35 Burst results for "Rosh"
Hendrick Motorsports Nears Petty Win Record After 1-2-3-4 Result
"Hendrick motorsports the first one two three four finish for hendrick in its team history. Only the fourth time in cup history. That's been done in the first and the cup series since rosh benway racing team. You have some knowledge of two thousand five at the season finale at homestead miami speedway so just to give you a little context henrik has only been a four car team since two thousand and four so i one two three four finishing essentially seventeen years. I that they've been able to do that but you know what's your first reaction to that. When you hear the hendrick motorsports for the first time ever in what thirty. Seven years of history has a one two three four finish. Well i think about is two years ago when we were talking about. What's wrong with hendrick right. And we we. We had this expectation level of hendrik. That's pretty high. We expect to see them contending for championships winning the lottery to me to me. In the era that i raced in hendrick was the most dominant team out there and that faded faded over time and it was. They didn't jump right back into it. They had to work themselves back into it. And now here they are and they also invested you. Think about what they did. They invested in a lot of youth right so took brought a lot of young drivers and that has cultivated into a very young team with a lot of winners on it heading into right direction. This is the opposite of what we were talking about. Two years ago. I think hendrick motorsports is repositioning themselves to be dominant force. They won the championship last year. We chase elliott now chase elliott. That hasn't wanna raise this year and alex bowman's want to i know chase elliott fans. Think well that's not good but it is good if the guy that won championship you last year is the guy. That's not winning this year and everybody else has stepped it up. That's a good thing. Now they've chase elliott rezoning twentieth every weekend. That what that's not chase elliott's running okay. He's not been winning expecting to do. But but that's a good problem for a team to have. It's almost impossible to have all four clicking. You know what i mean. It's really really difficult. But i just i just i think a reversal of where we were two years ago. That's the first thing that pops in my brain
Why Does the Year Start on January 1?
"Every year. The earth orbits around the sun and we celebrate each revolution on new year's day. But what's so special about this particular spot in our orbit. Why do we use january first as the start of our year as opposed to some other day as we go back in history. Most human civilizations did not use a solar calendar they used. Lunar calendar's in fact if you look at the traditional calendars for countries such as china vietnam or for religion such as judaism and islam. They have lunar calendars and their new year's day changes it state every year. Our current calendar can be traced back to ancient rome. The very early romans way back at the founding of the city used to have ten months and that ten months system is still reflected in many of the names of our months today. Their first month was marcus named after the god mars which we call march after march came the months of april ass- maya's and junius the months after this. We're just named after their number until he has sex tellus september october november and december so yeah december are twelve months really means the ten months in latin likewise with november october and september however. Ten months didn't really fit nicely into a year. They had two full months worth of leftover dates. That didn't really fit into any month to rectify this around the year. Seven hundred pc. The roman king numa added two more months to the counter. I annual areas named after the roman god janus and february's which was now the last and shortest month of the year for romans. The beginning of each month was called the callan's so the start of the year was the callans of march or mark. I then at some point and no one is quite sure. When the year began being counted on the calendar of i warious january went from being the eleventh month to being the first month. This might have had something to do with the start of terms for consoles. Romans named their years after the two consuls and power instead of numbering them so for example the year fifty nine bc. Julius caesar wisconsin with kelp. Biblis it was known as the year of caesar bibi however was weak so there was a running joke that it was the year of julius. Caesar it might also had something to do with the fact that january i was the callans closest to the winter solstice. Caesar is actually really important to this story. While the names of the months were very similar to the months we have today. The keller itself was still a mess. Caesar instituted changes to fix this problem. Anti adopted the suggestions of a greek astronomer named side of alexandria suggested going to a tropical year more on that in a bit and created the three hundred sixty five day year with a leap year every fourth year. So that's pretty much. The story right. The roman set january is the first day of the year julius. Caesar sets the julian calender. And we get to where we are today. Nope because in the middle ages the system fell apart completely at the five sixty seven council of tours and there were a whole bunch of different councils of tours so you have to specify. The church declared that january. I was not to be celebrated as the new year as it was a pagan tradition. What replace january first. Well nothing there were. A whole bunch of different days celebrated oliver europe for centuries. Some places used christmas. Which was the winter solstice on. The julian calendar some use the floating date of easter someone back to the old roman march first. And some if you remember back to the episode on why. Christmas is on december twenty fifth us. The important date of march twenty-fifth start of the new year eventually. For a whole host of reasons pope gregory the thirteenth the problems with the julian calender and use the opportunity to standardize the new year back to being january first for good measure. They also made january first holiday which it still is. Today originally january. I was the feast of the circumcision of jesus. But now it's just called the solemnity of mary. Of course not. Everyone was on board with the new calendar. Catholic countries were quick to adopt it but protestant and orthodox countries were not in particular. One country was very late to adopt january first as the beginning of the new year. That country was england. England celebrated their new year on march twenty fifth. In fact their colonies in the americas. Did this as well up until seventeen. Fifty two in seventeen. Fifty england passed what was known as the calendar new style. Act also known as chesterfield's act which is when they adopted the gregorian calendar. The very first thing mentioned in the act was the problem with using march twenty fifth as the new year when everyone else in europe used january first including scotland so when england finally adopted january first as the start of the new year. So did the american colonies for the first time today. Most countries now use the gregorian calendar even if it's only for business purposes to stay instinct with the rest of the world new year celebration such as ted in vietnam chinese new year or rosh hashanah are still traditional festivities held on different days all over the world. The fact remains that there's nothing astronomically significant about january first even though it celebrating an astronomical event aka revolution around the sun so if we were starting new calendar from scratch. What would we pick before. I mentioned that sausage unease of alexandria suggested we celebrate a tropical year and pick that word carefully as opposed to a solar year because there are two types of solar years and they're very similar a tropical year is the time from one season to the next based on win the solstices occur. The current years based on the gregorian calendar are tropical years. However there's also a thing known as ideal year which is when we measure the position of earth based on the location of stars the difference between a ideal year and a tropical year is very small. He said you real year is only twenty minutes longer. This can add up. However the difference between the julian calendar and the gregorian calendar is only eleven minutes per year and that caused a lot of problems over the centuries this has to do with the procession of the orbit that is constantly changing their to logical places to define a new year based on astronomic principles. The i would be one of the solstices. This is something that humans have pictured for thousands of years and have recognized its importance. The winter solstice also is in too far away from january. First the solstice really has more to do with the tilt of the earth however and not the orbit of earth there is something significant about the orbited the earth. That is a point. We could use and oddly enough. It's really close to january. First even though the ancients had no clue the orbit of the earth around the sun is close to circular but it isn't perfectly circular it's a slight ellipse hence there is a point where the earth is closest to the sun. And it's called the para helium perihelion in the year. Twenty twenty one takes place on january second the date of para helium drifts. Over time in the year twelve forty-six para helium actually took place on the same date as the salsas in the year. Six thousand four hundred and thirty it will take place. On the spring equinox so january first is the start of our year which marks astronomical event even though the data itself has no astronomical significance set by the romans abandoned by the church only to be later adopted once again by the church so as the romans did celebrate the callans of january which honors janice the roman god with two faces one which looks into the past at the old year and one which looks into the future at the new
New School: a relaxation and story for your nap time routine
"Our story today is new. School was the first day at rogers new school as he waited for the bus he began to feel nervous rouge all kinds of things. He thought about the new friends he would meet. He thought about the new things he would learn this year. Then he took a deep dragon breath in doubt and slowed his running thoughts. He knew that staying present would help him through this exciting day so rosh took another deep breath in and out and then he took one more deep breath in and out feeling calm. The bus pulled up and rosh stepped on not sure where to set so that down quickly in the front seat maybe on the way home he would know who to sit by. Raj smiled at the kids across the aisle from him. Then they smiled back. That wasn't too bad. rash thought. The bus stopped again and again. Most of the kids got on knotted. Hello dhiraj and then walked back further on the bus then it one bus stop. Two boys stepped on high. One boy. said haven't seen you around before. I'm owing and this is andy. I'm rush rise replied. I just moved here great. We'll show you around. Do you mind if i sit here. Rosh shook his head known owen. Set next arrive. Andy sat in the seat behind them. The three boys chat at the rest of the way to school when the bus stopped. Andy said okay. Follow us. we'll show you what to do. The boys showed rosh where to put his backpack and where they waited in the morning while they waited. They found out that they all had the same teacher. The bell rang and it was time to go to their classroom since they were all in the same classroom. It was easy for andy owen to show rash where to go as they reached the classroom their teacher. Mr smith said welcome everyone. I'm your teacher. Mr smith look on the tables for your name and sit down in the chair next to it if you need help. Raise your hand. And i'll help you the class. Busily zipped around the room looking for their names soon everyone had found their own spot. With only a couple confusions there happened to be two inns in the class. So once the to ian found their spots mr smith went on to show everyone where all of the supplies would go step by step. Eventually everything was put away then. Mr smith got moving with the game. Afterwards it was back to explanations of the classroom team. Mr smith was very kind and assured everyone that soon it would be easy to remember everything until it was easy. He was there to help. The class seemed very friendly as well and roj began to feel more and more comfortable before long. It was time for lunch and recess. Owen and andy invited rush to sit with them. The three boys sat down at lunch finance. They finished andy said so. What would you like to do at recess. I usually play. football rash. said that sounds like fun. And said i'll get the ball. Andy said owen and roj found a spot to play football and andy grabbed the ball he brought over a brown oval ball and rash felt confused. I think that is a rugby ball. A football is black and white Puzzled that sounds more like a soccer ball. Why don't you come pick the ball that you mean owen suggested okay. Rush said in picked out around ball with black and white pentagon's. That's a soccer ball. Andy he said oh we call it football because you're only allowed to use your feet to touch it rosh replied
RIP Ruth Bader Ginsberg - A life lived for her community
"I was born. Under, very bright's stone. Solemnly. Swear that I will support and defend. The constitution of the United States Supreme Court Justice Ruth Bader Ginsburg died on Friday. She was eighty seven the second woman ever appointed to the Supreme Court she was known for her fiery dissents often in cases involving civil rights or equal protections. GINSBURG was appointed to the court in Nineteen. Ninety three and was well known for Championing Gender Equality Abortion rights, affirmative action, and other progressive causes in our final years. Thanks to those dissents and well everything about her she earned the nickname, the notorious RPG and to put. An other worldly stamp on it sundown Friday marked the start of Russia Shana. One of the Jewish High Holy Days according to Jewish tradition a person who dies on Rosh Hashanah is a sad dijk, a person of great righteousness NPR reporter Nina Totenberg explained the tradition on twitter writing a Jewish teaching says those who died just before the Jewish new year are the ones God has held back until the last moment because they were needed most and where the most righteous if you wanted to be a true professional. You will do something outside yourself. Something to make life. A. Little better. So people less fortunate. than. You. A meaningful life. Is. One lives not test for oneself but for once community just days before her death Ginsburg said to her granddaughter. My most fervent wish is that I will not be replaced until a new president is installed.
UN Fails to Pass Palestinian Resolution
"In the news stunning move from the Arab League failed to pass a proposed Palestinian resolution, which would have condemned the normalization deal between Israel and the United Arab. Emirates the Arab. League comprises twenty two member states that include Bahrain Libya Levin on Qatar Egypt Jordan. Saudi Arabia and more a senior League official was quoted as saying discussion around this point was serious and comprehensive, but it did not lead to. Agreement over the resolution proposed by the Palestinians. Steve this is a big deal the Palestinians. If you think about this, the Palestinians probably have more friends in the United Nations than they do in the Arab League where they actually have full membership status, the Arab countries believe this is what the Arab countries are saying to the Palestinians. They believe that normalizing a relationship with Israel is more important than their complaint. Now I do believe that this is going to take the Palestinians in a certain direction I. I believe that there's one way out for the Palestinians and it's not through the Arab League it's actually to go into the arms of Iran. This is something that I think the Israelis are looking toward something that two countries are looking toward as well to make sure that the Palestinians don't go in that direction they already are shaking hands in many ways, but some of the PAL with the Iranians. So we gotta keep our eye on that, but we'll have to wait and see ultimately what happens in the end but continue to pray for the peace of Jerusalem.
Pilgrimage to Sacred Activism
"Hi Andrew and welcome on to the hey house meditations podcast how wonderful to be with you and how wonderful to have the opportunity to speak to whoever's listening from my heart. Out wonderful wonderful. I'd like to talk to you today about the Fifteenth Century Poet Mystic Kabeer. Who you've been doing so much work on and and perhaps have you read a few of his lines. That articulate a meditative experience that is at once transcendent but also completely grounded I really appreciate that in computer But before we get there, there's a pilgrimage that I like to ask you to take us on a pilgrimage to the ark of of your own spiritual journey. An ARC that is has taken pauses with a variety of traditions, teachers, and Gurus and especially that are of the internal pilgrimage of the heart. So I wonder if you'd take us on that pilgrimage and then we'll sort of maybe conclude with Kabira. Does that sound all right with you? That sounds wonderful. Today and your little remission it it's. Never ends. I remember when I was with father bid when he was dying and. The thing that struck me most and move me most about him here. He was the greatest living Christian mystic but even on his deathbed when he was eighty seven, he was still striving for deeper and deeper realize. So he gave me a permanent image of what this really is journey of endless expansion. Shems of Tabriz said to Rumi. The world of God is wealth of endless expansion. We don't ever arrive. We just go Diba and DEEPA and Deepa went blasted where wild enough were brave enough into a mystery that always keeps opening onto wilder and holy vistas. This is my experience. Yes, and you're well I must say your your life has demonstrated that but I'm not exactly certain if you knew that when you were born. In mother India right you are. You're born in south India early in your life. You earlier in life you're surrounded by multiple religious by religious face including your your parents Protestant faith. And among the Hindus and Muslims. So how did that early on your life? How did that shape your outlook on the nature of humans on the nature of people and the nature of the divine? India is too big bomb in a well the distill known that live as cred experience. And that mock me forever I feel that I have an Indian. So a European mind and an American mission. So my deepest deepest ground is always in there especially in south India. When I was born. Nineteen fifty two was the twilight of the Rosh. So this. Was the atmosphere of an. Empire would still. Diffused itself through everything but India itself although it had been dominated by the British in never lost its passionate spirituality and that's what I met in the earliest and most impressionable years of my life. I loved going to temples with my Hindu coke. I loved learning the hail. Mary from my Catholic nanny and I loved it when the driver that we had to as a Muslim stopped the car in the middle of traffic and put his. Prem Don and chunk to Allah. In very early on. I met a saint and this is an extraordinary story because I had white Russian. Godmother. who used to smoke cigarettes out of black along black cigarette holder in Lyon dressed in gold she fall she looked like a Russian Melena dietrich and I was crazy about her she's. and. Every day off to school I would go running up the stairs of her flag. And jumped into bed between her and have great friend who is huge Rowley poterie Indian woman Shanti. Of course as a child I didn't know. Shanti Shanti, later revealed to me it was India's greatest living Quila and she is the child had been. A welcome to previous incarnation and a gunman, a group of journalists to the village that she'd been born in. As, a nine year old recognized absolutely everybody and Meta previous husband and said the money looking for is under a break in the back. So he went and found the money that he'd been looking for. Any. gave. Me a lot of profound simple instruction. She told me two things that have not my whole life. She said God is one. God is the sea and all religions alike rivers that run into the sea. So. Don't get hung up on anyone religion realized that they're all different expressions of the same unity, the different expressions of the same reality
"rosh" Discussed on The Rosh Reveal
"Which of the following is the most common pulmonary complication of influenza? All right this say so rather straightforward question. We need to know what is the most common pulmonary complication, and let's go through answer choices answer choice a, and by a is be pneumonia, secondary to superimposed bacterial infection and see primary viral pneumonia and answer choices de spontaneous numerous racks. All right, let's start with enjoys a and Baima. Empire Emma right develops when there is a bacterial infection of the pleural fluid. This is really much more typical in pneumonia, secondary to staff, orientation or club Zella pneumonia. It's less common with influenza, so let's cross out and by mom. Now let's move to see primary viral pneumonia. So this is certainly a less common complication. It is a possible complication, but this would be a co-infection of two viruses causing pneumonia at the same time. It is possible, but it is not going to be the most common pulmonary complication, and we're going to compare this to the correct answer in a minute and see why, and an we have answer de spontaneous, and with your ex, so this certainly could occur with the Mona's. It's much more common with bacterial pneumonia classically. You could see this in PCP. PCP pneumonia as well, and it's really not a complication of influenza, and that leaves us with answer choice B now pneumonia, secondary to super impose bacterial infection, and for those who are interested in history and disease, the influenza epidemic of nineteen eighteen. This was really one of the main causes of mortality in patients, a millions and millions of people died. They were infected from influenza and develop the secondary pneumonia. He superimposed bacterial infections, which ultimately caused their deaths. So we're going to go with answer, choice, B and sure enough. That is the correct answer. Everyone before you go, remember you could also watch the reveal at the Rosh Review Youtube channel where you can see me interact with the actual question and answer choices. And if you're interested in your own Q. Bank, whether.
"rosh" Discussed on The Rosh Reveal
"All right so we have a thirty two year old G Zero P. Zero, woman presents would Dole crampy, pelvic pain that has been intermittent over the last six months. She's currently menstruating and notes. The pain seems a worsen with Massey's shelter reports pain with intercourse, but denies any vaginal discharge on examination. She is in no huge distress in his febrile. She is scant blood in the vaginal vault, and no significant focal tenderness. No masses are appreciated. Pregnancy test is negative. What is the most likely diagnosis right? So this is a rather straightforward question, and let's just go over the answer choices real quick. We have a endometriosis be middle. Sh- murs see pelvic inflammatory disease and D. RUPTURED OVARIAN CYSTS We've been giving a gift from the question writer. There is so much rich content in this question for us to make the diagnosis, which is what we're being asked to do to find the most likely diagnosis. Let's go through this. We have crampy pelvic pain. It's intermittent over the last six months. So this is a chronic issue. She's currently menstruating good and the pains worse with Menzies, and we'll see why that's important. Chelsea has this Peradeniya and no vaginal discharge, and no vaginal discharge is we pair that with being a federal right, which is going to be important to think about any? Any infectious process. She has scant blood and no significant focal tenderness, and no masses on exam. Okay, and she's not pregnant good. That's always important and no. Let's go through. Are Answer choices we have so this is so rich, and we should be able to make chooses answer pretty straightforwardly, so we have middle. Moore's mental. Schwimmer's is it's a unilateral mid cycle pelvic pain, right? It's ought to be due to release the egg related to ovulation, and there's no sign of right we have. This patient's pain is worse with Massey's not mid cycle, so we can cross that out right away and. And be confident about that pelvic inflammatory disease anti-choice. See Right so for that we're. We're going to have fever pelvic pain, which patient has but no fever. They're going to have cervical motion tenderness. We're GONNA vaginal discharge again. We're convinced that this is clearly not pelvic inflammatory disease from information in the Vignette an ruptured ovarian cyst. Typically this will present with acute on set, and what we've already been told here is that this is a this patient has intermittent symptoms over the last six months so right away I can tell you that this is unlikely going to be correct and you know. Know Rupture Ovarian Cysts sometimes. If it's on the right side, it could seem like tour. Shane could seem like appendicitis. And that's the picture we're getting here, so I'm going to cross out that and that leaves us with endometriosis. And as we know, this is, it's really it's an estrogen dependent condition where endometrial tissue at develops in the extra uterine sites okay, and will be associated with this Ria, pelvic pain and despair. UNIA everything that we see here with this patient's presentation is shouting at us that this is in Michio says so we're GonNa select answer, choice a and sure enough. That is correct. Everyone before you go, remember, you could also watch the reveal. Rush Review. Youtube Channel where you can see me interact with the actual question and answer choices. And if you're interested in your own Q. Bank, whether you're an MD or do a. p., A. or an.
"rosh" Discussed on The Rosh Reveal
"All right, so we have a thirty nine year old woman who presents an emergency per month, right leg, pain and mild swelling. She denies any previous medical history or trauma. She does not take any medications. Examination is remarkable for a tenderness along the right calf, Venus, distribution and minimal swelling of the right lower leg. What is the most appropriate diagnostic workup for this patient? All, right so, this is a good question. It's a complex question and requires some knowledge of wells criteria of how to manage deep-vein thrombosis, so let's look at the question first and see what we could take out of this, so we have in otherwise healthy woman. She has no previous medical history or Traumas, not on any medications and remember when we're given information. On a standardized exam it's given to us for reason just like information that's not provided is not provided for a reason. So what were provided with here is tenderness along the right calf, Venus distribution and minimal swelling of the right lower leg, so if we review wells criteria right the pre test probability of a DVD tee. We'll see that this patient actually is considered moderate Res-q for a DVD She has two points and therefore the workup. The diagnostic workup is going to reflect her moderate probability. Now you need to know what the Algorithm is four moderate probability and glancing at these answer choices I see that there's duplex ultrasound in here that there is a di Di Mer and this is the important point I'm going to start off by saying this, so a di Di Amer is a test that has high sensitivity, but lower specificity right so ideally it should be used as a rule out test, and not a rule in test. Okay, so if we use that as the premise, let's go through answer choices and see what we come up with so answer choice a duplex ultrasound to evaluate for DVD and if negative, send a D. Damer. If demerge positive treat for DV T. All right. Let's dissect this so if we have a duplex ultrasound that is negative. That's a really good position to be in to not have a DVD. If for some reason, they're still clinical concern and Adidas famer sent in that dimmers positive. That does not confirm the diagnosis of a DVD right because the Damer is sensitive, but not specific. So this case the proper management would be to perform. Perform serial ultrasounds. Let's say if you suspect that this patient is truly at moderate risk. Because if she had let's say a small dv that wasn't spotted on duplex ultrasound and she's moderate risk that Devi. T that thrombosis could propagate, and it will be caught on a repeat ultrasound. So that's the thinking. They're so answer choice A. We're going to cross out as not being the most appropriate. Answer Choice B duplex ultrasound to evaluate for DVD and if negative, the patient may be discharged right while along with the reasoning of answer choice a. it's a good thing that the ultrasound is negative to start with, but because this patient is moderate risk, there is the possibility that you could have a thrombosis that is just not being picked up and it may propagate. Propagate over time due to her risk, and therefore you would WanNa have a repeat ultrasound performed for this patient to see if there is any propagation, so she shouldn't necessarily just be discharged without any other. Follow up, so there is some truth here in that you may discharge this patient, but there should be follow up arranged. That is not part of this answer choice. So, we will cross that out as well. Let's go to answer choice de send a D. Damer, if positive treat for DVD so D- Damer is a rule out and not a role in so we shouldn't make any treatment decisions based on the positive de timer, so just from that we're going to cross off as in cracked that leads us with answer choices. Send a Di Damer and. And if negative, the patient may be discharged so in low to moderate risk patients. If we send a highly high sensitivity, di Di Mer then is negative. It essentially a rules out a deep vein thrombosis, and if there is a low likelihood, a very low likelihood of DVD and this patient may be discharge, so this would be the most appropriate diagnostic workup answer choice, see and let's confirm. Short off. That is the case. Everyone before you go, remember, you could also watch the reveal at the Rosh. Review Youtube Channel where you can see me interact with the actual question and answer choices. And if you're interested in your own eubank, whether you're an MD, or do a PA or an MP simply go to the Rauscher view, dot, com website and sign up for a free trial. Keep learning, keep working hard and always have a sense of mission about your work. Now is your time this.
"rosh" Discussed on The Rosh Reveal
"Pain, she had palpitations and sweating, which of the following the most likely diagnosis to answer choice, a cute stress disorder be agoraphobia. See Hypo, mania and deep panic attack. So, this is rather straightforward. The lead in is asking us to identify the most likely diagnosis now when I look at these answer choices, this is really not a difficult question. What would make it more difficult is if there was the inclusion of some cardiac diagnoses, right or maybe endo chronologically like a thyroid disorder, because what we're seeing here is chest, pain, a impending doom, palpitations and sweating whenever we hear that right if I changed this twenty seven year old woman to A. Seventy five year old. We certainly are going to be thinking this patients having coronary Schema, so the key, though to be able to distinguish from what the answer is here to a cardiac disorder is that this patient is young? Now you could have an clinically speaking right. You can have an M. I and a twenty seven year old for shore, and a you don't WanNa miss the diagnosis and make a diagnosis of panic disorder when it's actually acute coronary Ischemia, and for example purposes for the board exam right. Right. We're told that she was about to give a presentation at her job, so she has these symptoms that occur right before she's going to do a stressful event and therefore when I hear that I'm pretty confident what I know the answer is going to be so. Let's go through the answer choices a acute stress disorder, so that's symptoms that are similar to PTSD post, traumatic stress, but typically occur after a stressful that not before so we're going to cross that out, and then we have agoraphobia, which is really. Really an anxiety or fear of situations from which may be difficult to escape right, and so we don't see any of that here in this patient, so it's crossed that out and see hypo mania, so that's not an anxiety disorder. It is a mood disorder where patients are going to experience symptoms of mania, and we don't see that here at all, and so we're left with a panic attack, and so this patient is having classic panic, attack and ray panic attacks are going to be classified or characterized by the. The sudden set of symptoms right you're GONNA have fear terror associated with this impending doom, so on board exams anytime you kind of get that constellation of symptoms as fear terror, impending doom associated with sudden onset of let's say palpitations or chest pain, dizziness, choking cessation in a young person. It's almost always a panic, attack or or something associated with a panic disorder, rather than some cardiac condition or pulmonary embolism, so we're going to go with answer choice de panic, attack and sure enough. That is the correct answer. Everyone before you go, remember you could also watch. Reveal Rauch Review Youtube Channel where you can see me. Interact with the actual question answer choices. And if you're interested in your own Q..
"rosh" Discussed on The Rosh Reveal
"So we have a sixty one year old man who presents with intermittent shock like spasms of pain in his right cheek, the pain only lasts a few seconds at a time, but recurs frequently. He notes that shaving each morning causes intense spasms of pain as chewing, but is the first line treatment for his most likely diagnosis. So this is a two part question, and this is a classic question comes up on board exams all the time, and so this. This is a give me question. Let's. Let's go through this. If we take a look at the question itself, let's see what we so. We have a somewhat older gentlemen, sixty one years old, and some of the reveals here are intermittent shock like spasms of his right cheek, so distribution of the right cheek seems to be in a tried Jemele like pattern that will see, and it just lasts a few seconds right, so we think about what is the diagnosis here? What's underlying the theology? We have tried Jamel Neuralgia and we. We need to know now. What is the first line treatment for try? Jamil Neuralgia, hopefully something you could commit to memory, and as we go through the answer choices. Let's see what we come up with, so we have answer choice a back Lafon, be botulinum injections, see compromise appealing, and de dies Bam so let's start with back Lafon back then, certainly, as used in a lot of different nerve, muscular disorders, the can be used in try jumble NEURALGIA. However, it's really not efficacious and definitely. Definitely not first line, so we're going to cross off backlift in here. Then answer choice, b, lynam injections also commonly used in muscular disorders, but in this case it is an option for people who may have refractory TriGem neuralgia after they've exhausted all other options, botulinum injections can be given, but this is not the first line treatment, so we're going to cross that out. Let's skip over to answer as Diazepam dies. Man's a great medication. It has muscle relaxing properties. However, it will not improve. Necessarily of TriGem on Algebra in there for we're GonNa Cross that out, and that leaves us with carbamazepine carbon as being is the first line treatment for trigeminal NEURALGIA and TriGem Maharaja. As you know, is typically characterized by these unilateral shock, like paroxysms of pain in one or more divisions of the trigem while nerve, so this is clinically a pathology that could really be debilitating for patients and classically. classically, you'll see people. Come in who say that any time if there shaving chewing or any light touch or exposure, hot and cold temperatures to their face, they'll get this shock like lightning. It's almost like you know a bad toothache. And when you get that nerve, feeling that pain in the tooth but Karmazin first line treatment answer choice e, let's select that and sure enough that is the case. Everyone before you go, remember, you could also watch the reveal at the Rosh Review Youtube channel where you can see me interact with the actual question and answer choices. And if you're interested in your own bank, whether you're.
"rosh" Discussed on The Rosh Reveal
"All right so we have a fifty nine year. Old Woman who presents with pain and swelling of the face began yesterday. She sits at the symptoms began abruptly with fever and chills physical exam reveals bright red integrated skin in a malar distribution. The skin has a pew orange appearance. What is the most likely diagnosis? Alright so answer. Choices are a era. Syphilis Be Rosetta. See Scarlet Fever D systemic lupus. Erythematosus so this is a great question. It's pretty straightforward. Though our lead in is what is the most likely diagnosis. So we need to dissect the information that's given to us and come up with the most likely diagnosis here. So we have a fifty nine year old woman and a couple of the key points here. The reveals are the pain and swelling began on her face and began yesterday. So it's very acute in onset and remember on board exams. Every word matters words that are part of the questions matter and words that are not part of the question matters. And so we're given that this begins abruptly with fever and chills okay. That's something that may distinguish some the answer choices and on exam. What we're seeing is as bright red inundated skin okay in a malar distribution so those are the key findings. Puteh Orange appearance is relevant. So we'RE GOING TO START WITH FROZE. Atia answer choice. B while Rose Atia certainly is era thema in Meller distribution however. There's definitely not going to be a pro Jomo fever and chills associated with it and that's more of a sub acute process so we're going to cross off rose here scarlet fever. Troisi typically caused by. It's STREP infection. A so you may have a sandpaper whenever you read sandpaper feeling hype rash. Typically maybe on the chest at also as circum sparing think scarlet fever. And we don't see any of that in this question so when across off answer choice so that leads us with Lupus Lupus. We know rate anytime. I hear Mallard distribution right. We think Lupus we think butterfly however lupus is. The rash associated with Lupus is not going to be abrupt in onset. And it's going to be inaugurated right. You're not gonNA have that Puta Orange appearance and so we're GonNa Cross off systemic Lupus Erythematosus and that leads us with Erysipelas. So Aristotle's is one of these rashes that doodoo infectious process typically Beta hemolytic STREP. You're going to get an abrupt onset of fever chills. Malays patients could look pretty good with it. They don't necessarily have to look very sick. But the rash is intense era thymus and it's like a plaque on their face. Very well demarcated and it's tender to pal patient and that is important nor that's something that you'll see clinically. The terminus and superficial lymphatic whereas cellulitis involves more of a deeper durmus in the subcutaneous fat. That's why an ultrasound you get that cobblestone like appearance for cellulitis and not Ariza's with that we're going to go with answer choice a here. Arison and sure enough. That is the correct answer. Hey everyone before you go remember. You could also watch the reveal at the Rosh Review Youtube channel where you can see me interact with the actual question and answer choices and if you're interested in your own Q. Bank whether you're an MD or do a PA or MP simply go to the Russia view dot com website and sign up for a free trial. Keep learning keep working hard and always have a sense of mission about your work now. Is Your time this Dr Adam rush signing off?.
"rosh" Discussed on The Rosh Reveal
"All right so we have a seventy five year. Old Man with a long standing history of constipation presents complaining of abdominal pain. For the last two days he is now experiencing abdominal distension constipation inability to pass gas for the last twelve hours unexamined. His abdomen is distended. And Ten nick to Percussion you obtain an upright abdominal x ray as seen above. What is the most likely diagnosis? All right so are answer. Choices are a Seco Vavi Louis. Be In a secession. Cc Irritable Bowel Syndrome and de signaled. Fatherless is a really good question. It is a high likelihood question to appear on a board exam. So let's go through it if we look at the question itself it's rather straightforward and were asked to make the most likely diagnosis here right because clinically. A PATIENT. Like this comes in you know. We may not have a definitive diagnosis. Let's say in the Emergency Department. But for our aboard exam. Were given enough information that we can making the most likely diagnosis. And that's what's important here. So let's go through answer choices. A sequel so seek oculus certainly is associated with Donald distension abdominal. Pain positive gas in the distal colon and an x Ray. That may look similar to what we see here. Now for those of you that cannot see the X ray. What we're seeing is large bow. That is significantly distended and it has almost like a bent innertube appearance okay now. A sequel Volvo euless the classic x Ray Finding is something closer to a coffee being appearance of the coal in or the Seacombe or comma. And that's not what we see here. Sometimes it's you confuse the appearances here but this is definitely more of a bent innertube type appearance and that's important to know so we're going to cross out answer choice. A SECO Vavi Lewis here and just one thing to note is the patient is seventy five years old hurry and that makes me start thinking about what the answer choice is here when we combine that with abdominal distension and constipation and this X. Ray and we'll see why that's important shortly answer choice. B In a secession. Interception is really at least on the boards. It's going to be a disease process of children. So let's cross that out. It is of course. It's possible on adults but very uncommon. Then we irritable Bowel Syndrome. Well that's more of a condition that's associated with chronic alterations of bowel habits. You could certainly have abdominal pain. You can have diarrhea constipation. A seventy five year old gentleman. Who's has this x Ray with abdominal distension constipation for a short term onset rate last twelve hours on the board exam? We're given that. This is a an acute process. Okay with have an acute process last twelve hours here so we're certainly not going to select irritable Bowel Syndrome as an answer choice because that's only a chronic process so that leaves us with signaled Vagelos and whenever I think about signal Bob I think about older people who are maybe nursing home patients. They may be bed. Bound and associate with chronic constipation and you see X. Rays that look like this. The sick might call kind of twists on the mezin Terry. And you get this bent innertube appearance so I'm going to go with answer. Choices de signaled Bob Ross and sure enough at his cracked. Everyone before you go remember you could also watched the reveal at the Rosh Review Youtube Channel. Where you can see me interact with the actual question and answer choices and if you're interested in your own Q. Bank whether you're an MD or do a PA or an MP simply go to the Rauscher view dot com website and sign up for a free trial. Keep learning keep working hard and always have a sense of mission about your work. Now is your time. This is Dr Adam rush signing off..
"rosh" Discussed on The Rosh Reveal
"All right so what is the most common site of Compartment Syndrome? This is a factoid based question you're GonNa know it or you're not gonNA know it but there are some things that we can think about to help narrow down the answer choices so the answer choices are a anterior compartment of the lower leg. Be Anterior compartment of the thigh. See lateral compartment of the lower leg and di volare compartment of the forearm. Let's start with answer choice. D. and the fuller compartment of forearm. That certainly is a known or common location for Compartment Syndrome. It is most commonly associated with super condylar fractures in children and radiohead fractures and adults. However it is uncommon overall and while it is possible it is certainly not the most common. So we're going to cross that out and then we're left with two answer. Choices include the lower leg and one answer choice includes the Thi- now let's just think about compartment syndrome and what it is okay so ultimately right. You have some type of usually. It's a trauma could be an infectious process as well or post surgical at say but you have increased pressure. Within a non expandable compartment in that results in compromised Venus blood flow that results in worsening congestion and subsequently arterial compromise. And this leads to escape necrosis of the muscles and the nerves within the compartment. So what you're really thinking about here is if it's going to be the most common. It's probably not going to be a large compartment. Okay so I think about. The thigh is pretty large. You know the FEMUR runs through it but there's seems to be a lot of area for expansion or a Dima so I'm going to cross off anterior compartment of the science or choice B that leads us with anterior compartment of the leg or lateral compartment of the lower leg. And if you think about the anatomy of the lower leg you have the Tibia which rate if you feel your lower leg. You're essentially right. You feel that Tibia. It's more difficult to feel the femur because you have so much muscle on top of it and the Tibia. It's pretty superficial. And so that's a very small compartment very tight compartment of the lower like your and so the lateral compartment. You could feel on your leg. There's a little more soft tissue there and Fibula is not as prominent so These two answer choices. I'M GONNA cross out lateral compartment of the lower leg and stick with the anterior compartment of lower leg and I know that tibial fractures are at highest risk for developing compartment syndrome. So let's go with answer choice. A. And sure enough that is cracked.
"rosh" Discussed on The Rosh Reveal
"All right so we have a twenty four year old woman who presents an emergency department with a headache and receives a lumbar puncture. She's eventually discharged home in improved condition but returns twenty four hours later with a worsened headache now. Throbbing Nature which is worse in a standing position and relieved pine position which of the following reduces the risk of post lumbar puncture headache. Alright so let's look at the answer choices a inserting the needle bevill perpendicular to the spine. Be Lying Supine for one hour after the lumbar punctures completed sea using a higher gauge needle. Or d using a quickie needle. So let's dissect the question and find out exactly what it is. We're being asked on one hand. This is a rather straightforward question which is good because anybody who returns to the emergency department after receiving a lumbar puncture and continues to have symptoms or worse symptoms is always concerning clinically. Of course post girl headache posts. Lp headache is the most common complication of a lumbar puncture. But you just never know. Maybe you know if you were doing a lumbar puncture for meningitis. Maybe the meningitis is getting worse. And so that's always concerned but in this case on the board exam the test a writer is being a little generous to us and the Ledin asks which of the following reduces the risk of a post lumbar puncture headache. All right so now. We need to know about post. Lp headaches let's go through answer choices inserting the needle bevill perpendicular to the spine. So you're probably familiar with the positioning of the needle does affect the likelihood of a postel p headache. So the question is what is? The position is perpendicular. Actually it is not perpendicular in fact inserting. He'll perpendicular the BEVILL may lead to worsening risk for Moselle headache. It's parallel so we're going to cross this answer choice you wanna when you're doing a LP. The proper positioning is insert several parallel to the spine. Right and so. He's been lying supine for one hour. After the LUMBAR puncture is completed. You know it's certainly that's practice clinically. However it really has not been shown in studies to decrease the risk of post. Lp headache so we're GonNa Cross off answer choice. B as well using a higher gauge needle or using a quickie needle now acqu inky needle. It's a standard cutting spinal needle and it has a Bevo. If you've ever seen it. It has a nice kind of slanted. Bevill it is the most common needle that is used in lumbar puncture kits. However the reason why we use it is it's thought to separate dural fibers as opposed to cutting them. However the needle itself has not been shown to reduce the risk of posts. Lp headache all right. So I'm going to cross off answer choice D so that leads us with using a higher gauge need on. This is absolutely correct. Now remember a higher gauge needle right corresponds with a smaller caliber needle. Right Higher. Gauged needle smaller caliber needle. And you can think about that like right when you're placing IV an eighteen gauge IV verse Twenty Four Gauge IV. The twenty four gauges. The caliber is much smaller. So the smaller you could go the less risk of a leak and so this is our answer choice. See using higher gauge needle. And sure enough. That is the case. Everyone everyone before you go remember. You can also watch the reveal at the Rosh Review Youtube channel where you can see me interact with the actual question and answer choices and if you're interested in your own bank whether you're an MD or do a PA or an MP simply go to the Russia view dot com website and sign up for a free trial. Keep learning keep working hard and always have a sense of mission about your work now. Is Your time this is Dr Adam rush signing off..
"rosh" Discussed on The Rosh Reveal
"All right so we have a twenty five year. Old Man who is brought to the emergency department by police for bizarre behavior is family arrives in states that his behavior changed about eight months ago. He does not abuse drugs or alcohol on examination. He is a flat affect and appears to be responding to internal stimuli his speeches disorganized and he says I've been running from the Russians. Were trying to steal my thoughts. Laboratory and urine studies are unremarkable. What is the most likely diagnosis? And give an answer choices. A schizo affective disorder schizophrenia. See Schizophrenic form disorder and de Schizo tipple personality disorder all right so this is a scenario that if it was in the clinical real world. Probably Unlikely that we're making a diagnosis in the mercy. Barmen in the primary care setting. This is something that would have to go to psychiatry for the diagnosis. However on a board exam we know the criteria to make the diagnosis and so we will find an answer choice. Here that is correct now if we go back in dissect the question. It's a pretty straightforward question. What is the most likely diagnosis? And that's always important on board exams. The most likely diagnosis right because there may be a few possible diagnoses. But we're going to go with the most likely so if we look at what's provided to us so we have a young gentleman bizarre behavior so whenever I hear bizarre behavior it could be psychogenic right so underlying psychiatric disorder or it could be infectious or it could be toxin or drug related. Now were given a few bits of information to help us narrow this down one is. He does not abuse alcohol or drugs. That's pretty clear. And the other is his lab in urine. Studies ARE UNREMARKABLE. So given that he doesn't use drugs or alcohol labs are and urine are unremarkable. This makes me think that this is organic ideology such as some underlying psychiatric disorder. Okay a few other really important points here and the reveal really for this is that we're given that his family states that is behavior change eight months ago so this is relevant information on a board exam. Whenever there's information in a question that you asked why is that being given to me. There's a reason and so the reason for this is because the diagnostic criteria is based on a six month. Cut Off in schizophrenia. So let's take a look at our answer choices and run through them schizo. Affective disorder is a condition in which symptoms of schizophrenia exists concurrently with a mood disorder. Okay now what we see. Here is this patient. Has Bizarre behavior and his speeches disorganized. Okay so this is certainly making me think that he's delusional. And he also has negative symptoms right a flat affect and so this is pretty clearly some type of skills oh related disorder and the fact that it's eight months is important here schizo affective disorder. The question information is not giving me any other insights about a mood disorder. So we're GONNA Cross off. Gets AFFECTIVE DISORDER SCHIZOPHRENIA? Certainly is the most likely correct answer. Let's just set that aside for a minute and see what CDC schizophrenic form disorder while in this case. It's very similar to schizophrenia. And the important point here is that schizophrenic form disorder is characterized by the same symptoms of schizophrenia. That lasts more than a month. But the key thing is that its less than six months okay. So we're told that it's eight months ago that a symptom started so let's cross off see so that's a good distracter there and then skews. Oh tipple personality disorder this a cluster a personality disorder. And really it's more about really unusual social interactions and interpersonal relationship issues. So we're not seeing any of that here. This is pretty clear. Cut Delusional disorder that this patients presenting with someone across off answer choisy. That leaves us with schizophrenia. Which we will select answer choice B and Sure Enough. That is the correct answer. Everyone before you go remember you could also watch the reveal at the Rosh Review Youtube Channel. Where you can see me interact with the actual question and answer choices and if you're interested in your own Q. Bank whether you're an MD or do a PA or an MP simply go to the Russia view dot com website and sign up for a free trial. Keep learning keep working hard and always have a sense of mission about your work. Now is your time. This is Dr Adam rush signing off..
"rosh" Discussed on The Rosh Reveal
"Is associated with increased mortality. And the answer choices are a a St of two hundred B Cranston of three point one C glucose of three hundred thirteen or D lite base of nine thousand. Okay so this is one of my favorite questions for board exams. It invariably comes up and it's rather straightforward. You just need to know right what you need to know ransoms criteria right so this patient here. Classic for pancreatitis. So we have a forty two year old. He has issued alcohol abuse. He comes in with Severe Bommel. Pain and vomiting. Now we diagnose acute pancreatitis with a lab value of light pace being elevated here significantly elevated. So is that the answer choice. Answer Choices de Light Base from nine thousand is that the lab value. That's associated with increased mortality. Well in order to answer this question correctly we need to know ransoms criteria. And so when? You're doing this question when you see this question this is the spoil right here. This light face value because everyone knows. It's associated with pancreatitis. However it is not part of Ranson criteria so right away. I'm going to cross that off because lice is not associated the value is not associated with increased mortality. So we're left with three options. The next most likely confused answer choice would be a s t right because we're thinking someone's drinking alcohol their ASC's going to be elevated which it certainly gets elevated in pancreatitis and it is part of ransome's criteria but ransoms criteria for as tea is greater than two hundred and fifty so an. Ac of two hundred does not meet that criteria. Now we're left with Cranston glucose so creating is not part of France's criteria right so let's just review ransoms criteria very quickly so added mission. You have age over fifty five White Blood Cell Count Over Sixteen Thousand Glucose over two hundred L. D. H. Over three fifty an ast over to fifty and at forty eight hours after admission adequate fall greater than ten percent be UN rise gritted and five calcium less than eight peo- to less than sixty base deficit. Great on four fluid sequestrating great and six liters. Okay and any. If you have any ransoms criteria your mortalities automatically one percent thing about that if you have one of those you one percent chance of dying and then it goes up so three to four is fifteen percent if you have more than seven. It's one hundred percent which one hundred percent seems. Nothing's really one hundred percent so all right of Krant. Nina and Glucose Crandon is not ransoms CRA- part of Ranson criteria. So we're GonNa Cross that off. That leaves us with Glucose of three hundred thirteen. Indeed that is part of Ranson criteria a glucose over two hundred and so this patient already has a single risk factor here meets criteria and therefore is a one percent of mortality due to his pancreatitis. Let's choose answer choice e and sure enough. That is correct. Hey everyone before you go remember. You could also watch the reveal at the Rosh Review Youtube channel where you can see me interact with the actual question and answer choices and if you're interested in your own eubank whether you're an MD or do a PA.
"rosh" Discussed on The Rosh Reveal
"All right so we have an eighty one year old man with a history of atrial fibrillation who presents with abdominal pain. He fell two weeks ago and was advised to stop his quotation medication. After the fall you reports diffuse severe abdominal pain but is minimally tender on examination. He has symmetric pulses in his extremities. What is the most likely? Anatomic location of his pathology. We have answer choices. A BIFURCATION B. Seeley Trunk See Inferior. Mezin teric artery and the superior mezin teric artery. So this is a second order question. We first need to make the diagnosis and from that diagnosis. We need to understand which vessel which part of a vessel is leading to this individuals presentation. So this is a great question and it shows an understanding of pathophysiology and anatomy. Let's just go over and dissect the question itself and if we start by looking we have an older gentleman who has a fib and he's off of his anti coagulation. So anytime I see this a question someone stops anti coagulation and not just a question but in actual clinical practice. If someone's supposed to be on antiquated relation they stop. Then they become prone to thrombosis. So that's what I'm thinking about just from reading this one line here and let's look at a few other really important areas one. He presents the domino pain. And what's interesting is. His abdominal pain shows minimal tenderness. And any time I see diffuse or severe abdominal pain without tenderness right. That's pain out of proportion to exam. So that always makes me think some type of visceral or some type of schemic process that may be happening in the intestines for example. Okay and the last part of this. That's going to be very important is he? Has symmetric pulses in his extremities. So knowing all this let's go and answer the question which is the most likely anatomic location of his pathology. Okay so one. What does this patient have? What's the diagnosis? So he is pro thrum botic at the stage because he's off antiquated relation and now he has abdominal pain out of proportion to exam. This sounds like he has an intestinal or some type of ischemia due to a thrombosis in the MEZIN. Terry okay. So are answer choices. One of these four answer. Choices are the anatomical location. Let's go through them. I we have a Arctic bifurcating. Now you can see thrombosis there. But it's a pretty wide caliber area. And if you caught it off a ordered bifurcation you're gonNA get probably decreased or absent. The pulses in the extremities. So we do not see that. He had symmetric pulses. So I'm going to cross off Eric by formation and then we're left with all of the branches that go in order here so we have Celia trunk superior presentation artery than infirm as enteric artery and these supply a lot of the abdominal viscera of the duodenum the colon and so which one of these is going to be the right answer so first of all. Let's look at Celia trunk to see trunks of first branch of the order and it supplies the gut but mainly the distance and delayed. I'm here so could this possibly be the answer. Maybe so let's keep that here. And then we have the inferior mezin. Tarik artery which is going to be in line here. It's GonNa come after the SMS. So it's the third in line of these branches and it arises about six or seven centimeters past the SA in supplies the distal third of the transverse colon to rectum. So it's possible that this is causing it as well. Dall- let's look at the superior Mezin teric artery and we know that the ESA may it's the largest caliber of these vessels and it has a narrow takeoff angle from the order. Okay so it the most likely path for Klotz to travel to all right so the most likely anatomic location here now remember. It's not the only anatomic location. It is. The most likely Anatomic location is going to be the superior Mezin Tarik. So it's cross off Celia Trunk. Let's cross off inferior misinterpret artery and let's go with the S. M. A. Which also supplies. Most of the time you'll get schemic changes in the genome. And the reason why you get this is because it has the least amount of collateral circulation right so S. M. A. Answer Choices D. And Sure Enough. That is correct. Everyone before you go remember. You could also watch the reveal at the Rosh Review Youtube channel where you can see me interact with the actual question and answer choices and if you're interested in your own.
Exam Question: Trimalleolar Ankle Fracture After a Fall
"All right so we have a sixty one year old woman with no past medical history or family history or heart disease presents with a try. Malaya Lar- ankle fracture after a fall. As part of her pre-operative workup an e. C G has obtained a portion of the rhythm strip is shown above which of the following is the most appropriate. Okay so this is a two step question and the first part is to take a look at the rhythm strip and interpret the rhythm ship because that is going to be important to answer this question and when we look at the rhythm strip we see a p wave cure s complex t wave P wave curious complex t wave so we have a P. before every cure s the only thing. I see here abnormal that the PR interval appears to be a little prolonged so it is greater than one whole box here The width of box. So this is going to be a little greater than two hundred milliseconds however we see no drop p waves and so this is consistent with first degree heart block okay so now that we have in E C G A rhythm ship with first degree heart block. Let's take a look at our clinical scenario and trying to affect the question and what is asking so the question wants to know which of the following answer choices is going to be most appropriate here. So let's read. Those answer. Choices a administer I v Calcium Chloride Insulin Glucose and sodium bicarbonate answer choice b order cereal cardiac biomarkers and admit to cardiology. See Place Trans Cutaneous Pacer Pads and make arrangements for Trans Venus Pacemaker. Md reassure the patient and orthopedic surgeon that no treatment is necessary so when we look at this question the key thing here is that we have a pretty typical presentation of primordial or ankle fracture and the question is telling us there's no heart disease here and at the patient has no past medical shree so when we are given this information in a question. It's for a reason right. And so when we look at the C. C. G. A lot of people say well. Maybe it's a little abnormal. Maybe we should do a a workup or something. Let's go through answer choices and see why this information of no past medical history and no heart disease annonay symptomatic patient is important so answer choice a IV calcium chloride. Insulin Glucose Sodium bicarbonate. That's the treatment for hyper Kaley. Mia We have no indication at this. Patient has hyper Kalia. There's no peeking of the t wave. There's no widened cure s complex. So answer choice. A I'm going to cross out it's choice. B Order Cereal Cardiac biomarkers and emits cardiology. Well with an abnormality in E C G in an older woman. Who's sixty one you know? It's something to think about right. However in this case the patient is otherwise as she has no past medical history or hard sees and really a first degree heart block. On an EC- G. is can be abnormal. Right it's abnormal but it doesn't necessarily mean that there's disease right you could get first degree heart block in young healthy athletes. You get it from some medications such as Beta blockers. You could get it with individuals who just have a little increased. Vega tone than normal so as long as the patient is. Acm thematic knock complaining of chest pain. There's no need to order cereal. Cardiac biomarkers and admit the cardiology. So let's cross that out. Answer Tracy Place. A TRANS CUTANEOUS PACER PADS and make arrangements for transient is pacing. This patient does not need a pacemaker. Even Trans Cutaneous if a patient has complete heart block and so for example. If this patient was coming in with chest pain shoes Dr Frederick and there was a heart block. We'd be concerned that that may progress to complete heart block and in those cases you may want to consider Trans Cutaneous Pacer pats. However this patient is totally fine otherwise other than the ankle fracture. So let's cross off answer choice. See that leaves us with answer. Choice de reassure the patient and the orthopedic surgeon that no treatment is necessary. And I'm GonNa Choose Anti-choice D. and sure enough. That is the correct
"rosh" Discussed on Conversations with Rosh Review
"The aluminum is still there every morning. You know. And they're other people marianel in the Clinton Pharmacist. Who started the day? I came to Bellevue. She she came she. She was set up to go. Be on the cardiology service. She was from Saint John's university. They were offering her free. Clinical Pharmacists. And Richard Wiseman who came on that day. He's Day started also he that same day that I started in Bellevue in October of nineteen seventy nine Richard. Wiseman was supposed to envy sexual gynecology service but they were both from. Saint John's university that didn't that prohibited them to be involved with any abortions so they left floors the cardiology cardiologists said. This is necessary. We don't need anybody to help us do cardiology where the best clinical pharmacologist of our stuff he had. Richard Wiseman had elite. Because school wasn't let him bring students to the obstetrics floor so they came down and I didn't know them yet but they were both Hinson toxicology. So they'd bread. Maybe the second edition of our Tex. Maha came in. They said I don't have a job. I said what you can both have jobs with me immediately. They were paid by Saint John's whenever their salary is covered. I said one of you can be at the centre me and one of you can work here in the emergency department. You're hired and you can bring the students here anytime you want. So that's how we got started marrying. Alan comes from Trenton New Jersey by train every day and sits down in and goes to conference and then teaches all day long important center and those that goes back home. I used to see her on the train. S A student coming from New Jersey. This just circle back real quick to go. Frank Toxicology Ecology Book. That's been looted to head of how it started putting together some maybe case reports when you're in the South Bronx and I believe you're working on now. Which addition the Eleventh Eleventh Edition? And you've had input from hundreds or probably thousands of toxicologists and people have contributed to that book. You think it was more of circumstance that you started practicing the South Bronx and these pathologies were present. And this is what you're seeing that led you into toxicology. Or do you think there is a predilection. You had that attracted you to toxicology. Because I think when you know a large part of of how your defined as the clinician and your contributions a large part of that ease your contribution to the field of toxicology is that something that started just circumcision toxic plants as a child. That was interesting plants. I did a lot of reading. Botany I love Botany in College. I had an NSF grant National Science Foundation grant working on cobalt species. The fellow was interested in whether it might be related to something like rheumatoid arthritis in worked on cobalt toxicology. For while in college. So I Love Botany and I saw awful lot living in the woods and thinking about what was poisonous and wasn't deny Had these experiences and we had you know. A number of terrible poisonings in complex situations. When I was in Brussels I can see that. Alcoholism was prevalent. So I think it was interesting. I could look up other things in books in the South Bronx that had to do with internal medicine the head to do with surgical issues as I was learning them. But there wasn't any place to look the toxicology. So let's see and the other thing is that the epidemic of heroin epidemic going on for some time and we had the number of overdoses was overwhelming and it was just. Naloxone was just released people laboratory nine sign. We're using it. It just become improved. We were the first places in the world using the locks so really began to use it and it was remarkable with the lives. We save everybody. People were on Methadone. Then he locks on was a big asset. The way it is day and people aren't using other longing acting long acting preparation so it was just. We didn't know how to intubate people very well and we didn't have great equipment right. You didn't have fiber optic devices. You have a video assisted efforts you. You didn't have much in the way of technology so it was very difficult for everyone. People hadn't the training I hadn't had any training had a little bit of training but not much and so this wasn't easy to do so it was remarkable it. We did begin. This basic life support discussion. So bag valve mask was available and so no oxygen was something that we use very commonly. You didn't really have any method on to worry about at that point. So people didn't have dramatic withdrawal. They had short term withdrawal that they might have if they were on heroin and so it it changed the course of human events in the South Bronx and save lives became a big deal and then thought about the other toxins we began to see and so it was an uncharted territory in the midst of it. I mean I I had to learn all the other stuff but this was one that no one else was interested in right right. And how would you compare the opioid crisis of the seventies and eighties? Would you consider I mean? Was it a crisis then or just tremendous number of deaths. Tremendous and people were just dropped. In those days. There was a Rockefeller and standard. Was You're supposed to report people immediately? Anybody who's using heroin so the few people we knew in the city everybody agreed. We're not gonNA report anybody that would chase. People were already. People were just dropped on the on the door style because there weren't ambulances to pick people up and they didn't want to be seen with the person because they'd be arrested right so it was a battle but ultimately they gave us the state government gave us addiction counselors who would walk people from the Emergency Department to a detox center right after they either came in and withdrawal or people who had overdosed and then stabilized because we were already thinking about continuity of care and to do some harm reduction getting people places and they took them whether it did much good in those days. I was optimistic. That detoxification was going to help him to there. Wouldn't have that optimistic at all right now. I I spent time working in Portsmouth Ohio which is really start of the pill mills and with some people consider the main driver of the current opiate epidemic. What lessons can we take from the seventies and eighties or to apply now? Is there any lesson I would say that those of us who worked in the South Bronx are here? And when I got here said late seventies where to still heroine is going on in these people using lots of heroin. Is that most of the people who saw were poor people or African Americans or Hispanics the wrong so all the papers were about that right. Everybody assumed this was a problem of color right. And you couldn't get a strong OPIOID. They didn't exist yet at this time. You'll pill form or any other form. So that we never had opioids of any consequence available people so they weren't using that and what the inherited bias that probably saved. African Americans lives with it. There was a level of racism may be and not giving people who were of color enough that no one wanted to give them right. More drugs that we're GonNa Foster this EPA gray old epidemic and so it was the rich or that the Ellen Vermont New Hampshire in Staten Island as opposed to the South Bronx or West Virginia. Who were used getting these pills? And they were being prescribed them and many of them conceivably there are people who are doing it because they thought it was the right thing to do but they obviously. The design of those molecules was inherently catastrophic or the ability to resist dependency. Wow so I think that we now have a problem. That's comparable headed not into the election of trump probably with Obama's effort and holders effort would have been really dramatic changes in how we deal with substance dependency and probably presumably with Scott to come because the only solution is you can cut down. On all the opioids at people are prescribing. But that's GonNa tip large numbers of people into withdrawal who go to Fenton Hill and go to heroin. So you're going to have to work on decreasing numbers you're GonNa have to find solutions. And you know you're GONNA transform a lot of people into people on Buprenorphine now trek zone or method on to get through this epidemic where the plasticity of the brain is just become dependent and these people are very low success rate to become the absence. I duNno five percent. Maybe I'd say today whereas I used to think I was optimistic. The Su- thousand eighteen and I don't WanNa put you on the spot here. But what do you think? GonNa Happen with this. Current OPIOID epidemic in. Say three years. Five years are we going to be in a better place? What's IT GONNA look like? I mean what do you think it's GonNa look it's interesting? I have a I teach a class to the students who rotate in the emergency room. Almost everybody in the medical school does. Let's say and then we get a lot of outside rotator and so. I do it to our symposium where we all talk. Fifteen people are on each month. They talk about their experience with opioids in their community or for them as adolescents or them as young adults a- and there's always someone who talks about a next door neighbor who died or brother died or friends who've been treatment or the fact that they were on medication for something for dental extracted or for sports injury. And we're getting opioids for too long and really felt. They were on the verge of becoming dependent. And how it's disrupted people's everybody's got a story in the way they tell you know how some people say well we're having an opioid free emergency department and they see patients suffering because they need so. I don't think I mean I didn't have that kind of lecture when I was a student and people didn't have that up until recently so I think that's kind of thing that's probably mandatory in every training site in America and we have grants. We have people working on here. We've been doing for a decade or fifteen years working on treating the people giving sending people home with no lock zone working on getting it out in the community working on. We have some of our people who came here to work on an mini medical school community. Name our and altruism going out and teaching kids in grade school about drug risk and someone else roussel scouts talk psychology fellow very committed and it was also one of our residents whose out teaching kids about all of the drugs. That are at high risk. So we're doing a lot of stuff we're doing in. The pipeline of education is going down into the school's going into the community. And we have a lot of symposia about it. I mean everybody's talking about it and things are changing. I mean the doctors and dentists and whomever were using someone and things are stopping so I think it will be better but we're going to have a population who's AIDS epidemic. Where it was terrible and people were stabilized. And they'd thought they'd never live and they're living. And how do we get them to the next stage so I think doctors have changed and I think it's it's valuable when your next door neighbor is also on drugs and causing a lot of trouble. You recognize it's not color. These drugs were universally designed to keep the OPIOID CONCENTRATION. Such that people became dependent very effectively. Yeah so I think you probably turn the corner. As far as the providers. Go and the there'll be some little lag time before society feels those affects overall with GonNa have a lot of it depends on what they do. With regard to opioids for the Medicare population. They want to cut back on delivery. So what is going to go into withdrawal? We've seen people in their seventies who around using heroin so I think we'll have a tremendous problems but at least people are talking about it and some are doing something about it and we have some reasonable depot treatments naloxone and Naltrexone and Buprenorphine. So there we need a lot of creativity. GonNa need more support. You're GONNA need more protection for people but I think there's much more openness to action because then everyone's even a guy like pence or someone else like that has seen that the can have crises in Indiana. It just doesn't happen in the inner city so in a few hours. You're going to be doing something you've done. Probably for thirty forty years. Most days of the week. You'RE GONNA walk from Bellevue to Grand Central Terminal. You've been doing this. Walk Day in day out. Tell us about. Why do you walk? Would you think about when you're walk? What's that part of your day like when I had two kids it almond wife at home? We had a chance to think through all the stuff I do and to get peaceful time about doing it. I knew that I was going to be in the country and relaxing. Think about it With family and have a very complex where there's no sounds to figure out the house maybe the spring peepers and things like that and the walk in the. It makes you think about. Who's on the street. What kind of problems are there? You go past sign. That's selling jewels for Sixteen fifty for package and you recognize that what some thought was going to be good to help the people who are smokers. Get off smoking in the worry about whether they don't get it off and then they're getting worse deal because the nicotine concentration and smoke or you think about the kids who are buying these up in the same marketing as with opioids. So that's reminds you of stuff you see poverty You see affluence and then you feel whether know what it means when you're coming in when it's so hot you can't bear it and people are dying because heat stroke and you see The winter when it's so cold and people are freezing and you know..
"rosh" Discussed on The Rosh Reveal
"All right so which of the following is a known complication of chronic lithium toxicity. This is a rather straightforward question. Let's just I suspect it. Make sure we know exactly what it is asking so we have chronic lithium toxicity and we need to identify which one of these is a known complication of it are answer. Choices are a diabetes melodies be hypothyroidism. See nefer genyk diabetes and separatists and De Syndrome of inappropriate and I'd erratic hormone so looking at these answer choices. I group them in that scene. D- are related right. They both have to do with. And a diuretic hormone. And what's interesting about this is. You can't have both of these necessarily at the same time right because one is too much. Adhd and one is too little adhd so keep that in mind. When we're thinking about these answer choices and this is a one approach you could take on an exam. If you don't know specifically the complications of chronic with the talk city if you look at the answer choices you could see that you have two competing answer choices. Here Seen D. So my suspicion without knowing anything about chronic lithium toxicity is that either. C or D are likely the correct answers. And then what's interesting is we have answers. A diabetes Mellitus and we see diabetes in the answer. Choice and we see a diabetes and answer choice. See so again you know. A is a distracter in their most likely and then be Hypo parathyroid. We just need to think about that a little more deeply. So let's look at each answer choice and see we come up with the diabetes. Melles that is as far as I am aware of not a complication of chronic lithium. So we'll cross that out answer choice. B Hypo parathyroid ISM So as far as I'm aware that is also not a complication. You can have hyper. Parathyroid isn't right. Because I know that you could see hyper. Calc- MIA in chronic lithium toxicity. But hypothyroidism would not lead to that. So I'm going to cross that out. So now we're left with never genyk diabetes and Simitis and syndrome of inappropriate. Adhd release so. Here's what I do know about. Chronic lithium toxicity is that patients who get this. Typically I exhibit A. Neurologic symptoms relative to acute lithium toxicity. Where it starts off with early. Gi Symptoms and neurologic symptoms are delayed. And so when I think about with chronic lithium toxicity at least clinically my mind. They always seem like they're like dry and dehydrated and so if we look at those answer choices which one of those would present a patient like that well never genyk. Diabetes is the result of in this case. It's the kidney becomes resistant to adhd. And therefore you will have a patient who's urinating frequently right WHO's plasma level of sodium rises because they're urinating so much losing free water and what happens is that becomes a vicious cycle right so the more free water you lose the greater the concentration of lithium and therefore you become more toxic all right so I never genyk. Diabetes is certainly a known complication for chronic lithium toxicity. And therefore I'm going across out syndrome of inappropriate and I'd erratic hormone and go with nefer. Genyk diabetes and separatists. And sure enough. That is the case. Everyone before you go remember. You could also watch the reveal at the Rosh Review Youtube channel where you can see me interact with the actual question and answer choices and if you're interested in your own eubank whether you're an MD or do a PA or an MP simply go to the Rauscher view dot com website and sign up for a free trial keep learning keep working hard and always have a sense of mission about your work now. Is Your time this Dr Adam rush signing off?.
"rosh" Discussed on The Rosh Reveal
"All right so what is the most likely cause of acute anemia in African American patients with HIV infection? Who recently began Numa says this pneumonia prophylaxis all right. So before we go into the answer choices. Let's dissect what this question is really telling us. And what is it asking us to find out so we need to know what is the most likely cause of an acute anemia and in a patient African American patients with HIV who recently began PCP pneumonia prophylaxis. So the key to this question is understanding. What medication is given in? Pcp prophylaxis and that is try method. Prim Sulpha Mkhsel. And why would they be giving us this information that we have an African American patients with HIV infection? Let's go through answer choices and then we will answer this question. So answer choice. A glucose six phosphate dehydrogenation deficiency or g six P D deficiency be hereditary. Fear Psychosis See proximal nocturnal hemoglobin area and de Peru kindness deficiency so. I love this question because all of these answer choices here lead to anemia so we need to focus on specifically in the context of a patient. Right they give us. The question is giving us information that the patient is an African American with HIV and therefore they are taking PCP prophylaxis. So something about try. Metha- Sulpha mccaw is the key to this question. Let's go through the answer choices and figure this out. So as a UGO six phosphate D hygienists g six P deficiency so this one absolutely jumps out at us as a possibility to be correct because we know patients who take trimethyl SOFA. Methodic says all have problems with G. six P D deficiency so. This is the front runner right now. Let's return to this. Let's first review the other three and NC where we're at so entries be hereditary fierce. I told us this condition will absolutely cause anemia. It's a congenital condition right. So you're born with it. You're red blood cells are shaped like spheres and you test for this with Osmanovic fragility testing but in this case. Medications typically don't lead to Himalayas. So we're going to cross out B. C. Will Nocturnal Hemoglobin area? This a stem cell defect in the red blood cell where you'll have this complement mediated destruction of your red blood cells. This is not caused by any medications and so and choice see. We're going to cross out as well and Troy's deep Peru kinds deficiency so this is something that typically diagnosed in newborns or infants and not something that is going to be seen in an adult necessarily due to taking medications causing him also. So let's cross us out so this leads us with g six P deficiency and just kind of put this all together g six PD the enzyme. It's part of the process. Where if you lack the enzyme then any oxidative stress on the red blood cell membrane can lead to Hamas Mollis. And that's exactly what's happening here in a patient who's on. Pcp Prophylaxis and they are taking the medication. Try Metha- self A-M-A-C says all that could lead to an oxidative stress and then you'll have hemolytic anemia. G SIX PD is also classically associated with a Heinz body as well right. That's that little inclusion within the red blood cell. So we're going to go with answer choice. A here also. You can have a question where it's not. Just try methods himself a macaw but it could be other oxidizer such as methylene blue fava beans is a classic one. The Sofa Drugs Nitro Franson anti-malarials. Right any oxidative stress could lead to a moss in these patients. Let's make sure we are correct and sure enough that is the case g six P D deficiency. Hey everyone before you go remember. You could also watch the reveal at the Rosh Review Youtube channel where you can see me interact with the actual question answer choices and if you're interested in your own Q. Bank whether you're an MD.
"rosh" Discussed on The Rosh Reveal
"All right so we have a sixty seven year old man with a history of hypertension and diabetes melodies who presents to the emergency department with sudden onset of left leg weakness. His exams notable for three to five strength in his left lower extremity as well as diminished sensation over his left toes foot and leg. He's a flat affect and appears slow in his speech which of the following vascular territories is most likely affected in this patient so this is a pretty straightforward question. You're going to need some knowledge of territory of infarct in strokes and the answer choices here include a left Lynn Tikolo straight arteries be left posterior cerebral artery see right anterior cerebral artery and D- right middle cerebral artery. Some key pieces of information here. Is this patient clearly is set up for a stroke? He has hypertension diabetes and he has sudden onset of left leg weakness. The also has diminished strength. Here we see that three to five strength of the left lower extremity where also told few more important piece of information he's diminished sensation on the left side as well so now we know he has left sided motor weakness left sided sensory and he also has a flat affect and slow in speech. Okay now we need to determine which vascular territory. This patient is suffering a stroke in anytime on an exam and even in clinical practice. Anytime I see that someone has maybe a personality change in a setting of a ski Mea. I always think frontal lobe. We have the prefrontal cortex there and a lot of times. That's involved so right off the bat in this question I'm thinking something in the frontal lobe. Now in ischemic stroke. We know that the most common artery involved is the middle cerebral artery and we see that as one of our answer choices and typically the anterior cerebral artery is less involved in clinical practice because of collateral blood flow from the anterior communicating artery. But in this case on an exam things aren't always perfect and what we really need to do in this exams. Identify the key features given in this vignette in which most closely resemble the vascular territory here. And what we see here may differ than clinical practice. So let's start with answer choice. I The left Lynn Tikolo straight arteries. These are small arteries off of the middle cerebral artery. And they're small. They caused like these look. Kunar marks that you may have just motor and some sensory deficits you know they go into the deep structures of the brain but in this case we would be seeing rate cited symptoms and in our Vignette were given the left side so we could in fact cross out answer choice a for that reason. Now we go to answer choice. B Left posterior artery four exam purposes. Anytime WE'RE TALKING ABOUT. The left posterior cerebral artery. This supplies exa below. I always think that the patient will have visual symptoms right. They may have visual field cuts. I always think about a taxi of Vertigo. And they'll have contra lateral motor weakness as well and therefore given that we see that this patient this would be ipse lateral motor weakness because the answer is left post serious infarct so coming across out answer choice B as well now we're unanswered Troisi right anterior cerebral artery. So this one seemed pretty consistent here and we're left with seeing a right middle cerebral artery so associated with motor and sensory loss. So you know this is definitely a possibility as well. So how we distinguish between these two specifically. Let's say on an exam anytime we're dealing with the right middle cerebral artery on an exam. We will have contra lateral findings of motor weakness sensory loss but almost always you'll be given some type of deficit in the face as well. The patients may have facial droop. They may have slurred speech. And the other part of this is that with the MCA in forks. On an exam you will usually have upper extremity weakness greater than or more involved than the lower extremity weakness. Now what are we seeing this vignette? We see? The patient has left leg weakness. We are not given any exam of the opera extremities. Nothing about the arm. So we have to presume when we're not given that there's an abnormality that there is no abnormality and so the ACA or anterior cerebral artery is known to cause greater motor and sensory deficits in the lower extremities then compared to the upper extremity so these will be common answer choices on exams you may have to distinguish between the ACA anterior artery in the MCA middle cerebral artery and you know clinically. This is a different story but on an exam. The way you do it is you most likely will begin these lower symptoms greater than upper and that means the ACA and we're also have the benefit of the patient in this vignette having a flat affect and slow in his speech so the flat affect is what gives it away from me that I could really confirm on this question. This is GonNa be the anterior cerebral artery because of the personality type of deficit. So we're going to cross out answer choice d. here and I am going to go with the right anterior cerebral artery answer choice. See and sure enough that is correct and we could see here the distribution of the anterior cerebral artery. Everyone before you go remember. You could also watched the reveal at the Rauscher View Youtube Channel where you can see me interact with the actual question and answer choices and if you're interested in your home to bank whether you're an MD or do a PA or an MP simply go to the Russia view dot com website and sign up for a free trial. Keep learning keep working hard and always have a sense of mission about your work now. Is Your time this is Dr Adam? Rauch signing off..
Boston: Fired Holliston Dog Trainer Pleads Not Guilty To Animal Cruelty Charge
"Line a former dog trainer from Holliston pleads not guilty today after being accused of abusing a German shepherd on a treadmill show rosh was standing in front of a judge with her attorney charged with animal cruelty the video her attorney blames for that charge shows the former dog trainer walking a young German shepherd on a treadmill when the dog tries to get off Rossell forces it back on ultimately lifting the dog up bye Felicia brushed one was no longer allowed to have any unsupervised contact with animals other than the pats she already owns left court without comment she's heartbroken she's never abuse an animal more her life she's never heard any animal in our life this is just abhorrent attorney insisting her two decades of experience as a dog trainer is filled with nothing but love for animals
"rosh" Discussed on The Rosh Reveal
"Fusion with collapse of the right ventricle. During dastardly which classic electrocardiogram findings are associated with this disease process? So it's a two step question with the first make the diagnosis. And then correlate the Classic E C G Finding and that's an important term here classic E C G because there may be a diagnosis or condition. That has more than one. E C G. Finding this question wants to know the classic finding so. Let's just review the answer choices very quickly here we have a delta wave and shorten PR INTERVAL BE DIFFUSE ST allocation see low voltage and electrical alternates and D. S. wave in lead one an acuity of an inverted t wave in lead three. So let's go back to our question. There's a few important things to pick out so if we look at the vital signs here. There are some insights which are going to be helpful here so patient has cardia in hypertension. So this is a significant process. Whatever it is here and they have a narrow pulse pressure and that is a critical finding anytime. I hear narrow pulse pressure on a Board Exam. I think about pericardial Tampa nod. Okay and let's just go a little further here. We see a large pericardial fusion on ultrasound and collapse of the right ventricle during dastardly so I am pretty much one hundred percent. Sure that this patient has a pair of Cardio Tampa nod and what happens. Here is the cause is going to be lupus right. So we're giving right at the very beginning that this is Lupus so some of these findings that you'll see narrow pulse pressure right because fluids surrounding the heart fluids in the pericardial and the more and more fluid. You get in there the less you could ask right. You can't expand the heart anymore to fill with blood so the difference between these systolic diastolic rusher becomes very small very little. I should say and you get a narrow pulse pressure and really when the pressure around the heart the rights out of the heart of particular gets too high then you get ventricular filling becomes impaired Ryan. You'll actually get collapse of the right ventricle so these are classic findings associated with pericardial Tampa. Now what is the classic? Sag Finding because that's what the question wants to know. So let's go through our answer choices here and will start with ends choice say Delta Wave and a short P R interval that certainly is a classic E. C. J. Finding and that the finding is Wolff Parkinson White Syndrome right where you have an accessory pathway which leads to the shorts appear interval and a Delta wave is really a slurred up stroke of the cure complex and that's that's due to the accessory pathway. So we're going to cross off answer choice a Delta Wave Insurance PR invol- and Choice B diffuse St Elevations well diffuse St Ovation. Whenever I hear Salvation Right. We immediately go to mark cardiac infarction in this case when it's diffuse associated with acute pericarditis so pericarditis is not what we're seeing here. Although pericarditis is associated sometimes with the pericardial fusion. In this case what we have is pericardial. Tampa not so. We have an fusion that is having a much greater effect on the heart and circulation. So we're GonNa Cross off diffuse St elevation and Tracy low voltage electrical alternate means. Well this certainly seems like a contender. So low voltage we see in pericardial fusion because the fluid surrounding heart doesn't allow the signal to get out and that's the way I think about it and so you get low voltages of the cure as complex as mainly an intellectual alternate ends if you think about there's so much fluid surrounding the heart. The heart is kind of moving in that fluid kind of changing directions. And so you'll get our wave. Our way variations right height variations. So that's what I think about that. That certainly is associated with Tampa nod and pericardial fusion. So let's keep that answer choice e viable and move onto the next one answer is D. S. wave in lead one and a Qa an inverted t wave in lead three so this is the classic `Swan Q. Three t three pattern which is associated with right heart strain and you may see this and condition such as pulmonary. Embolism or anything. With right sided heart strain Dino Tampa pericardial fusion may cause something like this. You may see this but let's go back to her answer to our lead in which states which classic e CG findings associated with this disease process so this is where a good test taker says. I'm GonNa Answer the question that they're asking so anti-choice D. S. wave in lead one and Qa essentially s q three t three that is associated with right heart. Strain more so classically with pulmonary. Embolism so we're going to cross off answer choice D. which leads us back to low voltage electrical alternate ends. Which of course is the Classic E C G finding of pericardial cardio if fusion which in this case we know the patient has and the patient has actually something more severe as well continuum of pericardial Tampa. So we're GonNa go with answer choice. See Click next and sure enough. Pericardial Tampa nod is the answer. Hey everyone before you go remember. You could also watch the reveal at the Rosh Review Youtube channel where you can see me interact with the actual question and answer choices and if you're interested in your home to bank whether you're.
King Midas and the Satyr's Song
"King Midas and the Sater's song. Once upon a time in ancient Greece King Midas was bored. You'll may remember King Midas as the man who wished for a golden touch and soon found himself cursed by golden food. He couldn't eat and golden wine. He couldn't drink. You'd think that would have taught him his lesson for good but MIDAS was forever a misguided man misguided and full of agreed so strong he would have stolen the sun from the sky if he thought he could fit it into his his purse without burning his fingers. Baugh there's nothing to do old Midas blustered walking about his throne room. I'm taking a walk. Walk through the Royal Woods. See that no one bothers me. He took off his robe in stocked out the door near his palace. The wilds of Greece were open into him and wild were. This was still the time of Gods and monsters. Were you were as likely to run into a center as you were a horse and any any random apple may contain curse or blessing. So it wasn't much of a surprise when Midas soon came across a seder playing his pipes sater's were rogues but of mostly pleasant kind. They would play their tricks especially on those who didn't respect nature but usually we're content to enjoy themselves selves in the woods from the waist down they looked like goats standing on two legs and from the waist up they looked like men except for the great curving horns warns that adorned their heads. This particular Seder played his pipes. Beautifully spinning a lively rustic tune that soon had MIDAS tapping his does say. Did you enjoy the Song King Midas the Sader said when he had finished minus was surprised that he was recognized for a moment moment but then he realized this later was none other than pan himself God of the wilds and Lord of all sater's finally played aide Pan MIDAS said. What do you call it? Not One is called a lower for MIDAS. The Sader said. I wrote it for you do as I I need help. Man King Midas puffed himself up a bit that pants should need help from him made him feel royal and Regal indeed indeed. Of course my good man Herb Seder or pan he said. What can I do for you? Well L. I've made a wager with Apollo. He said we're supposed to have a musical competition this very afternoon. You Bet your pipes against Apollo the god of Music King Midas said shaking his head. I think you play beautifully but Apollo is music. It comes from him rolls off him like heat from an oven. I don't see how you could win at this pan laughed. Roguishly Shot MIDAS a wink. We'll see it's my job to bring a judge to the competition. He said you come as the judge in declare me the winner. Well this sounds all well and good for you said MIDAS leaning on an old olive tree but why should I do that. We both know Apollo is sure to sound best true true who said Pan but if you declare me the winner I'll split the prize with you. Apollo has wagered a Golden Lyre and a golden draw against my pipes and a bounty of fruit and herbs. Call me the winner and and the Golden Lyre is yours. My Good King Midas now any half clever man would have learned their lesson when they turned their own kid to gold and nearly nearly starved to death trying to eat golden food. But as we know King Midas was not half clever he was maybe a quarter clever on a good day but even that was pushing it so when he thought of Apollo's Golden Lyre all heavy bodied with finely woven strings like rays of Sun. His mouth began to water. His palms began to each his hair began to sway and tickle like grass in the breeze. His brain began to sing into him a simple chance. That went gold Gold Gold Gold Gold Gold Gold Gold I think MIDAS said licking his lips tips that we have a deal. Perfect said Pan slapping the king on the back. I'm supposed to meet Apollo at the river nearby. You're by come now. Let's go win a contest together. They made their way through the woods. It was a gorgeous day with the birds birds singing and the critters of all kinds leaping and rustling about the trees when they came to the river it was even more lovely than before. Because they're air sat apollo he was a tall and golden figure holding the U shaped harp called the Liar sitting on a rock by the river near him. The birds seemed to sing sweeter. The river babbled beautifully and all the myriad harmonies of the natural world seem to come together in a single. Google heartwarming song then King Midas. He called setting down his lawyer and clapping his hands. Even the clap seemed to be a song in itself. I'm glad you've decided to come. Pan I see you have your pipes and Midas you must be here to judge King Midas. It's not a degrading and took a seat on an old log. Your exactly right sir. I wouldn't miss the chance to hear to gods such as yourselves make music. I'm I'm sure it'll be quite the show. So should we take this contest off said pan knocking his pipes free of for against his thigh. Why we got our instruments we gotTA judge? Oh about that said Apollo. I think more judges are better than just one. Wouldn't you say well said Pan looking about nervously. I suppose one could say that good. Well I invited a couple of our friends to be impartial. Judges he said shooting a sly. Look at King Midas come onto the Mola's come now. Texas King Midas gaped as the two judges emerged from the wilds quite literally to Mola's was the spirit of the mountain itself and Ted. This was the grandmother of the fresh rivers that gave Greece life now pan immediately saw that he had been outsmarted. He was the god of nature so the mountain and the rivers were his domain. He couldn't accuse them of being biased against him. If anything they would look on him more favorably than other judges. Hello to Mola's allowed at this. He said it's lovely to see you on this shah. This fine day Tethong said her voice a watery whisper. We look forward to hearing your music. Yes boomed into Mola's with all the might of the mountains play for Rosh pay on what I hear. Your Song Pan nodded and leapt nimbly upon Hannah flat rock by the river using it as a sort of stage. He put his wooden pipes to his lips and began to blow a melody. It was simple a song of the wood and the trees. It's melody was that of a hiker speed and it's notes soared like an early spring breeze by anyone's judgment. It was a beautiful song. And when he finished and laid down his pipes king midas tumultuous tempests and even Apollo had tears standing in. There is beautiful. Wonderful cried King Midas his. His heart soared pan. Could win and it wouldn't even be cheating. The Seder played that beautifully MIDAS turned and looked at Apollo Paulo eyeing his heavy Golden Lyre. The arms were solid and shining the strings like he imagined finely woven rays of sunshine. And soon soon it would be his wonderful tune said tests but we must hear Apollo play. Yes rumbled to Mola's the nature. God has proven his worth. And now it's time for the Golden God to show us. I saw song. Apollo smiled and stood towering over pan and King Midas. He stepped up onto the flat rock. Stage each and then sat cross-legged cradling close his lyre. Here is a simple song for you. He said brushing the golden strings rings and sending out a ripple of music like the warmth of a perfect summer day I hope you like friends When the song was finished they didn't have tears in there is no? They were weeping openly any pan and king midas included. The song had touched them deeply. It was more than natural. It was supernatural. It was more than music. It was a great therman Cord that stretched from the Heavens to Earth and echoed deeply through their souls
Ice Sculpture Steals Show at U.K. Climate Debate That Boris Johnson Skips
"Yeah in the U. K. the Conservative Party has complained to the media regulator of the channel four refused to let Michael gave stand in football is Johnson in a climate change debate that was held last night that's after the bold because they used a melting ice sculpture to replace the prime minister the niece program huddles the leaders of the key political parties to take part in the debate ahead of next month's election however Jones and then breaks apart he needed Nigel for Rosh chose not to
How Do I Learn to Say No?
"Today's question is from Raj and Rosh says yes. I constantly feel overwhelmed and I'm not getting enough things done because I don't know how to say no to others. I know this is wrong long and a poor way to manage what's on my plate. The how do I get out of the habit of saying yes great question. Raj and I have some really good advice for you today day and some really good resources. You should check out. This is a very common challenge for people especially those who are getting started in business or in their professional life because for very long time you are excited for opportunity and when you have opportunities in front of you people are asking need to do things take on work. Take on tasks. You're just not in the habit of saying. No you just want to say yes because hey the great opportunities but here's here's the reality you only have twenty hours in the day. You'll have three hundred sixty five days in the year and whether you know it or not every time you're saying yes this something. You're you're seeing no vice. Say Yes to having lunch with somebody tomorrow. I am saying no to having lunch on my own or doing something else. During that time that time is take it so in today's lesson. We're GONNA talk about how to prioritize how to essential is. They'll talk about Greg McEwen's work in a moment so we learn to say no one we need
US approves first new type of flu drug in 2 decades
"Washington. Health regulators have approved the first new type of flu drug into decades. Correspondent Jan Johnson. Reports last winter the government counted some eighty thousand Americans who died a flu and it's complications the highest death toll in at least four decades. Now just in time for this year's flu season comes a new pill Zo loser. The pharmaceutical firm Rosh, which also makes tamiflu says so fluid that can. Produce
Could a magnifying wine glass be the next big thing?
"This is the big show. What's so funny about investing money? You ask the big Bishop Russell Sally hope to answer that top rated insightful financial analysis. If you're looking for insightful, financial perspective on key market strategies. Keep looking told you this is the big show. This is Russ and Sally. Dot com. Television network. Iheartradio. Everyone. One hundred seven five hundred dollars at the armed forces. Where you God bless. Serve our country overseas underway, especially on a day like today. Oh god. I love it. Yeah. It was home getting the kids ready for bed. And I was doing a show called the big ass show with a guy actually we were not. That's not accurate. I had two shows at the time. I was on the air. I was driving to work. I was doing morning drive at a station called aim eleven thirty Casio. And I was driving to work that I heard our good friends at Prescott who's in for you here. JP Jeff Prescott was is a very significant news guy here in southern California. The first report was that a plane a biplane or a single plane clipped, the flagpole hours. That's what you on the radio. This little loops turns out it was something different. So then we're I was on the air actually back then you didn't really have one computer in the studio dirt slow, and we had two TV's on in the studio as we're of watching the national news and kind of talking about it. And then as we actually were now facing this crazy. I remember I mean, it was just surreal there's certain times in your life where things happen. Like, the challenger disaster was just these big black stran- horrible events happen. And you're and you're hearing this stuff anyway. So Todd bless our military men or women for serving our country is underway. And. It's a tough day. We're going to get through the business. We did you guys pull up numbers tonight. See the numbers close today's numbers still chugging along pretty twenty one smartphones on fear and greed. I want to see what the emotions of the market today. We're. Yeah. We're so that doesn't surprise me of a somber day Jesse was Rosh Hashanah. It was a holiday where even on the NASDAQ is not now. One of those. We're still. Before we get to will Waldrop our guest very quickly. Can we spend just a minute and why have wine glass? On the on the Tim, Bob as you know, I like to drink. And. My eyesight is going as I get older. So here I am at the at the bar and drinking my wine. The Bill comes who printed this somebody under twenty five life state lifestyle. Lice tight so's along. What it's so small. I can't I really can't see I can't squint enough. Hold it far enough away can't squinted up. See you. All right. So I start to finish my glass, and I'm looking through my glass, and I realized what the hill it's kind of magnifying all my is this could this be. So I'm like another Lord Russell hang on the phone and working with a glass manufacturer in China. So this could be Lord. Russell industries. What's it called Magda China glass? No that one. No, no. What's this going to be? This could be maybe for our viewers and listeners could come up with the name it's drunk. No more. So this part of the glass. Yeah. See this megaphone glasses when I'm thinking is if we Bamble it or ARCHE, can you say more invention terms, somehow manipulate the glass? To facilitate the heart of seeing which is me you got this big bubble down. You're gonna benefit and you go like zoom zoom you could tie in Bevill beverage in almost does it now. But it looks like it looks like Russian. Letters. So you have to think it's possible.
What Actually Happened Between Cardi B and Nicki Minaj?
"That there wasn't altercation between the entourage is of Nikki manashian Cardi b. or at least between Cardi b. and one of Nicki Minaj is onto Rosh. It's a little confusing and you can't really see too much. There are few videos out, but you can't really see exactly what happened. Partly because this occurred at the bazaar cons party during New York fashion week, so people weren't supposed to be filming. Anyways, this was sort of a high fashion event both Cardi and Nikki were wearing very high fashion dresses and heels. But this seems to have been involving Raleigh who's a member of Nicki Menaj his entourage and car. Be and supposedly someone Nikki herself or someone in the entourage, or this is referencing previous thing that was said or multiple things not quite clear, possibly said something about Cardi b.'s daughter, and she got very upset and attack them, and it doesn't seem that Nikki was hit or injured in any way that I heard a lot of several comments about how she was behind security and also possibly that Raleigh stepped in front of her. So it doesn't seem that Cardi manage to actually hit Nikki. She did. It seems take off her shoe and throw it at her, but then she was escorted out and it's not clear if anyone hit Cardi b. back. But as she was escorted out, you can see in the photos. She has this very sizable not on her head above her left eye that she looks, you know, pretty almost collected, but she's not like cry or anything, but that looks like it hurts like that is that is a large, not. Just how from people who were there. They say that they think that came not from a member of Nikki's entre, but from security being hit in the head by Elber, whatever security was trying to break that up. Cardi b. then later posted a note on her Instagram, not necessarily referencing Nikki by name but clearly seeming to be directed to her about, you know why she went off and why she lost it and how she's not gonna take it anymore. But what I love most about the story is the fact that this happened at like a super high fashion event because you know, Cardi b.'s a mother now, and most mothers are definitely protective of children. It sounds like she and Nicki Menaj we're having issues even before this. So I'm not too surprised that Cardi b. would have been like, I will go at you anytime anyplace about this, but it's just like, okay, what you're those are not fighting close. You're in. What I'm sure is a very expensive, very, you know, very high fashion dress and he'll at least NICKY was 'cause I definitely saw the video of her arriving at this and I'm like, I probably couldn't even walk in those heels. Never mind in those skills with that dress because it's got a bit of a train, and I just I'm not that coordinated, but, but you want to actually start a physical altercation in those outfits like at least at least take off your shoes before you start that altercation to like, give yourself the ability to maneuver. I, I don't know why thought that, but like that is interesting. So this clearly not finished. This might only be the start of things. It's not even clear people did remark that Nikki didn't seem to faze about anything. And again, she doesn't seem to have actually been Cardi b. doesn't seem to actually been able to get to her that she was behind security, but clearly this is not
Boy, 15, dies after being shot outside Providence school
"Counseling services. This week will be offered to providence students who are mourning. The death of a fifteen year old classmate who were shot on the second day of school this year. City officials say despite the schools being closed until Thursday due to Rosh Hashanah and primary day trauma. Supporting professionals will be at several providence rec centers on Monday through Wednesday for any student who may wish to talk William Parsons, we shot this past Wednesday outside the providence career and technical academy. He was a student at central high school police say he was an innocent. Bystander a sixteen year old reportedly associated with a gang is facing murder and other charges in connection with the
Trump, Rush Limbaugh and President discussed on Rush Limbaugh
"President Trump responds to leak, audio recordings, of White, House meetings made by former administration staffer Omarosa manigault. Newman including one that came? Right after she was fired. So what's going on News at you thinking. About leaving what happened general Kelly general Kelly came to, me and, said that, you guys wanted me to leave I nobody even. Told me about it But I didn't know she released a recording over. The weekend from the actual firing in the, situation room today the. President tweeted wacky Omarosa who got fired three times on the. Apprentice now got fired for the last time manigault. Newman as a book coming out tomorrow
China: Hundreds of thousands of children given fake vaccines
"No, the hill, this as a significant breakthrough. However, here comes the cold water part when it comes to the weapons program in North Korea, this slight, although it has been part in significant part in developing ballistic missiles dismantling. It doesn't necessarily mean that it's ballistic missile capability has been dismantled because they know have the capability to fire from mobile sites. Yes, it's a small step forward, but it is that because there are dozens if not hundreds of sites connected to the weapons program across North Korea, which we don't even knew about. Meanwhile, North and south are continuing little dialogues today. It's been announced by the South Korean defense ministry can reduce the guard posts along the demilitarized zone along the border. That's a big step. But the big steps and the bigger picture will need to be between North Korea and the US or correspondent in Seoul. Chinese officials are battling to control public anger following a scandal over vaccine quality that's engulfed. One of the country's major pharmaceutical corporations, worried parents are rushing to hospitals to see of their children's vaccinations are valid and stocks in Chinese medicine and biotech companies have tumbled China correspondent. Steven McDonnell reports from Beijing. I'm standing outside the children's hospital next to written park in Beijing's east. It's busy here at the best of times. But today there's added concern hats. Not surprisingly parents flooding in here just like they are hospitals Rosh around the country to make sure that children are okay though. This seemed to be no cases. So far of people actually getting sick as a result of taking these inferior vaccines. Parents are wanting rish. Short that children are actually safely covered right now for diseases like hooping cough and tetanus. They're asking for copies of their children's vaccination records, so they can check for themselves just with hospital bought the vaccines. This is also becoming a crisis of confidence in the Chinese system with many seriously doubting the ability of the authorities to guarantee that medicines will be safe in the park across the road from the hospital. People walk with their children after visiting the doctor. Here, it's not hard to find those who've given up on Chinese pharmaceuticals and to hoping to buy from overseas from now on shall which we knew he doesn't. It hasn't been that long since the last incident like this, the inspection routines clearly don't work believe. We've been let down again and gain from milk powder to food safety to this vaccine scandal. It's all unsafe. They sent a guy if this hadn't been in the press, we would never phoned out purity. Inspections are China's state. Drug administration officials might feel little unfairly criticized for allowing this situation to develop after all. They were the ones who caught one of this country's big drug companies lying in its records. Following a flesh inspection Chong shown biotechnology was ordered to put a halt on its sub-standard production of a rabies vaccine. The company tried to reassure inspectors, but none of this batch of lift the factory. The en- later Drug administration offices discovered that two hundred and fifty thousand doses of an inferior diphtheria whooping cough and tetanus vaccine had already been sold. They had to be recalled. And now there is to be a major investigation Xu Jing heard deputy director of the state. Drug administration went on state television. Threatening criminal prosecution coming cheer, Young Australia time, we discovered that the company forged production and inspection records, these actions are serious violation of the law. And now the company itself has responded in an official statement Chaozhou about -nology. We'll call rates with drug regulators investigation the company deeply apologizes for this incident. This is all along way from China achieving its goal of becoming a reliable, global exporter of safe vaccines that report from Beijing buying Steven McDonnell..
President Trump, Russia and Tesla discussed on Chip Franklin
"A Cumulus. Station now on, Amazon Alexa Jio eight, tenths Afternoon. I'm Nikki medoro the, White House says President Trump is looking to host. A Russian President Vladimir Putin in the fall in Osmond comes a few days after Trump drew criticism for saying he did not think Russia would have meddled in the two thousand sixteen elections correspondent Bob Costantini has the comeback from a top intelligence chief at the Aspen security forum director, of national, intelligence Dan Coats undeniable that the Russians are taking the lead on this To undermine our basic values of divide us with our allies they're. The ones, that are trying to wreck havoc over there election process after President Trump's Monday comment of why would it be Russia to interfere in US. Elections coats issued. A rebuttal statement reemphasized, what agencies under his umbrella continue to say it. Was Russia and Russia's still at it Bob Costantini Washington to bay area Democrats are re introducing legislation that would require presidential candidates to release their tax returns before they appear on the ballot in California senators Mike McGuire and Scott Weiner say they decided to bring back their legislation following, President Trump's, summit with Putin governor Brown vetoed similar legislation last year An analyst says cancellations for Tesla's model three cars have been increasing in recent weeks Rosh of Indra. Gill says, refunds now at pace. Deposits for Tesla's new mass market electric car that's a figure tesla denies part of the problem is the expiration of a seventy five. Hundred dollar, tax credit former air force disc jockey Adrian krone our has died you newest character by a play by Robin Williams in the movie.