DIP Ep 611: Imaging and The USMLEs (Part 2)

Wait, this stuff is actually pretty high yield to know for my exams. Um, the the thing is there's a lot of nuclear medicine tests that are done in honestly in medicine, and um there's a reason the USML is loved to test. And one thing I'm gonna say is, you know, this is probably like if you're a person that is very physiology inclined, if you're going into diagnostic radiology, uh, this is probably gonna be one of the most fun parts of diagnostic radiology you're gonna see.

Um in fact actually there's a specialty called nuclear medicine, um like literally on its own, although it's rapidly dying. Um it's one of those uh disciplines that's pretty much come under the umbrella of just regular diagnostic radiology. All right. Um, but many radiology residents hate this material because it's kind of hard. But honestly, it's really not hard if you just put in a little bit of work and effort to try to understand.

Um, but again, we're gonna focus on this from the USMLE perspective. But I'll try to give you some bit of logic so that this stuff just kind of makes sense in your brain.

So again, a lot of nuclear medicine tested on the US MLEs, right? So let's kind of start off with one that many of us are familiar with and that's the thyroid, right? So what if they give you a question about like a thirty-five year old man? And this man you're told that for the last month, you know, he's been having shortness of breath, having palpitation.

Right. They tell you that, you know, on physical exam, you notice that he has increased deep tendon reflexes, has lead lag. Right with his eyes, lid lag, right? And then um they tell you that, you know, which of the following is the most and you know, you notice that the person has an irregular rhythm on, you know, cardiac or scotation. And

You know, the person's heart rate is like one twenty beats per minute, right? And then they say what's the most likely etiology of the patient's presentation? Well I'd hope you're picking the answer that talks about uh thyroid stimulating immune globulence, right? This person clearly has Graves disease.

Remember, Graves disease is the most common cause of hyperthyroidism in the US, right? So whenever a person has graves, the first thing you're gonna hopefully check is the TSH, right? For many thyroid disorders, first thing you're gonna check is TSH. And the TSH is going to be decreased in this percent.

Right? Because you have these thyroid stimulating immunoglobulins that are literally stimulating the thyroid gland to make a lot of T3 and T4. If you make a lot of T3 and T4, that's gonna suppress uh that's gonna suppress TSH production, right?

So how do we diagnose Graves' disease? Well, one of the ways we diagnose it is to do a RIU scan, a radioactive iodinoptic scan, right? Radioactive iodinoptic scan. You know, sometimes on the exams they will call it thyroid scintigraphy. Thyroid scintigraphy. Right. So basically, um we know that the thyroid gland takes up a lot of iodine.

So the thing we're gonna do is to basically give i131, iodine one thirty-one, that's a radionucleide, um is gonna be taken out by the thyroid, right? Now the thing is for USMD purpose. Better ways to learn this is to ask yourself what causes increased optic with a Rayu scan and what causes decreased optic. Right.

Increased uptake, and I'm gonna provide like hey, this is why you get increased uptake, and this is the reasoning. I think having that understanding of the reason will just make it make more sense to you and it can stick in your brain better. Right. But like for example, if a person has a toxic multinodular goiter, you're gonna see increased optique, right? Because in a multinodular goiter, you have like an autonomous group of cells that are literally just making their own thyroid hormones.

Right. Um same thing with toxic adenomas. You just have a bunch of cells making their own thyroid hormone. So since these cells are just on their own of their own volition, making a ton of thyroid hormone. That's gonna cause them to take up this I-131 because again the thyroid loves to avidly take up I-131.

So you're going to see increased uptake in a like a toxic adenoma in a multinodular goiter, right? And you're going to see that as well in Graves' disease, right? So if a person has Graves disease, These thyroids stimulating immune globulins. They literally stimulate the TSH receptor. They're pretty much acting like TSH on the thyroid gland.

So because you're having this continuous stimulation of the thyroid gland, the entire thyroid is gonna light up, right? So make sure you can distinguish that from a toxic adenoma and a toxic multinodular goiter where Just subsections of the thyroid light up, right? They affected parts. In Graves' disease, the entire thyroid lights up, right? Now.

Typically on the USMLEs, you're gonna get a decreased optique on a RIU scan when you have two things going on. Either you have your TSH suppressed or you have inflammation in the thyroid gland. Your TSH is suppressed or you have inflammation in the thyroid gland. But that TSH suppressed situation is

A big exception there is going to be Graves disease. It's going to be Graves disease. And again, I've explained why, but I'm going to explain it again. Right? But let's talk about the inflammation part and then I'll talk about the TSH. When you have inflammation, right, the thyroid gland is just heavily inflamed, heavily inflamed, heavily inflamed, right? So, like for example, um in Dequervine's thyroiditis.

In those circumstances, in those circumstances, the thyroid is not going to be taking up iodine, right? So you're not going to see any optic on a Ryu scan. So if your thyroid is going through an inflammatory cycle, it's not going to thick up radioactive iodine. Right. So great remember dequer veins, right, which we also call subacute thyroiditis, uh which we also call granulomato thyroiditis. I remember basically the way that works.

is um you have like a viral URI and then a while after that, you know, you have like very painful thyroid. And usually they're gonna start off with thyrotoxic symptoms, right? Because all that inflammation is going to lead to the release of prefronthyroid hormones. And then over time, you know, they'll they'll recover, right? So because of that inflammation, right, the thyroid cannot take up iodine, you're gonna have decreased optics on our RIU skin.

Right, but I also said that man, if you have decreased TSH, you also have decreased opticonoraio scan, right? Because think about it, if you have Low TSH, then your thyroid gland is not being stimulated. Remember, TSH literally stimulates the thyroid gland to take up iodine for the production of thyroid hormone. So if your TSH is low for any reason, then

Your thyroid gland will not be stimulated to make to take up that iodine to make thyroid hormone, right? So say for example you have um you're using thyroid hormone exogenously, you know, like factitious hyperthyroidism. Um Then you're not gonna have any good uptake on a Ryu scan, right? Because you're taking thyroid hormone exogenously, that's gonna suppress your TSH. So your thyroid gland is not being stimulated. Since it's not being stimulated, you're gonna have a decreased uh

Decreased uptake, right? Or let's say a person has like a teratoma that is making uh thyroid hormone, right? Like stroma ovarii. Um But personally. Thyroid gland, uh, you you know, you have this teratoma making a ton of thyroid hormone. Your T3T4 is high, your TSH is going to be suppressed, so your actual thyroid gland will not be stimulated. That's gonna cause decreased.

But I said that Graves' disease is an exception where your TSE should be low, but you actually have increased optic on a radioactive iodine optic scale. The reasoning there is that the thyroid stimulating immune globulin. That we see in Graves disease, they pretty much work like TSH receptor agonists. It's not they pretty much, they are essentially TSH receptor agonists, so they're pretty much working like Tsh.

Right. That's what's stimulating the thyroid to make tons of T3 and T4. And then that suppresses TSH production. So again, that's why the TSH may be low, but you have increased uptake on a RIU scan, right? And the thing is there are a few quirks with the I one hundred thirty one business that they love to test on the exams, right? First things first again, make sure you can identify these different Rayusca scan findings, like hey, what does Graves disease look like?

What does a multinodular goiter look like? Right, you're gonna see many spots of increased optique. What does a toxic adenoma look like? You're only gonna see one focus of increased optique, right? And don't forget that um um You can also do one I-131 for like ablation. You know, you can use that for Graves' disease. That's actually how we treat Graves disease.

or toxic multinodular goiter. Just give I-131 to ablate the thyroid gland, right? Because those radioasotopes they make radiation that can destroy the thyroid, right? So you give I-131 obviously a bigger dose than the imaging dose. Right. And that will update the person's thyroid in graves or toxic multinodular coronavirus.

And then I guess I just wanna discuss this as a s side point. Um actually two side points, right? Fir first things first. Um they can give you a question about Graves' disease in a pregnant woman and ask you how you should treat it. Um I would really hope that you're not picking the answer that involves giving I-131 in pregnancy. Please. Do not give I one thirty one in pregnancy. It is very dangerous, right? It's gonna deliver radiation to mom and the baby, and that's not that's not good, right?

And also they can actually give you a preventive medicine question after a person gets I-131 radio ablation. If you get I-131 radio ablation, you need to basically stay away from people for a while. You need to stay away from people for a while because basically that I-131 that's in your thyroid, you're just reading it out to other people, right? So you just kind of want to be careful about that.

Right. And one other side point I don't know why this is just kind of in my heart to talk about, but it's actually pretty high yield to know for your exam. If for example a person has you you you you get a scenario on your test and a person has got in I 131 radio ablation

And then down the line, you're trying to check for a recurrence. You know, let's say they got the I-131 ablation for something, right? Let's say for like thyroid cancer or whatever, right? How can you check for a recurrence of the thyroid cancer? Well I'd really hope you're saying, ooh, divine, I'm gonna check the thyroglobulin levels. Because remember, thyroglobulin is like the C peptide of the thyroid gland.

So, if you have functioning thyroid tissue that has come back, you know, like cancer that has come back, or recurrence of like thyroid disease. You'll be making a lot of T3, T4, but you'll also be making a lot of thyroglobulin. So your thyroglobulin may be elevated, right? So checking thyroglobulin levels is actually a pretty great way to assess a person for like recurrence of thyroid cancer, right? So just something you want to keep at the back of your mind for.

Now the next thing we're going to talk about, right? What if they give you a question about a person that is pregnant and over the last three hours she has been having like significant shortness of breath? And you're told that uh you know you you get an EKG and you notice that the EKG is completely normal, but the person's heart rate is pretty high, right? This person probably has a PE, right? You're probably seeing the sinus tachycardia on an EKG, right? So typically what kind of

Well, I'd really hope you're saying that uh, especially in for PEs in pregnant women, I want you to think of a VQ scan, a ventilation perfusion scan, right? So who are the people that get these VQ scans? Number one, it's gonna be people that are pregnant that have a PE. Right? That you suspect the P E N. Another group of people that you do this with are people that have um like uh

Allergies to iodinated contrast because remember the contrast that we use for you know CT chest angiograms. Uh they're made of iodine. If you have allergies to that, then obviously you can't do that other study. You need to do a VQ scanning. Or let's say for whatever reason. Um you have renal failure, right? Because remember iodine contrast can torture your kidneys. If you have renal failure, then in that case a VQ scan will be indicated if you're trying to roll out a P. Right.

Uh there are actually two phases to the study. There's a reason it's called a VQ scan, right? It assesses ventilation, that's the V, and perfusion, that's the Q, right? Q is a Just general term in physiology for perfusions, right? So the thing that happens is first you you inhale a radioisotope, right? You inhale the radioisotope and then we take Scans of your lungs, right? We take scans of your lungs. So we assess the ventilation, right? Because you're just inhaling that.

And then after that we give you a tracer that that's injected intravenously, right? And that tracer just because of the stuff it it gets trapped in the pulmonary uh like your pulmonary capillaries right so that gives us an idea of hey how well is blood flowing in your lungs how well are your lungs being perfused right so let's look at the normal situation the normal situation is that What you see from the scans, the radioisotope scans with ventilation should roughly match

what you see with that radioisotope that you injected with perfusion. There should be a match, right? Ventilation and perfusion in the lungs tend to match generally. And you can see this beautifully on imaging. I've actually seen a lot of these kinds of images. Right. So the V scan should match the Q scan, right? So the the the thing is uh P E is something you're gonna worry about when the V scan does not match the Q scan. So you see good ventilation with the V the ventilation scan.

But you notice that man, there are these like defects, like these areas that did not take up the tracer. Uh, when you do the scan, after you've injected that. Radioisotope intravenously, the Q part of the scan, right? So you're gonna see things like wet-shaped infarcts, for example. If you see that, right, think of a PE, right? You'll be, you know, basically you're getting good ventilation, but you're seeing poor perfusion. That tells you that, oh, this person probably has a PE.

Right, this person probably has a PE because remember, a PE is a perfusion issue. Right, in fact, sometimes our friends at the MBMEs, instead of using the term pulmonary embolas.

They can just use the term uh pulmonary perfusion defect, pulmonary perfusion defect uh to talk about a pulmonary embolus on your exams. Right. So again, when do we use these uh when do we use vq scans rollout peas in pregnant women people that have like really bad con allergies to iodinated contrast or people that have renal renal failure right and the thing is vq scans tend to report result in probabilities

When a VQ scan tells you that you are high probability for a PE, then yeah, we're pretty worried that that person has a PE, right? Most of the other probabilities are not as useful, right? But if it says high probability for a PE, yeah, you definitely probably have some kind of

All right. Now let's look at uh what if they give you a question about a p person? And they tell you that this is a fifty five year old male. Um, you know, that has chest pain that is uh kind of worsened by activity, right? Kind of worsened by activity. Um

You know, but when he rests for a few minutes, he feels better, right? So this person um has angina, right? Probably has stable angina, right? Typically, when people have angina, it's usually reasonable to do some kind of stress test, right? To do some kind of stress test. Now remember stress tests involve two things, right? There is a method of stressing the heart, you know, either like exercise or dobutamine or adenosine or dipyridamol or you know whatever. And then uh

There is a method of assessing the cardiac response to that stress, right? You can do an EKG, right, to assess the heart's response to the stress. You can do an echocardiogram. Or you can do these nuclear medicine tests. So let's focus on the nuclear medicine test. Uh the nuclear medicine tests uh they usually use uh things like technetium 99m or thallium 201. Technetium 99m or thallium 201. Right, so we use these for cardiac scanning as a part of a stress test.

right, uh to assess the cardiac response to to that stress. So the thing is Technician ninety nine M, we kinda pref prefer that to Thallium. Because thallium two zero one delivers like just tons and tons and tons of uh radiation, right? And the thing is you you may wonder like man divine like these tests are like a black box in my brain. Uh

Why do we even do them? Uh let me give you like a little bit of context. I'm not gonna go into detail on this. Like honestly, this can easily be like a one plus hour lecture just on this stuff, right? But just to give you a little bit of context, right? We we use these tests to determine if

We're dealing with ischemia of the heart, or we're just dealing with straight up infarction of the heart, right? We're dealing with ischemia infarction, right? Because the thing is when you inject these radio tracers. You then try to look at the flow, you know, like in your coronary vessels, in your myocardium, right? Amongst your myocardium and stuff, right? So

We're looking for flow defects basically. And we're doing this at rest and at stress, right? So typically we're gonna take images and we're gonna give you know we're gonna take images at rest and at stress, right? So say for example, if you see flow defects. At rest and during stress.

At rest and during stress, then that tells you that oh, this is probably an infarcted myocardial tissue. Because it's like at rest, you're not seeing any flow. During stress, you're not seeing any flow. You're getting the same results at rest and stress. This is myocardial tissue that has infarcted, that is probably scar tissue, right? That tissue is no longer viable. It's not revascularizable. But if you see flow defects only during stress, well, you notice that, oh.

Those flow defects are not present at rest. So when you're resting and your heart is not working as hard, you notice that there is no flow defect. But when you're stressed, right? When you're running on a treadmill or your heart is being stressed pharmacologically, you notice that there's a flow defect. That tells us that there is some kind of ischemia going on, right? Some kind of ischemia going on, right? So that tells you that, oh, okay. So at rest, profusion is good.

But that during stress profession is bad. Hmm. This heart is at risk. This myocardium is at risk, right? That's a good candidate for revascularization. That tells you that, ooh, you're dealing more with ischemia than than infarction, right? Then you're dealing with ischemia than than infarction, right? So again

And trust me, there's way more permit permitations than this, like viable, non-viable, blah, blah, blah. Right. But again, that's more for radiology residency or nuclear medicine residency. I'm not gonna go into those details at all in this podcast. You literally don't need that for your exams, right?

So again, you can use these nuclear medicine tests, especially on your exams where for whatever reason you cannot do an EKGB stress test, right? So let's say a person has a pre-existing abnormal EKG, then you cannot use an EKG-based. In those people you should use either an echocardiogram or a nuclear medicine uh test.

And many times when we do these nuclear medicine tests, we use them with pharmacology as the way to stress the heart, either like dobutamine or dipyridamol or adenosin, right? Something to keep at the back of your mind for for exams. All right.

Now, the next one I want to talk about, right? So what if they give you a question about a patient and this patient presents with like significant right upper quadrant pain and fever, right? But the patient has like no jaundice, but they have leukocytosis and things like that, right? Clearly this person has acute cholocystitis. And we know that when a person has acuculisticitis, the first thing you're going to do is a right upper quadrant ultrasound, right?

But what if that right upper quadron ultrasound is unremarkable? It's negative. Are you done ruling out acute cholesteritis? Well the answer to that is gonna be no, right? In that case, what kind of scan are you gonna do? Well you're gonna do a hida scan, a hida scan. Right. Remember another name for a HIDA scan on the USMLEs is hepatobiliary scintigraphy. Hepatobiliary scintigraphy. Right? Hepatobiliary scintigraphy. Right? Again, the typical use on your exam.

Is when a person has, when you suspect acuculous cystitis and the right upper causal ultrasound is negative, right upper causal ultrasound is negative. Um So How does this test even work? Again, let me give you a little bit of context. You've noticed my context, I'm not spending too much time on that, but let me give you a little bit of context, right?

You pretty much inject a tracer intravenously, right? And this tracer is conjugated to a protein that is taken up very heavily by your hepatocytes, by your liver cell. So the thing is, I mean, after it's taken up by hepatocytes, well we know that stuff that's taken up by hepatocytes, they're going to excrete it into bile, right? And bile is going to be excreted into like the gallbladder, for example, right? And into the biliary trick.

You know, so this test takes a while, right? So you notice that oh you wait like an hour or whatever, right? So you would hope at that point that hey by that time your hepatocytes have excreted this thing into a bile, right? So what's gonna be the normal situation? Well, the normal situation is that this radio tracer should be taken out by the gallbladder because when the hepatocytes excreted into the biliary duct.

It then goes into the cystic duct and then goes into glue gallbladder. So after like an hour or so you should be able to visualize the gallbladder pretty well with a hida scan because that tracer has Gone through that patent cystic duct and entered into the gallbladder, right? Entered into the gallbladder. So if you notice, however, that way. I can't visualize the gallbladder like a few hours after I've injected this tracer, you know, with like the specialized nuclear imaging.

Then that tells you that the cystic duct must not be patent. It means the cystic duct must be obstructed. It means that ooh. The cystic duct is obstructed, so that's why I cannot see the gallbladder, right? It pretty much means that the patient has acute cholecystitis, right? Means the patient has acute cholocytis.

Right. So again on your exams if they tell you that and they can literally use this terminology, they say that oh a hydas scan or hepatobiliary scintigraphy fails to disclose optic in the gallbladder. Or they tell you that the gallbladder is not visualizable, like a few hours after you give that tracer, you know, like one hour or more after you give that tracer, then that tells us that, oh, this person probably has acute collectivist type.

Right. Now what are some other uses of the HIDA scan you mission you exams? Uh hydro scans are used uh to detect like bowel leaks, you know, postoperatively, right? You know, say for example you have gallbladder surgery. Sometimes you can have a bowel leak.

Right. You can see that if you inject that tracer, right, that again kind of floats around in bile, if there's a bile leak, you'll see that tracer going beyond the confines, beyond the boundaries of your biliary, of your biliary tree. All right.

And then as I wrap up, let me just maybe talk about a few more quick tests here and there, right? So don't forget the Mechel scan, right, is the Technicium Technicium 99M scan. We'll use that for Mechel's diverticulum, right? Remember Mechel. It's gonna be a young boy, you know, that for you know has been having just these painless bloody stools and things like that.

Right. Another one you may see on your exams is uh somatostatin scintigraphy. Somatostatin scintigraphy. This one is very, very good for neuroendocrine tumors, right? Especially like gastrinomas and carcinoid tumors. Right. So my dostatin scintigraphy is amazing, amazing, amazing for those kinds of uh tumors.

Right. Another one you may see on your exams is an MIBG scan. Right. An MIBG scan. We tend to use this for things like pheochromocytomas or for like neuroblastomas. You can also occasionally use them for medullary thyroid cancer. But typically on the exams, feels and neuroblastomas, especially when you're trying to look for like distant metastasis, right? Or let's say you do like a CTO and MRI of the abdomen and you can't find the feel. An MIBG scan is going to be very helpful.

And you may be wondering, Divine, why does the MIBG scan help? Well the thing is MIBG is a norepinephrine analog. It's literally a norepinephrine analog. Right. So we know that car uh you know, few chromocytomas, neuroblastomas, these things may produce calecolamine. Right. They may make and produce colocholamines, right? So you notice that ooh on MIBG scanning you're seeing a lot of optic, a lot of optique, right? Many of these nuclear medicine tests were just looking for optic, optic, optic.

Right. And then don't forget uh if for example they give you a question about a person that has like um uh you know. They feel dizzy, they have abdominal pain, you know. like twenty to thirty minutes after they eat a meal and they tell you that this person recently had gastric bypass. Oh, you want to think of a person that has dumping syndrome. You want to think of a person that has dumping syndrome, right? That dumping syndrome is associated with rapid gastric MT.

One of the ways we can test your gastric emptiness is by doing something called literally a gastric emptiness study. Sometimes on the USMLE exams they call this gastric scintigraphy, gastric scintigraphy, gastric scintigraphy, gastric. scintigraphy, right? It's uh basically a kind of MTN study.

uh to see how rapidly so there there are normals for how quickly your bowel should you know your your bow should uh empty. Uh your stomach should empty. But you know there's When when it goes beyond those boundaries, right, it tells you that it's either slow gastric MTN, which you may see in certain disorders like diabetic gastropares. Or you may see a rapid gastric MT.

uh in situations like uh dumping syndrome, for example, right? And then the next test I wanna talk about, right? So uh what if a person, for example, has been treated for H. pylori and you wanna do a test of cure, right? A test of cure for H. pylori, right? Remember If you want to do a test of cure

You don't want to do an antibody based test against H. pylori because those antibodies, once positive, they will always be positive. So they cannot really help you differentiate between a primary infection and oh wow, you've been cured or whatever, right? So it's not very helpful. You can use them to initially try to diagnose H pylori butt.

Once those antibodies are positive, they will always be positive. You cannot use them as a test of cure, right? One common test of cure our friends at the MBMEs love to use is something called the urea breath test. The urea breath test, right? You use it to make, you know, either a diagnosis of H pylori, but you can also use it to confirm that the person's H pylori has been eradicated.

Right. So how does this test work? Again, let me give you some context. Right. Basically, the thing that happens is that you get carbon fourteen, uh radio labeled urea, right? Carbon fourteen is a radioisotope of of carbon. And probably remember that from organic chemistry, but we're gonna go into chemistry here. Can you guys tell that I really love chemistry? But we're not gonna go into chemistry here, right? So you give radio labeled uh carbon fourteen.

And then uh uh so radio labeled uh urea that contains carbon fourteen, right? And then, you know, the hitch by lowering your GI tract is literally gonna because it's urease positive, it's gonna break down that radio uh, you know, 14 carbon 14 radio labeled urea. It's gonna break it up into carbon dioxide and ammonia.

Right. And then that carbon dioxide is detected in your breath. Right. If you detect that carbon dioxide in the person's breath, it tells you that ooh, there must be some kind of urease-positive organism in the person's GI tract. And who is gonna be the big corporate most of the time? It's gonna be what? It's gonna be H by Lori. So H by Lori. So you can use the URB test to either diagnose uh H by Lori and you can also use it as a test of cure. All right.

And then, you know, don't forget your bone scans, right? Don't forget your bone scans. You know, sometimes on the exam they call it bone scintigraphy. Um, you pretty much give like a tracer. We're not going to talk about the tracer, but it's like a derivative of Technicium 99M. Um that tracer binds to the hydroxyapatite in bone, right? It binds to the hydroxyapatite in bone, right?

Uh usually we're gonna use a bone scan for Paget's disease, for Paget's disease of the bone. Now, one thing I wanna say here is that you can also use Um a bone scan for bone mats of cancer, especially if a person has blastic lesions. Blastic lesions. Generally when you have lytic lesions of the bone.

You're not gonna get very great uptake, right, with a bone scan, right? So you know, lytic lesions, like for example, like if a person has multiple myeloma, it makes very limited sense to do a bone scan because multiple myeloma is gonna cause a lytic lesion, right? That doesn't really make sense in that structure.

All right. So I think we're gonna go ahead and stop here. Um again I think I've kinda talked about a lot of stuff here, but again, please, this podcast is pretty high yield and honestly, if you understand these mechanics behind these different tests. You notice that these things are actually pretty easy. You don't have to like endlessly memorize, memorize, memorize, memorize.

So thank you for listening to me today. I will see you God willing episode six hundred and twelve. Again, there's still more meat on this imaging bone. To be honest with you, I'm just basically I made up my mind that hey Imaging is a hard concept for many people on the USMLEs. So let me just make a series that thoroughly addresses it. If you listen to this series, I don't see why you should struggle with much of any much in the way of imaging questions on your exam.

And then if you're interested in my classes, if you love the way I teach, um I do offer many classes for step one to three, level one to three. Um like today this evening I do have a five hour social sciences quality improvement ethics and hospital medicine class. Uh it's for step one to three. Many people have taken this class and found it to be exceedingly helpful for their exam.

And then uh tomorrow for step two and three specifically, I have a three-hour last minute review, like a last-minute primer for step two and three. And then next week from Monday to Friday, four hours every day, so 20 hours total, I have a 20-hour class for step two, CK, and step three. Again, many people have taken these classes and found it to be helpful. I've literally had people take the classes as recently as within the last few weeks.

and get like in the high two seventies on their exams, right? Again I tell you these classes are well put together. They're they're they're pretty thorough, right? Many people find them to be exceedingly helpful, right? So take it as You know, take take these classes. They're they're really gonna help you in in preparing for your exams. And then I also have a test taking class and a biostats class. I'm gonna be offering those uh the first two days of next month.

All right. And then I have these podcasts on Apple, Google, and Spotify. So please check those out. I also have a YouTube channel you can check out. That's where I post the videos that I make. And then remember I also offer one-on-one tutoring for all the US MLE and Complex exams. And I also help with like Eras applications, personal statements, mock interviews and things of that nature.

Right. And then I have another website titled uh divine intervention life lessons.com. Divine intervention life lessons dot com. Uh basically every week, uh many of you know I'm a I'm a Christian, every week I post like two to three podcasts for from a biblical perspective, uh dressed a life lesson.

Many people have actually listened to these podcasts and found them to be really helpful. Uh there's actually an Apple podcast associated with this called uh the Divine Intervention Life Lessons Podcast. Divine Intervention Life Lessons Podcast. All right, it's an Apple podcast. So thank you for listening to me today. I will see you God will in episode 612. Have a wonderful day. God bless you and uh bye for now. Thank you.