DIP Ep 651-USMLE Step 2/3 Rapid Review Series 136

Okay. All right. So let's jump right into it. So uh what if they give you a question about uh and I'm gonna be making quite a number of uh kind of strange integrations today, so I'd keep this keep this in mind, right? So I wanna focus on a lot of uh you know You you'll see what I mean as I go. So what if they give you a question about an old guy, right, and he has like very severe abdominal pain? Right. He's a smoker.

And they tell you that you feel uh positive lower abdominal mass, right? Uh what should you be thinking about? Well, I really hope you're saying that, oh divine, this sounds a lot like a ruptured AAA, right? This sounds an awful lot. Like a ruptured triple A, right? So this person has a ruptured abdominal aiotic aneurysm, right? And remember, triple A's um typically

Typically they're going to arise below the renal arteries, right? I think that's one of those uh kind of high-yield things you want to make sure you know for your exams, right? They typically arise below the renal arteries, they typically arise below the renal arteries. Right. And again what's the biggest risk factor for an abdominal aortic anemia? Well the biggest risk factor is going to be smoking, right? Smoking is the biggest risk

Abdominal aortic aneurysm, right? Um, and one thing uh you'll notice on the USMLE exams, and this is something you should certainly look up, is that sometimes when a person has a triple A that is ruptured or about to rupture.

uh they may show you something called the dripped auder sign on imaging right the dripped the order sign on imaging right so what does that mean well the thing is typically when a person has the dripped the order sign uh it's something you see typically on on a ct scan right but you'll notice that

uh that the posterior wall of the yodor, right? The posterior wall of the yodor, like the margins are very indistinct, right? Uh very indistinct. Right. It's almost like the aodor, the posterior yodor, is draping over the wall. of the vertebra because remember the vertebra come behind or they're very close closely associated with uh a yodor, right? So that's something I certainly know for examples if I were you, right? So the drip the yoders.

Uh it's one of these things is old timer, old school, but it's pretty high you to know for your exam. Right. And uh remember people that have uh a rupture triple A, they're gonna be hemodynamically unstable, they're gonna have flank pain, they're gonna have back pain, right? Because again, remember the AAA, uh the the abdominal aor is is retroperitoneal.

Right. Now the thing is sometimes our friends at the MBMEs again, especially they they they know that these days we live in an archie and an AI generation, right? So One thing they love to do is instead of just asking about a classic association, they will ask you about the underlying mechanism or the underlying pathophysiology. Do not be afraid to pick an answer that talks about elasting and collagen degradation on your test. You're like, wait, what?

Yes, I mean exactly what I just said, right? Elastin and collagen degradation in the media, right? From increased matrix metalloproteinase activity, right? I'm gonna say that again. So the thing is when people have a rupture triple A or when people have an abdominal eulic aneurysm, right, the mechanism there is they have increased matrix metalloproteinase activity. Increase matrix metalloprotonase activity, right? When you have an increase in the activity of matrix metalloproteinase.

That is going to lead to the degradation of elastin and collagen in the media, in the media of your abdominal yodor, and that can cause problems, right? And the thing is, it is actually kinda high yield to know that statins decrease the activity. of matrix metalloproteinase.

Statins decrease the activity of matrix metalloproteinesis, but smoking increases the activity of matrix metalloproteproteinesis, right? Uh proteinase again something that breaks down proteins, right? Think about it if a person has COPD. Right. There's all these proteases in the lungs that have increased activity with smoking. Right. So I want you to kind of link those activities together. Proteinase, protease, right? They're kind of similar. Proteinase, protease.

Protease breaks down proteins. Proteinase breaks down proteins. Right? It's kind of the same, same idea. Alright, so this is part of the reason why when people have atherosclerotic cardiovascular disease. uh we tend to put them on statins on high intensity statins. Why? Because again, we want to decrease matrix metalloprotenase activity in those vessels, right? So that they don't uh you know

uh plaque rupture or whatever, right? Again, guys, please, today's podcast has a lot of strange things, but they are very high-yield things to know for your exams, right? And again, you know, again, sometimes on the exams concerning the triple E they can ask you like what's the mechanism behind these people having back pain.

Well again typically if it ruptures it's gonna rupture into the left retroperitoneum, right? It's gonna rupt I'm not saying always, right? But it can typically rupture into the left peritoneum, right? So they can have back pain, just kind of like you have with acute pancreatitis, which is also, you know, your pancreas. Especially certain parts are retro retroperitoneal, right? And again, what is the most common location?

of a triple A, of a triple A, of the rupture and whatnot, is typically gonna be below the renal arteries, right? And it's gonna be above the aortic bifurcation, right? Again the These days have become has become an exam of surrogate. Right? Has become an exam of surrogate. They won't typically test you on something direct. They will ask you about something that surrounds the concept, a surrounding concept, right? So it can be a triple A question, right?

It can be painfully obvious that oh yeah, of course this is a triple A question. But then they ask something that you're not expecting, right? So the most common location is gonna be below the renal arteries and above the aortic bifurcation, right? And again remember when people have uh aortic aneurysms, right, typically We're gonna monitor uh you know, we we we we monitor these people.

Right. We monitor these people like every year or thereabouts, right? And we're gonna intervene if the aneurysm grows by more than half a centimeter in six months or a centimeter in a year, right? We're gonna fix it. situation where we would also fix a triple A is if it's more than five and a half centimeters on initial screening, right? Or you have symptoms, right? You're like very symptomatic, you're having severe symptoms.

We're gonna go ahead and and fix it, right? Or if imaging shows something very concerning like this drip the order sign. you know, even if it has not ruptured, we're we're still gonna fix it as as well, right? Now, what if they give you a question about a patient and they tell you that, oh, this patient just came in for a triple A repair.

Right. And then they ask, uh they tell you that oh the patient uh passes away, you know, like twenty-four hours after repair. And then they ask you what is the most likely cause of mortality around the repair of this person's triple A. I would really hope that you're gonna pick the answer that talks about a myocardial infarction. I would really really hope that you pick the answer that talks about a myocardial infarction.

The USMLEs they like to ask these questions that talk about the most likely cause of mortality, the most likely prognosis, right? These are things that are addressed in many of my podcasts and also address pretty heavily my. But the most likely cause of mortality around a triple E repair, right? A person that is had their triple E repaired. Right is a myocardial infarction, right?

And the thing is sometimes on your exams they can ask that, oh, which of the following provides the best outcomes between endovascular aneurysm repair and open repair? The thing is that they likely have similar it's not likely, they they largely have similar survival outcomes. Right. And then what if they give you a question about a patient and this patient has had his abdominal aortic aneurysm repaired?

Right. And then they tell you that oh, prior to the patient departing from the hospital, they do a C T androgram of the of the of the abdomen, right? And they notice uh fluid extravasating into the excluded aneurysm. They notice fluid extraversating into the excluded aneurysm. On your exams you want to think of the answer that talks about an endolic. Think of uh think of the answer that talks about an endolic.

An endo leak is actually more common uh with an endovascular aneurysm repair than with an open repair, right? But make sure you know that concept of an endo leak, right? So that endovascular procedure you did, things are still leaking a little bit into the excluded aneurysm. All right.

Now, what if they give you a question about a patient that has had I I'm trying to make this uh rapid review like a thematic review. And by the way, this is rapid review uh series one thirty six. I want to kind of make it a thematic in a sense, right? So what if they tell you give you a question and they tell you that, oh This person uh

You know, has had his abdominal aneurysm. You know, the patient was admitted to the hospital twenty four hours ago, has had the aneurysm repaired. And then this patient has bloody diarrhea, has very severe abdominal pain, has leukocytosis. Right. When you see something like this, I want you to consider ischemicolitis. Ischemicolitis, right? Uh re repairs of triple laser are not necessarily low risk surgery, right?

There they're certainly not low low-risk surgery, right? So one thing that can happen is that you can have ischemia to parts of the um, you know, to branches of of the yodor, right? And that can cause problems, right? Like this person having ischemic colitis. Uh many times you can try conservative treatment for this, but if there are signs of necrosis you need to go ahead and reset, you need to go ahead

Resect, right? Or they give you a question about a patient and they tell you that the patient is like completely paralyzed in the bilateral lower extremities after a triple A repair. Then the thing you certainly want to think about is a person having a um

uh anterior cord syndrome, right, where they've pretty much uh infarcted the artery of a damcoate, right, which supplies the anterior two thirds of the spinal cord. Um you'll notice that those people they're completely paralyzed, you know. They're completely paralyzed. The only thing that will be intact spinal cord wise will be uh fine touch uh uh vibration and perceptive sense, right? Because remember the dorsal columns are in the posterior third of the of the spinal of the spinal

Right. And then what if they give you a question about a patient and they tell you that this patient, you know, had a a AAA repair two years ago and just returns for a follow-up exam. And this patient has a hemoglobin of of uh seven point five and you're told that um, you know. test of his stool for blood is positive, right? That he has hemococcal positive stool. Uh if you see something like this you really really want to think about a person having something called an ayodo enterity

festula and yodoenteric festula, right? So basically these people have formed a fistula from the aorta, right? From the adenorism that was ex that was excluded to their GI tract. So they're literally bleeding into their GI tract, right?

These people are gonna need vascular imaging of the GI tract pretty quickly, like a CT angiogram or something like that. And you need to fix that problem. If not One day they're gonna have a catastrophic bleed and then they're they're almost certainly gonna gonna die.

All right. Now, uh, what if they give you a question about a patient, right, that presents with a rupture triple A, right? What looks like a rupture triple A, and they're hemodynamically stable on initial presentation. What kind of diagnostic testing do you want to do?

Well again I'm hoping you're picking the answer that talks about a CT androgram. But if they're unstable, right, and they have direct physical exam findings, you know, like they have a pulse or dial mass, for example, pick the answer that just takes them straight to the operating room.

Okay, pick the answer that takes them straight to the operating room. But if they're unstable and they have no direct physical exam findings, get an abdominal ultrasound going. All right. So let's talk through these treatment decisions, right? Or these diagnostic workup decisions. If a person has a ruptured triple A and on initial presentation they are hemodynamically stable, pick a CT and geograph.

Right? If they are unstable and they have direct physical exam findings, right, like apostatile masks, take them to the operating room. But if they're unstable and they have no direct physical exam findings of a ruptured triple A, go ahead and do an abdominal ultrasound, right?

Now, what if they give you a question about a patient that has very severe epigastric pain, right? And they tell you that this person has a history of uh uh osteoarthritis and the person has been on chronic pharmacotherapy. Well I'd really really hope that you're thinking about a person having like some kind of uh GI ulcer, right? Like a gastric ulcer or a duodenal ulcer.

Right. Now the thing is I try to be kind here with my initial presentation. Uh person has a history of STS and chronic pharmacotherapy. Right? They know that all of you have memorized that. Let's get to a more difficult vignette. What if they give you a question about a patient?

Right. And and by the way, this person that I just gave the easy vignette for, right? Has um has a uh NSAID-induced peptic ulceral disease, right? But what if they give you a question about a patient and this person has a history of like severe acid? And the person has been on chronic pharmacotherapy, right? And then the person presents with acute onset very severe epigastric pain. Then I'd really hope you're saying that, ooh, divine, this person has a steroid-induced ulcer. Whoa.

Yeah. Right? You know, I I I tell people this in many of my classes, right? Many people always flip out about uh USMLE pool changes, right? Let me tell you this. The USML is when they do a pool change, right? It's not like they just manufacture like tons and tons and tons of new topics that nobody has ever seen before, right? Don't get me wrong, medicine is an ever expanding science, but

It does not expand so much that they can generate completely new topics every single time. No, that would be ridiculous. Because they still need to test the basics that people need to understand. But what do they do? What's a poll change? A poll change is the same concept tested differently in many cases. The same concept tested differently in many cases, right? So just keep that in mind as you prepare for your for your exams, right? So this person, um

You know, because they know that many of you have memorized this in probably every Anki deck known to mankind, right? Or you've probably seen a bunch of Cuban questions on this.

you know, a person chronically taking incest for whatever reason and then they have like sudden onset CV epigastric pain, they probably have like a ruptured ulcer, right? Uh a per sorry, a perforated ulcer, right? But you know What are other things that cause ulcers and the person can ha have acute onset CV epigastric pain?

It can be a person that chronically takes steroids, right? Or the person can even have just chronic epigastric pain, right? That steroids have caused our ulcers, right? This is why if people are gonna be on steroids for a long period of time, you tend to we tend to put them on PPIs, right? Or you see a person having like very severe epigastric pain. After they've been in the hospital for um like a

uh variceal bleed that was treated. Again they they they they have an ulcer, right? Remember if you have a lot of blood loss that can cause ischemia to your GI mucosa and that can cause ulceration of your GI mucosa, right? Or they can give you the exact same question in a person that has um

that has suffered a severe burn, right? And the person has had a stable course in the hospital and then they suddenly start complaining of severe epigastric pain, right? You see free air under the diaphragm, right? They have an ulcer that has ruptured, right? That's like a curling ulcer.

Right. So remember, we can see these things in people with burns, people with ischemia, people with increased intracranial pressures, and things like that. All right. Now, what if they give you a question about a person? Right. Um, that uh you know has a history of high blood pressure, right? Again, this is gonna be an easy vignette coming in coming through here, right?

Tearing chest pain reading to the back. I know some of you are like, you divine aortic dissection. Yes, it's aortic dissection, right? Remember typically on imaging you're gonna see a widened mediastinum, right? And again, sometimes on your exams, instead of putting aodic dissection as an i as an answer.

They'll put vascular intimal tear as an answer. Again, they'll put a Sorgate for what they know that you know, right? It's a vascular intimal tear that dissects through into the media, right? Creates that false lumen. All right.

Now, what if they give you a question about a person that is a forty five year old female and a BMI is uh forty two right and she has like very significant upper abdominal pain right on your exam.

Significant upper abdominal and back pain. If you see this on your exams, what should you be thinking about? I'd really hope you're saying that divine, this sounds an awful lot like acute pancreatitis, right? So again, remember, it's not always people that are alcoholic that will get acute pancreatitis.

People that are also obese can get acute pancreatitis. People on GLP1 agonists can also get acute pancreatitis. People on valpuric acid can also get acute pancreatitis. People on stavudine and didanosin can also get acute pancreatitis. There are many of the HIV drugs that cause acute pancreatitis, right? So keep that in mind.

Right. Now what if they give you a question about a patient and they show you an EKG and they tell you that this patient for the last three, four hours, has been having very severe upper abdominal pain, right? severe upper abdominal pain or they can see severe left upper quadrant pain, right? When you see something like this and they show you an EKG and you notice that wow, the QRS complexes are all narrow, but the spaces between the QRS complexes are diminished.

Right. Or they show you a a sawtooth pattern on an EKG. When you see something like this, I want you to think of acute mesenteric ischemia. Acute mesenteric ischemia. Right? So the thing is that first EKG I described is a person that has a fail. Right. The second EKG I described is a person that has a flauter, atrial flotter. Right. Believe it or not, it's not only people that have AFib that can get this problem that this person has of acute and mesenteric ischemia.

Right, if you have any other arrhythmia that causes an uncoordinated contraction of the heart, Right, so say for example a person has a fib or a person has a trofloter, the person can have acute mesenteric ischemia that way.

And also don't forget if you've had a recent MI, cardiac muscle has died. So your cardiac muscles are not contracting in unison. They're not contracting in a coordinated fashion. That can also cause acute mesenteric ischemia. Right? And this person that has the left upper quadrant hurting. Probably has an occlusion of the superior mesenteric artery. That's probably one of the more common arteries that are occluded in acute mesenteric ischemia on the USMLE exams. Alright, now.

What if they give you a question about a patient, you know, that has uh you know y you you you have this uh sixty eight year old male and they tell you that he has a history of like blood blood in his stool, right? And then for the last uh two days uh he has been having very severe pain. uh on the left side of his abdomen, right? And the you know, give you a temperature, you know.

left side of his abdomen, you know, they'll be intentionally vague. If they want to be nice, they'll give you left floral quadrant pain. But sometimes they can be intentionally vague and say, you know, le left side of the abdomen, right? And this patient has a fever. If you see something like that, you really want to think about diverticulation. Right. That verticulitis. So this person has a history of painless uh you know

Well, bloody bowel movements, right? That's gonna be diverticulosis, right? Uh now this person has fever, this person has left lower quadrant pain. Uh think of diverticulitis, right? And remember when a person has diverticulitis. Uh you want to diagnose it with a CT scan and do not do a colonoscopy. Do not do a colonoscopy. Right, so you don't rupture the person's uh bow. You don't you don't rupture the person's bow. Uh keep that at the back of your mind as you prep for your prep for your exam.

Right. And then uh let's just run through a few risk factors real quick, right? So what's the biggest risk factor for a triple A? You know, at least let's kinda talk about some of these topics we've talked about, right? Remember it's gonna be smoking, right? Well what's the biggest risk factor for a dissection?

Remember it's gonna be high blood pressure, hypertension. What is the biggest risk factor for a stroke? Or remember it's gonna be high blood pressure, right? And then what's the biggest risk factor factor for coronary artery disease? It's gonna be smoking. It's gonna be smoking, smoking, smoking, right? It's gonna be smoking, smoking, smoking.

You know, there's one confusion that many people kind of pop up with these days on the exams. And I see this all the time on Reddit. I'm like, what are these people doing? Right? See guys, the fact that something is a modifiable risk factor does not make it the biggest risk factor for a problem.

It just means that oh you can modify it basically like whoa you can maybe stop doing that thing and you won't get that bad outcome. But the fact that something is a modifiable risk factor does not necessarily make it the biggest risk factor for a problem. And then another basic we wanna know about Triple A since we've said so much about Triple A's today.

Right, remember the screening guideline, right? If you have any smoking history, right, and you're between the ages of sixty five to seventy five and you're a male, we're gonna screen you with an ultrasound, right? And also if you're a first degree relative, uh you should also s Screen first degree relatives, right? So if you have a first degree relative that has uh like a triple A or history of a triple A, you should get screened for a triple A if you're a man.

Right? If you're a man, if you're a man. So keep that in mind on your Right. And what's the normal diameter of uh of the odor below the renal arteries? It's typically up uh it's typically two, right? But once it becomes more than one, you know, if it becomes one point five times or more that amount, right? So like three centimeters or more.

Then that tells us that okay, you have an abdominal uh iodic aneurysm, right? So remember again, if it grows by more than half a centimeter in six months or a centimeter in a year, it's like, ooh, we're gonna fix it, right? If it's more than five point five centimeters on initial presentation, ooh, we're gonna fix it. If you're symptomatic, ooh, we're gonna fix it, right? So keep that in mind for your for your exams, right? Now what if they give you a question?

about a patient that has um sudden onset severe leg pain, right? And they have like no pulses in the legs. They have like just very severe pain. A lot of parasthesias, a lot of palos. Right, they have like power, they tell you that they have like unilateral lower extremity power. Then you want to think about acute limb ischemia. Think about acute limb ischemia. Today I'm trying to introduce concepts with simple. I I want to kind of kind of get you thinking like the MBME.

I want to introduce the concept with a simple vignette and then start going into the more difficult directions that they love to exploit, right? So you're like, okay, divine, yeah, pain in the low extremities, sudden onset, no pulses. uh paresthesias, pallor of the extremities, of course divine that's acute limb ischemia. All right good.

Right. And the easy peasy one is you're gonna find it in people that have a history of a recent MI or people that have a history of AFib, right? Um think of acute limb ischemia, no big deal, right? No harm, no foul. Okay. Now, let's go in some strange directions that you may see see on your on your exams, right? So uh first thing is uh

Obviously, right, these people formed an embola in their heart, right? The person probably has like AFib or Resin MI, formed an emboline embolos in the heart, and then he flicked off wind and occluded a uh low extremity vessel, right? Now, sometimes on the USML exams, they'll want to kind of trick you. With uh between this and compartment uh syndrome, right? So be be careful, right? The thing is people that have compartment syndrome typically they're going to have uh

Pain with just any kind of movement of the extremity, right? Pain with literally any kind of passive motion of the extremity. That's compartment syndrome. That's not going to be acute limb ischemia, right? So just keep that at the back of your mind for your exams. And typically, compartment syndrome tends to be associated with trauma. As against acute limb ischemia, uh that tends to be associated more with um, you know, like recent MI or or AFib and things like that.

Right. And then uh if they give you a question, again, let's do some simple things and then let's start hitting some strange things, right? So if they give you a question about a person that, you know, is a big time smoker, right, and the person has pain with walking that improves with rest, right? Think of peripheral arterial disease.

Right. Sometimes on your exams, instead of using the term peripheral at your disease, they'll use the alternate name chronic limb ischemia okay so there's acute limb ischemia and then there's chronic limb ischemia chronic limb ischemia is literally another name for uh peripheral arterial disease again remember the usm lease they may use alternate names on your exams right

And then remember, if a person has chronic limb ischemia and you notice that they started having paralysis, that may be an indication that those people need a uh some kind of uh probably they need amputation or they need immediate vascular intervention. Right. And then remember the most common cause of arterial embola is gonna be AFib. The most common cause of arterial embola is gonna be AFib, right? Okay. Now what if they try to give you an anatomy question with a person that has uh

uh acute limb ischemia, right? And they tell you that, you know, the person has like unilateral foot and calf pain, right? And the person has uh barely palpable or very indistinct femoral pulses. and no pulses in the no the, you know, penal pulses are absent and whatnot.

Where's the problem? Where's the occlusion? Well, the occlusion is going to be at the common femoral artery or the superficial femoral artery, right? But if they give you a question about a person that has like unilateral foot pain and they have intact femoral pulses, but they have intact absent pedal pulses, absent pedal pulses.

They want to think about this person having uh occlusion of the popliteal artery, occlusion of the popliteal artery, right? Now, our friends at the MBMEs, they can literally give you an acute limb ischemia question and ask you like what's the most uh likely mechanism behind this patient's presentation?

And they'll put an answer that talks about embolic phenomena. They'll put an answer that talks about thrombolic phenomena. They will put an answer that talks about a vascular interruption or something like that. What answer should you pick? Let me let you think about that for a second. What answer should you pick? おらずしりょうぺ Well please pick the answer that talks about thrombotic phenomena. Whoa.

Divine. I've always thought that acute limb ischemia was secondary thrombolic phenomena. No, it's not. No, it's not. The most common cause, actually, believe it or not, is thrombolic phenomena, right? So you have an atherosclerotic plaque.

in a vessel, especially in people that have a history of peripheral arterial disease, it ruptures, right, and then goes and occludes a a distal vessel or whatever, right? Kind of like an MI. It's almost like an MI of your lower extremities. Like in a lower extremity audit, right? So remember the most common cause of acute limb ischemia. is a thrombotic phenomenon, kinda like an MI, not necessarily embolic. I know many resources. Even I have, you know, talk about AFib, uh recent MI, A Flutter.

Forman embolus in the heart, flicks off, goes, occludes, a lower extremity artery. Yes, yes, yes, yes, yes, yes. But the most common cause is thrombotic, right? The USMLEs they love to throw these epidemiologic questions. They love to throw these epidemiologic questions, right?

You can see that if you've not heard this from this podcast, I can almost promise you you probably get this stuff wrong on an exam. Right. And again, remember, how do we treat acute limb ischemia, right? Uh pretty straightforward, right? Go ahead and give them heparin, right? Give them some kind of uh antiqualation, right? Heparin, right? And then do a v uh

Uh do a CT androgram of the of the lower extremities, right? And again, if you notice that they have like uh an irregular rhythm on oscillation, you should probably go ahead and get a uh transthoracic echocardiogram to maybe screen them for like some kind of clot in the left atrial uh appendage, right? And typically we're gonna manage it with uh embolectomy, right? Or you can do a uh

uh catheter directed uh thrombolysis, right? Although that tends to be more for for mild cases. And then what if they give you a question about a patient? That you know, they've they had acute limb ischemia, they were successfully revascularized, and then they give you an EKG and you notice that hmm, this person has like a YQRS and they're creating a study uh study right.

What's going on here? If you see something like this, I want you to think of a reprofusion injury, right? Reprofusion injury. Right. So remember, after you fix um uh a part of a limb that has been ischemic. Sometimes that reperfusion, you know, the influx of blood and oxygen back. Sometimes can cause like some free radical damage and you start having muscle cells exploding, right? You'll notice that these people's creatine kinase is elevated, right?

And they can have like uh because muscle cells are exploding because of the ferradical injury, they may have myoglobinuria. That's what's causing the creatinine to rise. Right. And as those muscle cells are exploding, remember potassium is an intracellular iron.

Right, so those people can have hyperkalemia. Those people can have what hyperkalemia. Those people can have what hyperkalemia. Right. Obviously, right, like if they're having these EKG findings, you want to go ahead and give them calcium gluconate. Calcium gluconate. Calcium, calcium gluconate. All right. So stabilize that myocardium.

So thank you for listening to me today. I think I'm gonna go ahead and stop here. I think I've made a lot enough of vascular integrations, right? So please, this podcast is just one of those uh rapid reviews that kinda sits there on its own. But there is so much high yield stuff I talked about today, right? And if you love the way I teach, you're gonna love my classes. You know, literally starting next week Tuesday, I have uh

25 hour step one review is for step one and for those taking step two, step three, to have a poor or a distant basic science foundation, right? Um I'm telling you that that class is gonna be really, really helpful to your to your study. It's gonna be really helpful to your studying.

Uh because again, uh the USML is these days on step two, step three. They have started testing basic sciences more and more, right? In fact, these days I think I strongly recommend more and more people take that step one class. And then, you know, um after that, so it's a twenty five hour class and then after that I have a uh a step three C C S framework class, right? So if you're taking step three and you wanna

Uh th think of it as like the pathophysiology of CCS cases, right? I have that class uh on the eighteenth. And then I have a testing and strategies class that's for step one to three, uh biostats class for step one to three, uh social sciences quality improvement.

ethics and a hospital medicine review also for step one to step three. Right. And then after that I have a last minute review just for step two and step three and a twenty hour step two step three review. Right. And then in the month of June next month, I have a very, very clutch 50 hour step two, step three review, right? We go through tons of questions. That that class is just exceptional, right? Very, very, very limited spots still available. So if you're interested.

shoot me an email and I can give you some more information. And remember I also offer one and one tutor for all the US ML and Complex exams. And um I have these podcasts on Apple, Google and Spotify. And I have a YouTube channel, Divine Intervention, USMLE podcast and videos, where I have some really good uh videos on there and some podcasts as well. And then also, um

Uh, you know, many of you know I'm a Christ follower. I have another website called uh divine intervention life lessons.com, divine intervention life lessons.com. Every week I post one or you know, at least a podcast where from a biblical perspective I address a life lesson. There's three hundred and ninety one episodes on there. Right. There's actually an Apple podcast associated with that called the Divine Intervention Life Lessons Podcast. So

Thank you for listening to me today. Share this with your friends and your colleagues. Please. This podcast is really high yield. There's a reason why you see me emphasize certain things I emphasize in this podcast. But I'll see you in episode 652. Have a wonderful day. God bless you and bye for now. Thank you.