today and feel free to let me know where you're logging in from say hello to everyone we have a international audience we're going to get started in just a little bit excellent we have people logging in from Romania Arkansas Texas oh this is epic and if you are excited for today's review and you want to share it with a friend of yours colleagues your class here is going to be the live stream link I'm going to post this on my Instagram story right now as well but feel free to share this live stream link if you are going to be joining this session and we'll get started in just a little bit excellent and if you have just joined us feel free to say hello and where you are logging in from excellent we'll give it just about two more minutes as people log in all right we have people from Phoenix excellent all right well if you haven't done so already I would encourage you all to open up your chat box say hello keep the chat box open I got my uh chai tea here for the uh session and we're GNA get started and just about a minute we have people logging in still great and if you have not yet shared the live stream link feel free to tag me on Instagram YouTube share this with your colleagues and friends it's going to be a very high yield review session today so I am super excited before we get started in just about a minute can you all say yes into the chat box if you can see my slides see these annotations excellent all right so audio visual everything is good great well let's go ahead and get started with our review today for those of you if this is your first time I want to welcome you all to the high Guru family and if this is your second third or 100th webinar with me a warm welcome back my name is Rahul I'm a practicing pediatric critical care physician and I'm also a extremely passionate medical educator I help students just like you kick ass for the USMLE step one shelf exams comp Step 2 CK and everything in between feel free to connect with me many of you have already signed up for my courses which I offer at H guru.com but we will be going through some of those nuances and details if you're interested towards the end of today's webinar so I know that there are so many resources out there there are many question Bank resources out there amboss uor Etc but I want to take a few minutes just to talk a little bit about what I think makes high Guru extremely unique when I started High Guru I wanted to really focus my whole curriculum and the lectures on evidence-based learning science hauru is a strategic Active Learning approach and throughout my videos what you're going to be seeing is a emphasis on vignette focused learning my goal is for you to not slam the space bar and just get small details it's actually for you to understand how these exam questions are written and what you're going to be seeing on Prometric exam day hi Guru really focus is on integration what you'll see today is we will be taking a singular concept from an organ system and see how it applies to other organ systems for example we're going to be going through all of the neoplasms and associations related to smoking so I want to integrate knowledge as I go through today's session and in my courses third I focus a lot on test taking strategy it's important for us to have a system so we can have a consistent output and finally I know that this is not just a Content question bank or test taking strategy grind but it's a mental grind as well and I want to make sure that I stay Dynamic throughout all of my lectures so that we can focus on Peak test taking psychology so you can perform on exam day so when I work with students oneon-one or when I am tasked to come to a medical school one of the things that I Center myself on is the Triad of usla Step 2 CK preparation it's all about making sure you have good accountability and study scheduling making sure that you are leaning into questions with a clinical reasoning framework and like I said before it's all about staying positive throughout the journey sometimes you're going to be getting some lower blocks other times you're going to do extremely well on the nbmes understanding that this is a nonlinear process and there are going to be ups and downs is essential for you as you go through the shelf and step 2 CK process most importantly and I see about 200 people joining me today which is absolutely phenomenal hauru is a lifelong Learning Community it is a global community that all of us can connect via because we have that common threat and that is succeeding on the US mle so in the past year 2024 this has been some of the uh success stories that I have been uh fortunate to be a part of both from a one-on-one tutoring standpoint as well as being a part of my courses and I'm so excited to have you join today and share in my passion and energy now many of you may be seeing on my YouTube channel that I have a growing top nbme shelf Concepts or step 2 CK uh lecture database and here I have my highest yield lectures posted it's a short sample it's only about five to seven videos this is a great sample if you are going to be interested in getting kind of the full comprehensive review of internal medicine peed surgery Etc I have a rapid review step two CK course especially if you are going to be going through your shelf exams or you are near your dedicated study or in your dedicated study this rapid review course is essential because what I do is take all of the highly tested Concepts from nbmes and I synthesize it into an active Recall review what I've also done with many of my lectures is as you can see here on the bottom I've mapped some of the highest yield questions you can engage in after I go through a certain concept so so this has been a Innovative approach you can sign up on hur.com and what I will do at the end is open up to a question and answer just to help you guys during your shelf and step 2 CK preparation at the end if you stick around we'll be going through that question and answer and then I can also at that time answer any questions you have about the course but first what we're going to be doing is starting off our family medicine review we are going to be focusing primarily on the US pstf screening guidelines this is also going to be relevant for those ambulatory medicine questions under the Shelf tab in your uld question bank so what are we going to be covering over the next 50 minutes to an hour we're going to be focusing on key definitions for preventative health everything from primary to quy screening prevention I'm going to provide you a test taking strategy so that then you can employ this when you get preventative health questions and then we will be breaking down the uspstf guidelines in a very integrated way first what I'm going to do is I'm going to be separating it by age and gender and then second what I will do is break it down by organ system and I'm going to be just hitting you all with vignettes so we can apply the uspstf guidelines rather than just root memorize them them there are some nuances with age and certain risk factors so if I create a framework for you all then we can apply it to relevant uh cases and then finally there is going to be a focus on vignettes especially the vignettes that you will see on nbme exams as well as in your high yield question Banks now many of you may be studying also for the family medicine shelf and I just wanted to highlight the family medicine shelf content specification outline what you see here is the breakdown of the nbme family medicine shelf and as you can see many of the questions are going to test your knowledge on adulthood preventative health and Family Medicine Concepts there is a small percentage that is focused on Child and Adolescent as well as geriatric what I also want to emphasize is the fact that the family medicine shelf in particular is chalk full of msk questions so what I would do is if you have for example your uor or amboss question Bank you should review specifically the msk questions in depth because as you can see up to 20% of your family medicine shelf is going to be msk and if you YouTube 100 Concepts in msk I have a nice step one review that I still think is very relevant for your shelf or step two that you can watch right before your family medicine shelf the other component that I want to emphasize here is our Focus for today Health maintenance it's about 20% of the questions that you will see on your family medicine shelf so I hope that this overview and outline helps you tweak your studying as you're getting closer to your family medicine shelf remember if you're in dedicated study for the US mle you will be getting ambulatory questions and that's the focus of our discussion today so before we do get started I do want to provide you all a nice link that you can use as a handout today you can download it on your iPad print it out after the session or pull it up on your computer or device feel free to open up your chat box right now and I am going to be dropping in a highi PDF link if you're watching this later on I'm going to put this in in the video description but this link is going to have the overview of all of the uspstf guidelines updated to 2025 there was recently just last week the osteoporosis recommendations that got a little bit tweaked we're going to be covering that but if you guys don't mind letting me know does this link work when you click on it go ahead and type in yes if you are able to access this link okay Fabiola PRI okay excellent wonderful thank you guys so much for following along with this link and again I do have a download link as well that is right underneath the um uspstf guideline handout that you can then just uh drop to your iPad or tablet and annotate with me all right so with that we're going to go ahead and get started is everybody excited to get started today see a lot of yeses from the prior question but I hope that that is Yes again all right anushri is Nader is yosra Isaiah has a let go excellent well let's go ahead and get into our first question today a medical student is participating in a health fair the student is particularly interested in understanding prevention to optimize his patient's Health which of the following best describes an example of primary prevention a lipid lowering therapy b c ing on smoking cessation C hemoglobin A1c monitoring D colonoscopy or E reducing poly Pharmacy go ahead and type your answer into the chat related to primary prevention excellent if many of you are saying B you are absolutely correct counseling on smoking sensation let's go through this pyramid of the prevention Concepts the us MLA is going to give you at times either a drug ad or some sort of experiment-based question and they may ask you to integrate these public health or epidemiology Concepts so these definitions and the examples are going to be very high yield let's go through this primary prevention is what our question was talking about it is preventing disease onset this is a lot of your counseling and lifestyle modifications before the disease even starts we want to nip it in the butt so an example would be counseling on healthy diet and exercise now what about secondary prevention secondary prevention is going to be a screening test this is going to be where our colonoscopies mamogram cap smars are going to be these are again the USPS or United States preventative task force screening recommendations these are what you're going to be tested on on your exam day secondary prevention is screening tertiary prevention is tea treating this is going to be where you are going to treat a disease that somebody has to prevent morbidity so what's an example of that it is going to be for example monitoring hemoglobin A1c or a urine analysis if somebody has type two diabetes so the goal of tertiary prevention is to treat the disease and make sure you understand the complications of the disease so that then you can prevent sequ and then finally we have quaternary prevention and the quaternary prevention is to essentially prevent harm and that is going to be preventing overmedication so an example is let's say a diabetic on your exam question is going to have recurrent hypoglycemia they're either on insulin or oral sanura quaternary prevention is discontinuing the oral sanura or reducing the level of amount of insulin medication you're giving the patient so that then they have less hypoglycemic events so quaternary prevention is quitting unnecessary medical interventions now if you subtly look at what I did as an educator I put a green light or traffic light uh type of configuration tertiary prevention stop you already have the disease secondary prevention that's screening and then you have green light which is primary prevention preventing the disease onset all right let's go ahead and apply this knowledge a 28-year-old female is diagnosed with gestational diabetes the OBGYN provides recommendations to monitor her blood glucose checks throughout the week and log it in a diary which of the following disease prevention strategies is most likely floyed in this patient who hint already has gestational diabetes go ahead and type that into the chat primary secondary tertiary or quatron excellent and if you're saying that this is tertiary prevention she has the disease already and we are doing things surrounding the gestational diabetes such as preventing sequella by logging the blood sugar that is going to be an example of tertiary prevention excellent work the other very high yield concept that usla likes to test you on are characteristics of the ideal screening program they may give you an experimental question and ask you which of the following is most likely in this screening program or related to the screening program what you have to know is that screening programs have to be related to common diseases these diseases should have a long asymptomatic phase for example colon cancer cervical cancer these are all very slow growing neoplasms second this actual disease has to be correctable if identified early it cannot be subject to lead time bias lead time bias is where you detect the disease early however that doesn't necessarily modulate or alter the ultimate prognosis if I end up screening for crud file yab disease or a pron based disease early well yeah I can catch it five years before but there's nothing I can do to modulate the mortality which is high in cral yakob disease so preon diseases there's not going to be any screening why because it's a rapidly Progressive disease doesn't have a long asymptomatic phase and there's no real treatment for those preown based diseases the other high yield characteristics is that a screening test must be related to a disease that has high prevalence in the screen population just like many of the public health interventions we have to have optimal cost and the screening test should have a very high sensitivity and specificity let's go ahead and go through this biostats concept what the usml will do is provide you two major graphs the first graph is going to be known as the area under the receiver operating curve this tells us whether or not we are going to have sensitivity or specificity and plots it so that then we can figure out the characteristic of that screening test so here we have on on the xaxis 100 minus specificity and on the y- axis we have sensitivity so the ideal screening test needs to be in this upper left quadrant if you don't know anything about Au curves you just need to know that the upper left quadrant is the most ideal but if you look at the axises you see that this upper quadrant has a high sensitivity and because it is 100 minus specificity it is going to have a high specificity as well because let's say that specificity is 99 well that then shifts the xaxis towards a lower number and as you can see left upper quadrant under the Au curve is the optimal for a high sensitivity and specificity the other component that the usml likes for you to know is a question related to the set point now here is going to be a curve that shows test results relative to the frequency of the disease what we notice here is that the dashed line is going to represent diseased individuals whereas the solid line is going to represent non- diseased individuals and you can see at Choice B this is going to be the best sweet spot for a screening test at level B you have a balance of sensitivity and specificity but let's go through this B question If a screening tool is changed to detect prostate cancer at a much lower threshold so rather than saying prostate cancer at for example a PSA of eight they're going to say a PSA of six now defines a higher risk of prostate cancer if the test was shifted to a lower threshold what parameter would change and so what the answer would be in this question is if we are going to lower our threshold we are going to then be capturing more people with the disease so a lower threshold means that you capture more people with the disease and that's extremely high yield for us to know because what that means is that we are going to increase the amount of sensitivity so if you capture more people you get a high sensitivity and if you get a high sensitivity you get a low false negative that means that if I get a test it is going to definitely capture me I will not be classified as falsely negative this is extremely important because in this curve we see here that level a is going to be where you're going to get more sensitivity so lowering a threshold of the test captures more of the population you become a lot more sensitive and as a result you are going to get higher sensitivity with less false negative rates all right so this is going to be the core of our discussion today let's go ahead and break down this timeline capturing all the highest yield uspstf guidelines I updated it based on the most recent B recommendations these are the ones that are highly tested for your nbme and family medicine shelf questions and again if you have missed the handout I've put it in the chat box right here all right starting at 18 years of age for adults you are going to start screening for blood pressure what you also have to note is that blood pressure or hypertension can only be diagnosed as essential hypertension if you have more than one reading and we'll talk about that in just a bit you also are going to start depression screening in adolescence particularly when they are 12 years old in my Adolescent Clinic as a Peds resident we started screening because those children were getting into middle school and high school all about thoughts of sadness or suicidal ideations you also will be starting to screen patients who are at high risk for STI but one of the interesting recommendations is that the uspstf is going to recommend HIV testing starting at the age of 15 and this is going to be at times irrespective of your risk status now speaking of risk factors if you have a teenager or 18-year-old young adult that is going to be obese is going to have a family history of diabetes or let's say that they have acanthosis nigran you're going to be doing a fasting blood sugar as well as a hemoglobin A1c starting much younger than the prescribed mid-30s recommendation of screening for diabetes so you start diabetes screening earlier for 18year olds who have a strong family history who are obese and who have signs of insulin resistance this is similar at the age of 20 for again patients or young adults who are at risk maybe they have obesity they have a hereditary dyslipidemia or uh a strong family history of coronary artery disease you are going to be screening for the lipid disorders using a fasting serum uh lipid panel and here are going to be some of the general recommendations in terms of threshold that you can see here what I want to do is want to say that I want to say that the USM MLA Step 2 CK makes it very obvious with these screening recommendations so don't stress too much with these nuances just focus on the concept that if you are at higher risk you're going to get screened earlier this one is very high yield especially for OBGYN shelf starting at the age of 21 up until the age of 65 you are going to be screening for cervical cancer remember that with screening for cervical cancer it is going to be every 3 to 5 years and we will be going through the nuance and that is that at age 30 you can get co-testing with HPV as well as the cytology we're going to cover that a little bit later on but remember cervical cancer screening in majority of females at age 21 there's also a recommendation to to screen young adults less than 24 years of age who are sexually active for STI this is going to be true especially if the patient or young adult requests the SDI screening or they have an active STI so there's a uor question that talks about a patient who has gonorrhea well if they have an active STI we need to be screening for chlamidia syphilis HIV Etc starting at the age of 35 no matter the risk you should be screening for diabetes as well as dyslipidemia so you will get a fasting hemoglobin or fasting uh lipid screen you will get a fasting blood sugar and a hemoglobin A1c at the age of 40 there is a cardiovascular intervention and that is going to be aspirin prophylaxis this is going to be starting at the age of 40 in s populations those populations that are going to have a ascvd or cardiac calculated risk of greater than 10% those patients who do not have a bleeding risk and those patients who are going to have at least a 10-year life expectancy so what is important for us to note is that if the patient in the vignette has thrombocytopenia or has a GI ulcer you do not want to give Aspirin because they are at higher risk of bleeding and thus you don't want to start a Cox inhibitor that will reduce platelet aggregation and activation at age 40 you also are going to be having the females get screened for breast cancer via mamography age 40 to 74 years old you do breast cancer screening every 1 to two years starting at age 45 5 till the age of 75 you're going to be doing colon cancer screening there are some nuances but colonoscopy is preferred there are alternatives such as stool based testing or something like a sigmoidoscopy which we'll cover a little bit later on from age 50 to 80 if the vignette mentions long-standing smoking greater than 20 pacur you will be doing a lowd do chest CT scan to screen for lung cancer remember a lowd do chest CT scan is not going to have any contrast based medium at age 55 there are recommendations to consider PSA screening I will say that this has fall out of favor but I put it here for completeness sake starting at age 55 PSA can be screened digital rectal exam is now out of favor for prostate cancer screening wrapping up here we have age 65 at age 65 if the patient is going to be a smoker or has ever smoked has a history of smoking then they will be screened via abdominal ultrasound for an abdominal aortic aneurysm this is from 65 to 75 it is a one-time screen and what you want to note is that regarding your AAA screening that is a one-time screening whereas the lung cancer screening is usually going to be yearly compare and contrast those two starting at 65 females especially will be undergoing osteoporosis screening what is important for us to know is that at less than 65 years of age if the female has menopause or any other risk factors you can do a bone mineral density scan which is going to be a dexa scan typically the dexa scans are going to be repeated based on your te score it can be anywhere from 3 to 10 years and the US MLA doesn't necessarily help make you tease those uh intervals out for osteoporosis screening now the prior recom recomendations before these last week recommendations came out emphasize that if the patient is less than 65 years of age they can be stratified using a fracture assessment score and this is the fra score but what these new guidelines just said were you can use the fra score but it is not mandatory so less than age 65 if in the vignette you see that the patient has celiac disease is on prolonged glucocorticoids or had menopause age 50 you can consider osteoporosis screening via dexa so just to emphasize the high yield ones here breast cancer screening starting at age 40 aspirin prophylaxis starting at age 40 colon cancer at age 45 smokers are going to at age 50 get lung cancer screening are going to get abdominal aortic aneurism screening at age 65 osteoporosis screening starts at age 65 however can be younger if there are going to be risk factors so I just like to draw this little schematic here for myself and triaa stands for abdominal aortic aneurysm you have lung cancer that is going to be starting at age 50 whereas your abdominal aortic aneurysm abdominal ultrasound is going to be at age 65 years old again I want to emphasize before I move on that the US MLA makes these questions extremely obvious the other point that I want to make here is the fact that the usml is starting to add in transgender health questions and what I note here is that if there is a transgender individual that has not had genetic modification surgery you will follow their CIS gender or the gender that they were assigned at Birth screening guideline and again these are very sensitive conversations however you do want to keep in mind the cisgender screening guidelines for any transgender individual all right this is dense but you know what we're going to do now keep this open take a screenshot we're going to be now applying it to different vget let's go ahead and go through this first nbme question to apply our diagram are you guys enjoying this review so far everybody doing okay go ahead and type in yes into the chat box excellent I want to definitely just like break it down for you all make it fun let's go ahead and go through this high yield vignette A 42-year-old woman presents for follow-up after recently being treated for a urinary tract infection with antibiotics during her visit to the emergency department she was informed that her blood pressure was quote mildly elevated she has no current symptoms a significant medical history or regular uh physician visits her family history is unremarkable and her lifestyle is pretty active she jogs twice week weekly she maintains a healthy diet she's not on any medications so what these all are are pertinent negatives they should rule you away saying that she is a relatively healthy female her blood pressure today is 142 over 91 and her BMI is 28 physical exam EKG and laboratory results including a basic metabolic panel are all normal again another pertinent negative which of the in is the best next step in managing this patient a advise weight loss B obtain multiple home blood pressure readings C obtain polysomnography D start double anti-hypertensive therapy or E start a single anti-hypertensive agent what do you think is the best answer here excellent well this concept basically tells us that you need to have confirmatory screening for blood pressure it's not correct to just do a single blood pressure screen and say that you have hypertension because there's that phenomenon known as white coat hypertension the other thing to note is that in the emergency department yeah anybody's blood pressure can be elevated so you want to do this essential hypertension screening when the patient is well this is going to be a phenomenal slide for you to save this goes through not only the definition of hypertension however what are the ways we can confirm the diagnosis so definitions of hypertension uh blood pressure greater than 140 over 90 is generally accepted there are some health bodies such as the American Heart Association that lowered that threshold in pediatric patients patients who I work with we typic in patients less than 13 years of age look at the normal normative uh guidelines of uh those patients and their blood pressure and if they are going to be greater than the 95th percentile for their blood pressure we diagnose hypertension now white cat hypertension is a phenomena and this is this concept that if the patient is in the doctor's office they could get a 5 to 10 mm Mercury High reading in the office so in this patient the patient was 142 over 91 and what we have to do is confirm the diagnosis of hypertension so what are the ways we can confirm it the first way is going to be an ambulatory blood pressure cuff this is going to be a wearable device that the patient can wear and it squeezes their arm every hour or so and they can wear it for about 2 days and get those readings second you can do home blood pressure monitoring this is where you can say grandma go ahead and measure your blood pressure in the morning and in the afternoon for a week and if there is a trend of increased readings then we can diagnose the patient has hypertension and then finally if the patient is unable to do home monitoring or ambulatory monitoring you can bring them back to the office for at least three occasions one week apart to diagnose hypertension again the Point here is that you need to have confirmation rather than a single blood pressure reading so let's say in your vignette the patient is diagnosed with the cenal hypertension what are going to be the next tertiary prevention components which you do need to get well you need to get a renal function panel you need to look at the kidney function what are the electrolytes looking like what is their bu to creatinine ratio what is going to be their UA does it show any signs of end organ damage like proteinuria when somebody gets diagnosed with hypertension you also must think about endocrinological causes and screenings you may want to get a hemoglobin A1c because hypertension dislipidemia and uh your um dis glycemia is going to be associated with metabolic syndrome patients may also get a thyroid function panel finally you could also consider further cardiac testing after you have a patient with new diagnosis hypertension usually patients will get an EKG but there's an increasingly push to also get an echo again why is this because if you think about hypertension it is going to be a chronic afterload state if it's a chronic afterload State what's the structural complication left ventricular hypertrophy and so what we want to do is look at the EKG for any voltage criteria or the echo just showing the thickness as a baseline of the left ventricle in particular what is also highly tested on your shelf exam questions are secondary causes so basically this is going to be uh or these are going to be vignettes related to the patient having a high blood pressure and then you extrapolating what could be other pathophysiologies or diagnosis the patient could have for example if they put Brey on physical exam you're worried about renal artery stenosis if the patient has hypertension and hypokalemia that's very important you may be considering some elevation in the renin Angiotensin aldosterone system maybe it's an aldosterone secreting tumor if the patient is going to have symptomatology such as weight gain abdominal stria poor wound healing you may be thinking about Cushing's Disease and remember these patients can also have hypoglycemia if the patient has per tox isms of hypertension headache calor you could be thinking of a sympathetic tumor like foch chromosoma and then another one that I find extremely high yield is going to be obstructive sleep apnea remember Osa is going to cause you to have increased CO2 throughout your body that can then cause you to be in a very stressed State elevating your systemic vascular resistance leading to hypertension I also like to note with Osa that patients on your are going to have morning headaches and also they are going to have potentially a reactive poly cymia and that means that their hematocrite may be low because they could be chronically hypoventilating that then is going to have the kidney sense oh gosh there's probably low oxygen throughout the body and thus it's going to upregulate the amount of erythropoetin thus increasing your hematocrite all right so with that I'm going to ask another application-based question this is important for us to go through please stick with me stay inspired stay active stay engaged cut out all your distractions here we go a 58-year-old man with type two diabetes presents for routine followup his medical history includes hypertension and diabetic kidney disease he is currently on met foran linil a tvasta his blood pressure is 138 over 82 his most recent hemoglobin A1c is 7.8 laboratory results show a GFR of 45 a elevated urine albumen to creatinine ratio what do you think we could do to reduce the progression of the kidney disease pay attention to the St a aggressive lipid management B switch lysil to a calcium channel blocker c a low protein diet d add sglt2 inhibitor like kagin or E aspirin therapy what does everybody think is the best answer here go ahead and type it into the chat box excellent in this patient who is going to have diabetes plus hypertension the USM wants you to know that you need to have patience on ace inhibitor that's why B is going to be wrong remember that if we go back to a high yield concept from pathoma what pathoma basically teaches us is that here is going to be the glomerulus aeren eerin arterial if you have diabetes you get preferential non-enzymatic glycosilation of the eerin arterial that then is going to cause a glomular stress that can expand the zum known as Kimmel and wilstein nodules and then you can have increased Glam capillary hydrostatic pressure that can lead to micro alua and subsequent macro albuminuria so what ACE inhibitors are going to do is they are going to dilate the AER e excuse me eent arterial and as they dilate the eent arterial you're going to get less mangial stress and less of the micro alua so it is protective but what we also want to do is we also want to make sure we have aggressive control of the underlying cause and that is aggressive control of the diabetes usually we want to for these high-risk patients make the hemoglobin A1c less than 7% because that then is going to reduce the progression of the kidney disease so an sglt2 inhibitor is going to make you pee out a lot of glucose and then hopefully red edce the serum glucose levels over a long term and thus you can make your 7.8 closer to that ideal seven Target all right so as we continue to break down our framework today I want to provide you a test taking strategy that you can use whenever you get a screening question number one you have to note that many US MLA Step 2 CK questions have patients in the office setting they're going to say a 55-year-old male presents to the office for routine Health evaluation just pay attention to the fact that screening questions usually are asked in the office setting second here is going to be the test taking framework I use number one localize the age I usually never use age as a basis for my diagnosis however what I do focus on is age if they are going to be asking me a preventative health question you want to also identify risk factors as you saw in Prior questions and in that summary diagram if the patient has a history of obesity or the patient has a family history that's relevant that could change your screening guidelines and then finally what you will do and this review helps you here is apply the uspstf guidelines all right so let's go ahead and go through three cases to solidify our knowledge a 68-year-old male with COPD presents to the office for routine Health maintenance so remember he's 68 he began smoking at age 18 so a long-standing history of smoking however he has quit in the past 10 years so he quit at age 58 what screening exams would be indicated in this patient I'm going to pause right here I want you all to go into your diagram isolate what this patient would need in terms of screening and type your answer into the chat box very good so screening exams that would be indicated lung cancer screening as well as abdominal aortic aneurysm screening so let's go ahead and go through this in a little bit more depth so this patient is going to require lowd dose chest CT scan and AAA surveillance screening lung cancer screening guidelines here we go it starts at the age of 50 up to the age of 80 it is going to be for patients who have greater than 20 pack year smoking history as you can see he began smoking at the age of 18 and he is 68 years old this is going to be a yearly interval remember AAA is usually a onetime whereas lung cancer lowd dose chest CT is going to be at a yearly interval and you are going to terminate screening either at the age of 80 or if the patient has successfully quit for greater than 15 years and as you can see in this vignette the patient quit in the last 10 years so he still does need lung cancer screening for the next five years if he continues to successfully quit for a total of 15 years so I want to provide an epidemiology integration obvious we all know the health risks related to smoking but remember that smoking sensation really reduces the risk of lung cancer on the Contra if you are going to have a patient that is going to have a heavy smoking history the probability of lung cancer in this hyperbolic uh uh relationship is going to go up what is really important for us to know is that if the patient even just quits for 5 to 10 years the patient has a 50% less risk of developing lung cancer and what's also interesting for us to know is that if the patient quits for more than 15 years the risk of lung cancer is the same as if you had not smoked ever and so that's probably one of the rationals as to why you stop when the patient has successfully quit greater than 15 years of age smoking is a very important risk factor in my step 2 CK course I have a whole set of videos just focus on risk factors because I think they're so high yield let's go through the various risk factors related to smoking the one that is highly tested is pancreatic cancer this in your vignette usually presents as painless jaundice you also want to note that smoking is going to affect blood BL vessels so it could be a risk factor for subarachnoid hemorrhage or aneurysms within the brain smoking is going to connect or contact with your oral fairings and thus you can have smoking as a risk factor for head and neck cancers smoking is also going to be a risk for oral cancers especially because the smoke is going to uh enter the mouth and then that can cause you to have carcinogenic mediated damage and you can have cervical lymphadenopathy that can occur or submandibular lymphadenopathy smoking is also going to affect the esophagus just think about how the smoke is coming in it's a risk factor for squamous carcinoma in particular it also is going to be an increased risk for blood vessel complications that can lead to abdominal aortic aneurysms again smoking causes endothelial injury that can break down the tunic am media and thus you can have an aneurysmal dilation smoking is going to be a risk factor for renal cell carcinoma as well as bladder cancer because remember the smoke or the polycyclic hydrocarbons are going to be excreted via the urinary system so it is going to uh come into contact with the renal and the bladder tissue remember that pancreatic cancer presents as painless jice whereas bladder cancer usually presents as painless hematuria so here's a basic science integration for us smoking is a cellular stress which can cause a histological change that can lead to neoplasia based on the metabolism of polyc hydrocarbons these are the things that are carcinogenic they cause free radical injury as well as endothelial injury and that's why it compromises the blood vessels all right same patient 68 years old has COPD he started smoking at 18 has successfully quit in the last 10 years that's great another screening that he would need is a abdominal aortic aneurysm screening via abdominal ultrasound now this starts at the age of 65 and as you can see he is 68 years old the abdominal aortic anism guidelines say ever smoking so I was like man if you just tried smoking once you have to get this no it is ever smoking is defined as greater than 100 lifetime cigarettes abdominal aortic aneurysm screening is a one-time compared to your lowd dose chest CT which is going to be yearly you're going to repeat it based on the size especially if the size is greater than 5.5 which is going to be a threshold as to when we are going to repair the abdominal aortic aneurysm if the size is close to that number you may come back in six months but the USM doesn't get too nuan in terms of the screening interval they just want you to recognize an abdominal aortic anism either asymptomatic or one that has a brewery that is large enough greater than 5.5 cmers that for your surgery shelf questions you need to repair so let's go ahead and do a compare and contrast between lung cancer screening and AAA screening lung cancer screening starts earlier 55 till age 80 it is going to be patients who have greater than 20 pack year smoking history at a yearly interval and you're going to terminate at age 80 or if they have quit for 15 years because now the risk comes back to the non-smokers AAA screening you're going to be thinking of Ages 65 to 75 it is going to be uh provided in ever smokers via abdominal uh ultrasonography it is usually going to be a onetime and if it is getting closer to the 5.5 threshold you may want to screen a little bit ear uh in uh frequent intervals tell the patient to come back in 6 to 12 months and at the 5.5 cimer Mark or if the patient is symptomatic you are going to be considering repair all right another very high yield screening guideline is going to be colonoscopy go ahead and type into the chat what is going to be the general recommendation for colonoscopy what age does it start go ahead and type that into the chat excellent if you are going to be saying greater than the age of 45 you are absolutely correct so typically it's going to be age 45 to 75 and can you go ahead and into the chat what are some Alternatives from your colonoscopy where you get a bowel prep and you see the whole colon what are some of the other Alternatives excellent very good so flexible sigmoidoscopy can be performed every five years you could get a CT colonography that is also going to be at a 5-year interval and then if you do stool based testing via feal occultt blood or a imuno assay the fit test any stool based testing where you poop and put it on a card is going to be every year remember that the fobt which is going to be the oul blood test that is going to detect heem whereas the imuno test is going to detect the globin from the hemoglobin and you can also combine that with DNA testing as well to again get a little bit more sensitive typically the USMLE is going to test you on the colonoscopy guidelines only however if you have a first-degree relative let's go through this vignette a 35-year-old patient has a brother who was diagnosed with color rectal cancer at age 52 when does this patient need screened go ahead and type it into the chat when does this patient need to be screened so many of you are saying 10 years before the diagnosis of the brother that would be 42 however I wrote this question strategically the answer is actually going to be colonoscopy at age 40 why is that because remember the guidelines are age 40 or 10 years before the age of diagnosis of the first degree relative whichever comes first and in this case it could be 42 or 40 what comes first it is going to be 40 so that's why you start this patient screening at age 40 so again whichever comes first that's why I plac this beautiful question in what's also important for us to know is that if you have a first-degree relative you may end up screening or repeating the screen every three to five years uh because these patients may be at high risk all right let's go ahead and go through this question is everybody enjoying this review everybody doing okay all right very good thank you so much a 52-year-old woman undergos colon cancer screening with colonoscopy during the procedure a 4mm pop is identified in the sigmoid colon and removed hystopathological examination reveals that this is a 4mm hyper plastic po there are a lot of pertinent negatives here no family history no smoking no alcohol no other significant medical history which of the following with this hyper plastic pop is the most appropriate screening recommendation for her next colonoscopy go ahead and type your answer into the chat excellent if you are saying repeat in 10 years you're absolutely correct the key concept here is that small hyper plastic polyps do not change the interval of screening so you are going to again start at the age of 40 and then just continue to move forward from there excuse me start at the age of 45 I apologize and you will do it every 10 years if you just see a small hyper plastic po it does not change the screening frequency all right let's go through this one a 20 3-year-old male recently was diagnosed with ulcer of colitis when would the patient require pocal cancer screening by a colonoscopy so this is a nuanced one and what you want to know is that it is usually going to be 8 years after diagnosis so in this case the patient will be screened at the age of 31 because that is 8 years after the age of 23 the other point we want note is that these patients are going to also be screened when they develop primary sclerose and colangitis so if they develop psse which typically presents as a ulcer of colitis patient who is going to have increased Billy Ruben itchiness jaundice and cogram showing this beating of the uh beating of the uh gallbladder tree indicating that there is going to be some sort of inflammation what we call onion skinning fibrosis of the intra and extra hepatic structures you then will start doing screening at the uh time they develop PSC remember you want to know that these patients with IBD they will not only start eight years post diagnosis but you're going to repeat it every one to two years all right next one let's say the patient is going to have a family history of the APC gene mutation when do you screen when you have a prediliction towards familial adomus polyposis that is going to be very young starting at the age of 10 years you're going to start doing screening colonoscopies so anytime you have a IC disease let's say that you have for example um ulcerative colitis faap Lin syndrome you typically are going to do yearly colonoscopies especially for familial adomus polyposis they are at high risk for developing colon cancer all right lint syndrome a patient with family history of ovarian cancer and msh1 mutation remember Lynch syndrome is hereditary nonpol colonic carcinoma it is going to be due to issues with microsatellite instability when are you going to start you're going to be starting at the age of 20 years and you're going to repeat colonoscopies every one to two years because chronic diseases get a repeat colonoscopy every year so just to compare and contrast when we think about the faap that is going to be at 10 years of age whereas lint syndrome is going to be 20 years of age all right let's go through this next question a 68-year-old postmenopausal female presents for routine Health maintenance she had a colonoscopy less than 5 years ago she is a non-smoker she exercises four times per week what screening exams would be indicated in this patient excellent if you are talking about osteoporosis screening as well as mamogram you are absolutely correct very good so let's go ahead and understand this a little bit more remember that this patient is 68 so cervical cancer screening is usually going to stop at 65 years of age and so that's why the patient does not need a pap smear for breast cancer you typically are going to start at age 40 and you are going to end at age 74 so not only does this patient need a dexa scan but also needs a mamogram so let's review the mamogram here mamography is going to be indicated in females greater than the age of 40 up until the age of 74 and this gry Zone is between ages 40 and 50 now there are recommendations to potentially start at 40 but the uspstf says that there is definite benefit no matter what at age 50 to start mam mammograms this is typically going to be done every two years and you want to pay attention to risk factors in your vignette speciic specifically age being a very non-modifiable risk factor related to breast cancer increased estrogen exposure let's say that the patient was nerous has not had any progesterone Cycles let's say the patient had early menarchy or late menopause and if the patient has a first-degree relative likely you're thinking of braa remember first-degree relative isn't that third cousin first-degree relative is Mother sister brother all right let's go ahead and go through this high yield question a 55-year-old woman G2 P2 comes to the office for a routine Health maintenance exam menarchy was at the age of 15 and menopause occurred four years ago the patient used vaginal estrogen cream twice weekly for the first year after menopause but currently takes no medications and takes no allergies a paternal aunt died of breast cancer this year again not first-degree relative the patient is concerned about her own risk for breast cancer her BMI is 24 everything else looks pretty normal which of the following confers the greatest risk for breast cancer in this specific patient is it a age at first pregnancy B age at menarchy C current age of the patient D family history of breast cancer or E use of vaginal estrogen for one year what do you think is the best answer here excellent remember age is the strongest risk factor if the patient was nerous or the patient had menarchy at a very young age let's say 10 years or younger then that would probably be a higher risk factor but in this case the patient's age is the greatest risk factor for developing breast cancer another high yield question that comes up on nbmes is the evaluation of a palpable breast mass now guys I'm going to make it very simple for you all when you see a palpable breast Mass just pay attention to the age in the vignette if the female has a palpable breast mass and the patient is less than the age of 30 then you're going to be doing an ultrasound this is because ultrasound is going to expose the patient who is Young to less radiation and second the D the breast tissue is very dense so ultrasound is going to pick that up whereas greater than the age of 30 you're going to be doing your mamogram if you have a palpable breast mass and that is in alignment with probably uh they're getting closer to screening so if you have a palpable breast Mass these females are going to be older they can handle the radiation and they are going to have less dense breast tissue and thus a mamogram can advised in those patients with the palpable breast Mass so same patient here many of us said that she also needs a dexa scan so let's go ahead and go through the high yield component for a dexa scan osteoporosis is going to be screened via bone mineral density it is going to start at the age of 65 years every 3 to 10 years there's no real recommendation or uh indication to do it less than three years apart so the lowest threshold is going to be every three years but again it is all dependent on what your t- score is going to show if the female is less than 64 years of age you can use the Frack score but the new guidelines say that it's not necessarily mandatory the Frack score is a fracture assessment risk score and that is going to give us a calculated score of the 10year risk of developing a fracture like a hip fracture for example so what's important for us to know here is that what is all in the fra score what makes a patient at risk for a fracture well it would be glucocorticoids active smoking a rheumatologic disease such as rheumatoid arthritis remember that if the patient has rheumatoid arthritis they are going to have a lot of inflammation and inflammation is going to reduce the tacular mesh work of the bone and then anything that is going to cause secondary osteoporosis and guys this is super high Yi think about it like this if the patient is going to have any sort of duodenal disease such as celiacs disease or Crohn's disease or if they have any pancreatic disease in which they cannot reabsorb fat soluble vitamins such as Vitamin D you are going to be at increased risk for weak bones I.E secondary osteoporosis so always think about those past medical history Celiac Crohn and pancreatic insufficiency as well as hyperthyroidism similar to rheumatoid arthritis lot of thyroid hormone is going to reduce the tricular mesh work of the bone so I do want to integrate a basic science tiin here and that is the discussion of rank and rank Lian so so remember that parathyroid hormone is going to be released from the parathyroid gland and it's going to tell the osteoblast to release rank Lian that binds the rank receptor on the Osteo class and thus the osteoclast gets activated remember the osteoclast is from a monoy lineage and then the osteoclast starts chomping on bone but there's also a very important chemical and that is going to be known as osteoprotegerin now osteoprotegerin is going to and I'll do it in pink inhibit rank Lian so if it inhibits rank Lian it prevents rank from binding to the rank receptor and thus you are going to have more protection of the bone why is that because osteoclasts aren't going to be activated so the goal here is to recognize that a high osteop deerin is going to protect the bone very important and how does it do that it is going to inhibit the rank receptor now let's go through this when we are thinking about estrogen guess what estrogen does it is going to increase osteoprotegerin and it is going to reduce rank lien so estrogen makes the osteoblast stronger and inhibits the Osteo class and that's why estrogen is protective to the Bone now like I mentioned the key definitions here are for us to recognize that the t-core is what we are going to utilize for our dexa screening in particular now the t-core Compares the patient to the peak bone mass of a younger adult counterpart it is going to compare the peak bone density of somebody of a younger age but similar sex and G or similar race and gender what's important for us to also know are these definitions what is it known as go ahead and type into the chat if the patient is going to have a tcore between minus1 to minus 2.5 go ahead and type in to the chat what's the diagnosis then excellent if you're saying osteopenia you're absolutely correct what about if the patient is going to be less than 2.5 that is going to be osteoporosis and remember it's less than -2.5 so that means a more negative number tells you you have a deviation from the peak t score and thus you are going to have weak bone I.E osteoporosis so the usml loves for you to know what are the risk factors related to osteoporosis you have non-modifiable which you can't control and modifiable which you can control with lifestyle modification non-modifiable are going to be things like age postmenopausal status and low body weight remember weightbearing exercise is actually good for patients other non-modifiable risk factors for osteoporosis is going to be a white or Asian race this is going to be a condition where African-American race is actually protected we talked about non-modifiable such as malabsorption diseases like Crohn's and celiacs as well as inflammatory conditions like rheumatoid arthritis chronic inflammation weakens the tricular mesh work now modifiable risk factors are things like smoking if you're drinking a lot of alcohol or you have a sedentary nonweightbearing lifestyle what's also important are going to be other modifiable risk factors for example if you are vitamin D deficient that can lead to osteoporosis so that's why we treat with a high calcium and a vitamin D supplement and then finally medications can actually lead you to osteoporosis go ahead and type into the chat what is one medication that can cause secondary osteoporosis or a weakened bone what do you guys think and we're almost done with this review so please stick with me here excellent if you are going to be saying corticosteroids you're absolutely correct so here we have a vignette a female who presents with the medication induced osteoporotic fracture I'll I'll tell you here that what they say with the osteoporotic fracture is the female has sudden back pain and point tenderness indicating if they have point tenderness to the uh vertebral body or the lumbar uh the spine you're going to be thinking of a compression fracture and that's important for you to know that that typically presents with point tenderness all right so anti-seizure medications can cause you to have osteop erotic fractures why is that because anti-seizure medications induce Z p450 and can increase the breakdown of vitamin D aromatase Inhibitors are going to cause you to have osteoporotic fractures why is that because remember aromatase like anastrozol letrozol they are going to reduce the conversion from testosterone to estrogen and thus if you have less estrogen you have less protection of the bone G n r Agonist such as lupoli especially if they are going to be given in a continuous manner will reduce the pulsatile nature of testosterone and estrogen release glucocorticoids you may want to put a star here they'll give you a patient who has a chronic refractory autoimmune disease they're on chronic steroids they can push the questions towards more Cushings or they can say secondary osteoporosis because what glucocorticoids do they're exact opposite of estrogen estrogen increased osteoprotegerin whereas glucocorticoids reduce osteoprotegerin and reduces the osteoblastic activity concurrently aprol is going to inhibit calcium absorption and so longstanding aaol use can actually lead you to osteoporotic fractures I also want to go through some high yield pharmacology this is going to be very important because the US loves for you to know the various medications that we use to treat osteoporosis let's go through a few of them the first one is bis phosphinates remember that they have the suffix dronate alendronate for example they are usually going to be first line and the key uh guidance that you want to give patients is you you want them to take it with water and take it upright because there is a question that I've seen on nbmes where they talk about a patient who has difficulty swallowing after bis phosphinate go ahead and type into the chat what is the side effect if the patient had difficulty swallowing after taking alendronate excellent if you're saying pill induced esophagitis you're absolutely correct you could have elevated eosinophils and longstanding you could have strictures the other thing that the US wants you to know is that bis phosphinates are associated with osteonecrosis of the jaw another medication for osteoporosis denus this inhibits rank Lian hey guys we talked a lot about rank Lian if you have forgotten it please refer to the prior portion of this lecture which goes through the interaction of osteoblast and osteoclast teriparatide is another osteoporosis medication teriparatide you can see or derive pth so it is pth like and thus it activates osteoblast nasal calcitonin can also be used again calcitonin is going to be Contra pth or complimentary to pth and it has been shown to reduce pain in compression fractures remember how compression fractures present point tenderness to the vertebrae and then finally selective estrogen receptor modulators such as relox ofine relox ofine I like to think of the pneumonic hey put a Rolex on your wrist that tells me that relox ofine not only is going to help be a antagonist to the breast estrogen receptor but it's an Agonist to the Bone so it reduces the risk of breast carcinoma but it is protective for osteoporosis and just remember that it does carry a side effect because it is an estrogen receptor modulator of hypercoaguable State so patients on serms can have an increased risk of dvts a 25-year-old female presents for routine screening she is sexually active she has no past medical history she takes no medications oh my gosh she requests STI screening so in addition to getting a wet mount for tronus making sure that we screen for gonorrhea chlamidia syphilis HIV what other screening tests would you provide to this 25y old female excellent this is our last case and that is going to be related to cervical cancer screening now cervical cancer is caused by HPV there are lowris strains and highrisk strains what are the low RIS strains 6 and 11 High RIS strains 16 and 18 very important for you to know now HPV screening let's go through this it starts at the age of 21 and between the ages of 21 to 29 you can just do cytology every 3 years however at greater than the age of 30 you can do cytology every three years similar to what you did in your 20s or you can do cytology plus co- HPV testing for all those strains and that will be every 5 years so that is extremely high yield for you to know is that Co testing starts at age 30 but there's a Nuance here and that is if the patient is going to be getting on their papsmear atypical cells of undetermined significance what we call ascus if you will start HPV testing not at 30 you can start it as early as 25 and the usly loves for you to know that they'll bring a patient for papsmear and now the patient got a papsmear it showed atypical cells of undetermined significance you will then look at the age and if the patient is like 26 years old you'll say all right I'm going to do HPV testing but the guidelines say 30 ah but this patient has Asus so ascus makes you do HPV testing a little bit earlier now the other thing for us to know is that let's say on your OBGYN shelf you have a pregnant female who comes in hasn't seen the doctor in many years but she's pregnant congratulations you can do papsmear during the first visit when you're going to start drawing all the labs RH etc for their first prenatal visit you will do a papsmear if they are due at that time all right we have a 19-year-old female who was found to be HIV positive she was diagnosed with lupus two years ago and is on immunosuppression therapy in the past year she has become sexually active go ahead and type into the chat would a papsmear be recommended in this patient again HIV diagnosis immunosuppressed but she's 19 H the answer is yes what is highed for us to know is that there are highrisk HIV as well as any sort of disease that you're on immunosuppression you are actually going to start caps smars much younger than 21 I.E you're going to start at the onset of sexual intercourse and you're typically going to do an interval every six months times two and then you'll move to annually and this is extremely important because what's high yield here is to recognize that remember you have the endocervix which is going to be columnar and then you have the Ecto cervix and the ectocervix is going to beamus a papsmear usually is going to hit this transformation Zone because just from pathoma we learned that HPV which is a virus is going to affect this transformation or transition zone between endo and Ecto cervix but what's also important for us to integrate here is the immune response to HPV in this area and the immune response for HPV is T cell mediated you need for example CDA positive t- cells to kill HPV but if you have HIV let's go through the pathophysiology you don't have good tea cells so you have more susceptibility especially with hbv being a contact mediated disease you have more susceptibility for H PV to affect your transformation Zone leading to if you have highrisk strains leading to cical cancer and that's why anybody with the te- cell imuno deficiency needs HPV screening the other thing for us to note here is that HIV screening which is going to be fourth generation antibody and antigen that in your uspstf guideline is going to be recommended as early as age 15 and so hey she's been sexually active you may want to do a HIV screening and remember for your ped shelf if the mom had HIV you need to in the infant or neonate you need to get a nucleic antigen test or basically the number quantitative number of the HIV in the blood for that neonate and usually those neonates with HIV positive moms the next best step in management the nbme likes to go for is start treatment with zidine which is going to be a anti-retroviral therapy uh agent and now we have come to the end of our session let's go through a few rapid review I want everybody to go ahead and put your fingers on the chat box please here we go what ages do you start AAA screening go ahead and type that into the chat yeah one time screening AG 65 to 75 who have ever smoked all right next question 33-year-old female presents for routine health screening if she wants to come back in five years for her papsmear what screening test needs to be initiated what do you think the answer is here excellent if you said co- testing with HPV cytology and DNA you're absolutely correct when should children receive oral fluoride this is interesting it's going to be the first tooth eruption in areas where there's low fluoride in the water which they'll never really test it's as early as six months but it's typically going to be first tooth eruption in areas where there is good fluorinated water a 14-year-old male presents to the Adolescent Clinic he is frequently teased due to his acne what is an appropriate screening recommendation for this child and that is going to be depression screening starting as early as the age of 12 a newborn baby is leaving the delivery room what antibiotic therapy is indicated in this patient yep when I was a peeds resident I would after uh I resuscitated the baby if the baby was healthy just go ahead and do eyes and thighs which means that you do the arthy ey drop for prevention of gacal opthalmia neonatorum and then thighs what was the thighs for what did I inject in the thighs vitamin K yep exactly because these babies need Vitamin K due to their immature liver and they need to develop their clotting factors all right last slide of the day what age should you start colon cancer screening excellent if you say 45 you are absolutely correct up until the age of 75 a very compliant patient is due for his first lowd do chess CT what is the likely age of this patient excellent if you're saying 50 years old you're absolutely correct and make sure that it is a longstanding smoker a patient had a friend who was recently diagnosed with the AAA after the doctor heard a brewery what age should this patient who is an active smoker be screened at excellent one time at 65 years of age and then you stratify based on size I want to end with this wonderful quote that I was reading as I Was preparing this webinar and that is an ounce of prevention is worth a pound of cure so as you go to your clerkships and you practice as a physician remember those bottom parts of the pyramid primary and secondary prevention is so essential no matter what field you go into I just want to say thank you all so much for joining me in this review I want you all to stick around for a Q&A and some updated content that is in my step 2 CK course 2025 my high Guru course has these very nice case based vignettes and multiple choice questions feel free to check out my step 2 CK course at hur.com it's an integrated way for you to go through the material I also have embedded into the high Guru Step 2 CK course a u World notetaking template it is produced on notion notion is kind of like an Evernote or Excel Word document it's very nice it's a template that many of my students have used to just categorize all of the U World mistakes in one place in my opinion it is superior to ankey cards because you have the ability to construct your own knowledge and guess what you also have the ability to create in a guided manner vignette based notes and so guess what I did for all of my lectures for the Step 2 CK course I not only mapped it to vignettes or practice questions from U world but but secondarily I have created vignette based flash cards and I'm going to be uploading them this week all of the vignette based flash cards underneath each video so each video will have three or five flash cards that I wrote that again look at this vignettes 50-year-old headache vomiting papal Adema what is the likely cause of the ICP and then bam on the back not only do you get the answer but you Al get a test taking tip so my goal is to create flash cards that are going to essentially force your mind to do higher levels of the thinking pyramid critical thinking application appraisal rather than just recall of random facts that maybe some low-level cards can do if you've stuck around until now I just want you all to smile congratulate yourself and if you feel that you gain something share hi Guru to your friends colleagues your school I would love to connect with each and every one of you if you guys have not yet written a review please do so just click this link right now it takes about five minutes I would be grateful for you to spread the word of high Guru one medical school at a time my goal here is to elevate your preparation and provide you an active recall integrated way of learning that's the end of today's webinar before you leave type in one thing that you learned today and then I will go ahead and go into a Q&A thank you for your time and attention