsiectasis.

Systemic imbalance in Starling forces (e.g., increased hydrostatic pressure [CHF] or decreased oncotic pressure [Cirrhosis]).

Local inflammation, infection, malignancy, or pulmonary embolism (PE).

Tuberculosis.

Pneumonia/Infection, PE, Malignancy, or Trauma.

Uncomplicated requires only antibiotics; Complicated requires antibiotics PLUS thoracentesis.

Pleurisy or pleuritis.

Uncomplicated $\rightarrow$ Complicated $\rightarrow$ Empyema.

Systemic imbalance in Starling forces (e.g., increased hydrostatic pressure [CHF] or decreased oncotic pressure [Cirrhosis]).

Local inflammation, infection, malignancy, or pulmonary embolism (PE).

Tuberculosis.

Pneumonia/Infection, PE, Malignancy, or Trauma.

Uncomplicated requires only antibiotics; Complicated requires antibiotics PLUS thoracentesis.

Pleurisy or pleuritis.

Uncomplicated $\rightarrow$ Complicated $\rightarrow$ Empyema.